Effects of altered portal hemodynamics after distal splenorenal shunts

Patients with cirrhosis who had undergone the distal splenorenal shunt were grouped based on preoperative to early postoperative changes in hepatic portal perfusion and corrected sinusoidal pressure. Early and late postoperative morbidity and mortality rates were determined for each hemodynamic group. Morbidity was least when both hepatic portal perfusion and sinusoidal pressure were maintained near preoperative levels (Group 1). Survival for this group was significantly better than for patients who lost portal flow to the liver during the early postoperative interval (Group 4). Patients with absent hepatic portal perfusion had the worst survival and greatest morbidity. Intermediate results were achieved for the two groups of patients that had postoperative preservation of portal perfusion but significant preoperative to postoperative alterations in sinusoidal pressure. Although survival curves for these two groups were not significantly different from Group 1, morbidity was greater, especially for patients with an increase in sinusoidal pressure (Group 2).     

Noncirrhotic portal vein thrombosis. Physiology before and after shunts.

Controversy exists concerning the proper therapy for bleeding gastroesophageal varices secondary to noncirrhotic portal vein thrombosis. Disparity of opinion exists regarding the significance of hepatic portal blood flow and the consequences of total portal-systemic shunts in this condition. One patient is presented who developed severe, crippling encephalopathy 20 years after a central splenorenal shunt. This was associated with loss of portal flow to the liver and marked nitrogen intolerance. Closure of the shunt resulted in restoration of hepatic portal flow via collateral veins (HPI 0.36), clearance of encephalopathy and return to near normal protein tolerance. An additional patient was studied with hyperammonemia and early suggestive signs of encephalopathy eight years following a mesocaval shunt. Four patients were evaluated before and after selective distal splenorenal shunts. All had "cavernous transformation" of the portal vein with angiographic evidence of portal flow to the liver. Postoperative angiograms revealed continued hepatic portal perfusion and a patent shunt in each patient. Radionuclide imaging postoperatively gave an estimated portal fraction of total hepatic blood flow (HPI) of .39 and .60 in two of the four patients. We conclude that 1) there is significant hepatic portal perfusion in noncirrhotic portal vein thrombosis (cavernous transformation), 2) loss of this hepatic portal flow following total shunts can lead to severe encephalopathy, 3) the selective distal splenorenal shunt maintains hepatic portal perfusion and is the procedure of choice when there is a patent splenic vein and surgical intervention is indicated.     

Proximal splenorenal shunts for extrahepatic portal venous obstruction in children.

OBJECTIVE: The results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction were evaluated. SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction, a common cause of portal hypertension in children in India, is being treated increasingly by endoscopic sclerotherapy instead of by proximal splenorenal shunt. It is believed that surgery (or the operation) carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly those who have limited access to medical facilities and safe blood transfusion. METHODS: Between 1976 and 1992, the authors performed 160 splenorenal shunts in children. Twenty were emergency procedures for uncontrollable bleeding and 140 were elective procedures--102 for recurrent bleeding and 38 for hypersplenism. RESULTS: The overall operative mortality rate was 1.9%--10% (3/160-2/20) after emergency operations and 0.7% (1/140) after elective operations. Rebleeding occurred in 17 patients (11%), and pneumococcal meningitis developed in 1 patient who recovered later. Encephalopathy did not develop in any patient. Four patients died in the follow-up period--two of rebleeding, one of chronic renal failure and a subphrenic abscess, and one of unknown causes. The 15-year survival rate by life table analysis was 95%. CONCLUSIONS: A proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.     

Distal splenorenal shunts for the treatment of severe thrombocytopenia from portal hypertension in children

Profound thrombocytopenia resulting from portal hypertension may exacerbate gastrointestinal bleeding, precipitate spontaneous bleeding, preclude surgical intervention for associated disorders, and severely limit life-style because of the danger of splenic injury. Although splenectomy can reverse the thrombocytopenia, the procedure should be avoided in children. We reviewed our experience with distal splenorenal shunting (DSRS) in children, particularly when performed for the sole purpose of reversing severe thrombocytopenia resulting from portal hypertension. DSRS was performed in 11 children between the ages of 7 and 15 years: five for severe thrombocytopenia (group 1), four for advanced hypersplenism and congenital hepatic fibrosis prior to renal transplantation (group 2), and two for esophageal bleeding (group 3). One child in group 1 with severe heart disease and Child’s class C cirrhosis due to hepatitis C died of progressive cardiac failure and was excluded from further analysis. Of the eight remaining patients in groups 1 and 2, four children had congenital hepatic fibrosis, two had portal vein thrombosis, one had hepatitis B, and one had Wilson’s disease. After DSRS, the mean platelet count increased from 37,000 ±18,000 to 137,600 ±81,000 (P = 0.01). The platelet count improved significantly in all seven children with presinusoidal portal hypertension or stable cirrhosis but did not increase in the child with hepatitis Band Child’s class B cirrhosis. The white blood cell count increased from an average of 3.3 ±1.1 to 5.4 ± 2.6 (P= 0.02). There were no postoperative complications in this group. The improved platelet count allowed the four children with congenital hepatic fibrosis and renal failure to undergo renal transplantation with full posttransplant immunosuppression including azathioprine. Postoperative Doppler ultrasound examination demonstrated shunt patency at 6 months in all cases. Spleen size decreased appreciably in all children in groups 1 and 2. All children were able to resume full activity including contact sports. In summary, DSRS effectively controls profound thrombocytopenia resulting from presinusoidal portal hypertension or stable cirrhosis without sacrificing the spleen and should be the treatment of choice for this condition. Presented at the British Association of Pediatric Surgeons Annual International Congress, Istanbul, Turkey, July 22–25, 1997.     

Risks in therapeutic portacaval and splenorenal shunts.

Analyses of the records of 120 patients who underwent portacaval shunting (PCS, 57%) or splenorenal shunting (SRS, 43%) from 1966-1973 disclosed that patients in each group undergoing elective shunts had the same preoperative physical condition and postoperative mortality rates (approximately 20%). Although the post-operative death rate from emergency shunts was 48%, patients having these procedures were poorer risks. Long-term incidences of encephalopathy were the same, irrespective of the type of shunt (PCS, 46%; SRS 36%, P greater than 0.5). Despite comparisons of data most unfavorable for PCS, 5-year survival rates were also the same after either type of shunt (all PCS, 29 +/- 7.5%, SRS, 42.0 +/- 7.4%, P = 0.23). The survival rate after elective PCS was also the same as after SRS during the entire 5-year period. However, the survival after all elective PCS and SRS was significantly greater than after emergency PCS (P range = 0.005-0.038); the poorer results of emergency shunting could be partly attributed to the poorer condition of patients selected. A numerical score based on serum bilirubin concentrations, ascites, and urgency of shunting reliably predicts postoperative mortality. Long-term encephalopathy is predicted by a history of encephalopathy and the urgency of shunting.     

Observations on fifty distal splenorenal shunts.

Fifty patients underwent conventional distal splenorenal shunts for bleeding esophageal varices. Five patient died within 30 days, giving an operative mortality of 10%. Three patients were lost of follow-up, but 47 patients were evaluated. Twelve patients died, 11 of liver failure, with more than half of the deaths occurring with 1 year, three fourths within 2 years, and all within 3 years after operation. Eleven patients rebled, and seven of these were among those who died. Sixteen patients had ascites prior to operation, but all responded to aggressive medical therapy. Twenty-two patients were available for study 2 or more years following operation. Eighteen (82%) are well with no encephalopathy, although the remaining four (18%) have had transient episodes of encephalopathy. Sixteen of the 18 patients judge their lifestyles to be productive. If the patient survived 24 months or longer, he had a four in five chance of living a normal life.     

Does portal pressure influence direction of portal flow and encephalopathy rates after 10-mm portacaval shunts in man?

Direction of portal flow after small diameter portacaval H graft has been found to significantly correlate with postshunt portasystemic encephalopathy rates. While some patients maintaining prograde portal flow were found to have a lower incidence of portasystemic encephalopathy, it has been suggested that high portal pressures are responsible for minimizing this complication. If both statements are true, then postshunt pressures should be higher in patients with prograde flow and in encephalopathy. Portal pressure and portal flow patterns were determined by shunt cannulation and fluoroscopy in 16 patients fully recovered from operation. Patients were screened for portasystemic encephalopathy over a 6- to 24-month period (average 12 months) at which time shunt patency was documented. Portal pressures were similar in patients with and without portasystemic encephalopathy and in patients with and without prograde flow. These results do not support the concept that portal pressure is an important determinant of portasystemic encephalopathy rates or flow patterns after 10-mm portacaval H graft.     

The significance of portal vein thrombosis after distal splenorenal shunt

The aims of this study were to determine the incidence of portal vein thrombosis after the distal splenorenal shunt, to identify any predictive factors, and to assess the clinical significance of this complication. Preoperative and postoperative angiograms and clinical evaluation were reviewed in 124 patients who underwent distal splenorenal shunts. Total and partial portal vein thrombosis were seen on 13 (10.5%) and 22 (17.7%) postoperative angiograms, respectively. The only preoperative variable correlating with development of portal vein thrombosis was portal venous perfusion, which was significantly lower in patients with than in those without portal vein thrombosis. In six of 10 patients with postoperative pancreatitis, portal vein thrombosis developed. The frequency of early postoperative complications was significantly greater in patients with total portal vein thrombosis than in those with partial or no thrombosis. Long-term follow-up has shown no significant effects of portal vein thrombosis on late ascites, encephalopathy, or survival.     

Prospective comparative clinical trial with distal splenorenal and mesocaval shunts.

In a randomized study, the rate of postshunt encephalopathy was significantly lower after distal splenorenal shunting than after mesocaval shunting. Either shunt can be performed electively with a low operative mortality. If initial hemorrhage cannot be controlled, mortality may be minimized by mesocaval shunting. Advanced cirrhosis is not a contraindication to elective or emergency portasystemic shunting.     

Selective distal splenorenal shunts: Technique and results

Selective distal splenorenal shunt was successfully performed in 20 patients from October 1974 to August 1978. All of them had had gastrointestinal hemorrhage from gastroesophageal varices, diagnosed by barium swallow roentgenography or esophagogastroscopy. Only one patient underwent emergency surgery. Portal hypertension was due to hepatic schistosomiasis in 16 patients, and all underwent rectal biopsy and examination of stools to confirm the clinical diagnosis. A small group of patients had ascites, jaundice and hemorrhage. Hepatic encephalopathy has not been a problem, although the follow-up study is short.     

生长抑素对门脉高压病人脾切除手术前后门脉压力的影响

目的 :探讨思他宁对肝硬化门脉高压病人行脾切除手术前后门脉压力的影响。方法 :肝硬化门脉高压脾肿大、脾功能亢进病人 2 5例 ,随机分治疗组 (思他宁组 ) 15例 ,对照组 10例 ,术前 1d及术后第 2天用彩色多普勒测定门脉主干内径、血流速度及血流量。手术中开腹后和术毕关腹前分别经胃网膜右静脉分支测得门静脉压力。治疗组在使用思他宁 5min后测门脉压力一次 (思他宁静脉维持 4 8h) ,记录术中出血量、术后第 1天脾窝引流管引出量。结果 :治疗组 :①使用思他宁前后门脉压力差异有极显著性 (P <0 .0 1)。在思他宁维持过程中 ,行脾切除前后门脉压力差异有显著性 (P <0 .0 5 )。②使用思他宁前后和脾切除术前后门脉内径差异无显著性 ,最大流速及血流量差异有极显著性 (P <0 .0 1)。对照组 :①脾切除前后门脉压力、最大血流量及血液流速差异有显著性 (P <0 .0 5 )。②门脉内径差异无显著性。两组术中出血量 ,术后第 1天腹腔引流管引出量差异有极显著性 (P <0 .0 1)。结论 :周围静脉持续生长抑素维持能降低门脉高压病人脾切除术后的门脉压力 ,降低门脉压力的机制可能是通过降低门脉血流速率从而降低门静脉血流量。术中及术后使用思他宁能明显减少术中及术后创面渗血     

Scintisplenoportography in assessing patency of distal splenorenal shunts

Scintisplenoportography was performed on 33 occasions in 28 cirrhotic patients who had bled from esophagogastric varices. In 17 cases scintisplenoportography was carried out after a retroperitoneal distal splenorenal shunt procedure and in the remaining 16 instances in patients without any surgical shunt. In four patients scintisplenoportography was performed before and after a surgical shunt procedure, and in one case, before and after the shunt thrombosed. Gammagraphic patterns and spleen-heart times helped determine which patients did not have a surgical shunt, which had a patent shunt, and which patients had a thrombosed shunt. A patent shunt pattern and a thrombosed shunt pattern have been defined. It is concluded that scintisplenoportography is a useful, reproducible, and safe method to assess the patency of distal splenorenal shunts.     

Comparison of portal flow distribution after portacaval and mesocaval shunts

The distribution of portal flow between the hepatic and systemic circulations was assessed in dogs using gamma-labeled radioactive microspheres. In control dogs all flow went to the liver. After side-to-side portacaval shunt, no flow went to the liver with all the injected microspheres entering the systemic circulation and becoming lodged in the lung. In contrast, interposition mesocaval and portacaval shunts resulted in preservation of 23 to 70% of hepatic portal blood flow.     

Clinical comparison between original and modified distal splenorenal shunts

This article reports on a retrospective clinical comparison between the original Warren shunt and one that we modified with Gore-Tex (expanded polytetrafluoroethylene) interposition. The former operation was performed on 35 patients between June 1969 and November 1983 and the latter on 29 patients between October 1983 and January 1986. There were no significant differences in the patients' backgrounds between the two study groups. Blood loss during surgery was significantly greater and operation time was longer in the original shunt group than in the modified shunt group. The incidence of postoperative morbidity and mortality was also significantly higher in the former group than in the latter (major complication rate: 20.0% versus 3.4%; operative death within 1 month: 5.7% versus 0%; in-hospital death: 11.4% versus 3.4%). The modified shunts had a 100% patency rate, and no variceal bleeding was evident, whereas shunt occlusion was observed in two patients and portal thrombosis in one patient of the original shunt group. The incidence of hepatic encephalopathy was 14.3% in the original shunt group and 6.9% in the modified shunt group, and the follow-up time was shorter in the latter group. A significantly greater rate of survival was achieved with the modified Warren shunts. Thus the current study seems to indicate that our modifications could be alternatives to the original distal splenorenal shunt in terms of postoperative morbidity, mortality, and survival.