Mesocaval and distal splenorenal shunts: Effect on hepatic function,hepatic hemodynamics,and portal systemic encephalopathy

Summary The effect of the mesocaval interposition shunt (n=12) and the distal splenorenal shunt (n=9) on the wedged hepatic venous pressure, the estimated hepatic blood flow, quantitative hepatic function, and the rate of portal systemic encephalopathy was evaluated in 21 patients who had bled from esophageal varices. After mesocaval shunt the wedged hepatic venous pressure was significantly reduced by 42% (from 26±3 mm Hg to 15±5 mm Hg,P<0.001) compared to 16% only (from 25±3 mm Hg to 21±2 mm Hg,P<0.005) after distal splenorenal shunt. The estimated hepatic blood flow also decreased significantly after mesocaval shunt by 61% (from 1.45±0.46 l/min to 0.56±0.25 l/min,P<0.001) compared to 29% (from 1.29±0.32 l/min to 0.91±0.39 l/min,P<0.05) after distal splenorenal shunt. Despite significantly different influences of both types of shunt operations on wedged hepatic venous pressure and estimated hepatic blood flow (P<0.001), postoperative changes of hepatic function were comparable in both groups of patients. The galactose elimination capacity, the initial plasma disappearance rate of Bromsulphalein, and the plasma ratio of valine, leucine, and isoleucine to phenylalanine and tyrosine were reduced by 13%, 26%, and 29%, respectively, after mesocaval shunt, compared to 12%, 25%, and 17% after distal splenorenal shunt. Only two patients of the mesocaval shunt group with the largest decrease in estimated hepatic blood flow developed portal systemic encephalopathy postoperatively, and the distal splenorenal shunt patients with their minor hemodynamic sequelae remained free of portal systemic encephalopathy.Abbreviations AP Serum alkaline phosphatase - BSP Bromsulphalein - BSP-k_i Initial plasma disappearance rate constant of BSP - BSP-45 min Plasma retention of BSP 45 min after i.v. injection - C_a Concentration of ICG in arterial blood - C_hv Concentration of ICG in hepatic venous blood - ChE Serum cholinesterase - DSRS Distal splenorenal shunt - EHBF Estimated hepatic blood flow - E-ICG Hepatic extraction of ICG - FHVP Free hepatic venous pressure - GEC Galactose elimination capacity - GPT Serum glutamic pyruvic transaminase - HCT Hematocrit - ICG Indocyanine green - MCS Mesocaval shunt - MRUS Maximal rate of urea synthesis - NCT Number-connection test - PHG Portohepatic gradient - PSE Portal systemic encephalopathy - PT Prothrombin time - PVP Portal venous pressure - R Removal of ICG - V + L + I/P + T Molar ratio of valine + leucine + isoleucine/phenylalanine + tyrosine - WHVP Wedged hepatic venous pressure