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World Journal of Surgery

, Volume 8, Issue 5, pp 722–732 | Cite as

The distal splenorenal shunt: An update

  • J. Michael Henderson
  • William J. Millikan
  • W. Dean Warren
Progress Symposium—Portal Hypertension

Abstract

The distal splenorenal shunt (DSRS), as the prototype for selective variceal decompression, has evolved over the 17 years since its introduction. Attention to detail in the preoperative assessment and perioperative management will minimize morbidity. Reported experience from over 25 centers has shown an average overall operative mortality rate of 9%, shunt patency and bleeding control rates in excess of 90%, encephalopathy in from 0 to 18% of cases, and a 5-year survival rate between 50 and 60%. Non-alcoholic cirrhotics (70–80%) have a significantly (p< 0.05) greater 5-year survival rate than do alcoholic cirrhotics (45%). The 6 prospective randomized trials comparing DSRS to total portal systemic shunts have been conducted primarily in alcoholic cirrhotics; they show no significant difference in survival. Current experience in schistosomiasis and portal vein thrombosis shows selective variceal decompression to be superior to total shunt. Quantitative data prior to and 1 year after DSRS show a fall in liver volume, stabilization of hepatocyte function, and variable change in hemodynamics: alcoholic cirrhotics have a 70% chance of losing portal venous flow, while nonalcoholics maintain portal perfusion. Loss of portal venous flow is associated with a systemic hyperdynamic response in those with poorer hepatocyte function. Splenopancreatic disconnection is currently being studied in an attempt to maintain portal perfusion better and preserve liver volume. We conclude that the DSRS has achieved its pathophysiological goals of preventing recurrent variceal bleeding, while maintaining hepatocyte function. Modifications in management and the operative procedure are evolving from increased understanding of the pathology of the underlying causes of the portal hypertension leading to variceal bleeding.

Keywords

Portal Hypertension Schistosomiasis Portal Vein Thrombosis Liver Volume Variceal Bleeding 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

L'anastomose spléno-rénale distale prototype de la décompression sélective des varices, a évolué depuis son début il y a 17 ans. L'attention apportée à l'appréciation des données cliniques et biologiques préopératoires ainsi qu'à la technique opératoire en ont diminué la morbidité.

L'expérience rassemblée de 25 centres a montré que la mortalité opératoire était de 9%, que le taux de perméabilité de l'anastomose et du contrôle de hémorragie dépassait 90%, que la fréquence de l'encéphalopathie était comprise entre 0 et 18%, que la survie à 5 ans était de 50–60%. Le taux de survie à 5 ans est inférieur chez les malades atteints de cirrhose alcoolique (45%) que chez les sujets dont la cirrhose n'est pas d'origine alcoolique (70–80%).

Six études prospectives faites au hasard comparant l'anastomose spléno-rénale distale aux anastomose portocaves totales pratiquées au cours des cirrhoses alcooliques permettent d'affirmer que la durée de la survie est alors identique. L'anastomose spléno-rénale distale est supérieure à l'anastomose portocave classique en cas de bilharziose ou de thrombose de la veine porte.

L'étude quantitative pratiquée avant l'anastomose et un an après sa réalisation montre une diminution du volume du foie, la stabilisation de la fonction hépatocytaire et des modifications hémodynamiques variables: dans 70% des cas le flux portal est perdu chez le cirrhotique alcoolique alors qu'il est conservé lorsque l'alcool n'est pas en cause. La perte du flux portal s'accompagne d'une réponse hyperdynamique de la circulation chez ceux dont la fonction hépatocytaire est défaillante.

La déconnecxion spléno-pancréatique pour essayer de maintenir la circulation portale et de préserver le volume du foie est en cours d'étude.

En conclusion, l'anastomose spléno-rénale distale a atteint les buts qu'elle se proposait: prévenir la récidive de l'hémorragie et maintenir les fonctions hépatiques. Des modifications dans le traitement et la technique opératoire sont en cours grâce à la meilleure connaissance de la pathologie des causes sous-jacentes de l'hypertension portale à l'origine des varices hémorragiques.

Resumen

El “shunt” espleno-renal distal (SERD) comprende dos principios básicos: primero, el control de la hemorragia varicosa, puede ser logrado por la descompresión selectiva del segmento gastroesofágico; y segundo, la función hepática puede ser mantenida mediante la preservación de la hipertensión portai y la perfusión venosa del hígado. El SERD, como portotipo del procedimiento para la descompresión varicosa selectiva, ha evolucionado a lo largo de 17 años desde su introducción en 1966. Una cuidadosa atención al detalle en la evaluación preoperatoria y en el manejo perioperatorio resulta en una menor morbilidad. La experiencia informada por 25 centros médicos ha demostrado una mortalidad global promedio de 9%, permeabilidad del “shunt” y control de la hemorragia > 90%, encefalopatía de 0–18% y supervivencia a 5 años de 50–60%. Los cirróticos no alcohólicos (70–80%) exhiben una supervivencia a 5 años significativamente superior (p<0.05) a la de los cirróticos alcohólicos (45%). Los seis estudios prospectivos y aleatorizados que comparan el SERD con los “shunts” portasistémicos totales han sido realizados primordialmente en cirróticos alcohólicos y no muestran una diferencia significativa en la supervivencia. La experiencia actual con esquistosomiasis y con trombosis de la vena porta indica que la descompresión selectiva es superior al “shunt” total. Estudios cuantitativos realizados antes y un ano después del SERD demuestran disminución en el tamaño del hígado, estabilización de la función del hepatocito y modificaciones diferentes en la hemodinamia: los cirróticos alcohólicos tienen un 60% de probabilidad de perder el flujo venoso portal, en tanto que los no alcohólicos mantienen la perfusión portal. La pérdida del flujo venoso portal se asocia con una respuesta hiperdinámica sistémica en aquellos pacientes con más pobre función hepatocítica. La desconexión esplenopancreática está siendo estudiada en la actualidad en un esfuerzo por mantener mejor la perfusión portal y, preservar el volumen del hígado. Nuestra conclusión es que el SERD ha logrado sus propósitos de prevención de la hemorragia varicosa recurrente al tiempo que preserva la función del hepatocito. Se están desarrollando modificaciones tanto en el manejo como en el procedimiento quirúrgico mismo, derivados de un mayor conocimiento de la patología y de las causas fondamentales de la hipertensión portal que lleva a la formación de várices esofágicas.

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Copyright information

© Société Internationale de Chirurgie 1984

Authors and Affiliations

  • J. Michael Henderson
    • 1
  • William J. Millikan
    • 1
  • W. Dean Warren
    • 1
  1. 1.Department of SurgeryEmory University HospitalNE, AtlantaUSA

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