Advertisement

World Journal of Surgery

, Volume 13, Issue 1, pp 92–99 | Cite as

Appraisal of distal splenorenal shunt in the treatment of esophageal varices: An analysis of prophylactic, emergency, and elective shunts

  • Naofumi Nagasue
  • Hitoshi Kohno
  • Yuichiro Ogawa
  • Hirofumi Yukaya
  • Ryuichiro Tamada
  • Yukiharu Sasaki
  • Yu-Chung Chang
  • Teruhisa Nakamura
Original Scientific Reports

Abstract

From June, 1969 to February, 1987, distal splenorenal shunt was carried out on 78 patients with esophagogastric varices. The operations were urgent in 9, elective in 40, and prophylactic in 29 patients. There were 52 males and 26 females. Age ranged from 16 to 76 years with an average of 53 years. Thirty-seven patients were alcoholics. Hepatitis B surface antigen was positive in only 15.5%. The causes of portal hypertension were cirrhosis of the liver in 67, chronic hepatitis in 5, idiopathic portal hypertension in 4, primary biliary cirrhosis in 1, and fatty liver in 1 patient. Fifty-two patients were in Child's class A, 18 in class B, and 8 in class C. Emergency shunts were performed only when conservative therapy had failed to stop variceal bleeding. Prophylactic operations were done in patients having Child's class A or class B liver disease and risky varices, in varices larger than 5 mm in diameter and/or varices with red color signs such as cherry red spots. Forty-two patients underwent the original Warren shunt, but the remaining 36 had modified distal splenorenal shunt with expanded polytetrafluoroethylene interposition. The operative mortality rates were 11.1% in the emergency group, 2.5% in the elective group, and 3.4% in the prophylactic group. The overall operative and hospital death rates were 3.8% and 7.7%, respectively. The patency rate was 94.1% and the incidence of rebleeding from esophageal varices was 3.8%. Hepatic encephalopathy, although mild to moderate in degree, was observed in 14.7% of 75 patients excluding 3 operative deaths. The 1-, 2-, and 3-year survival rates of the emergency group were all 77.8%. The 1-, 2-, 3-, 5-, and 10-year survival rates of the elective patients were 86.9%, 75.1%, 71.3%, 55.2%, and 29.4%, respectively. The 5-, 10-, and 15-year survival rates of the prophylactic group were all 85.5%. The long-term prognosis was significantly worse in patients in Child's class C and alcoholics as compared with otherwise.

In the light of this retrospective evaluation, it can be concluded that distal splenorenal shunt is a reliable operative method in the treatment of esophagogastric varices associated with portal hypertension and that it can be performed safely in emergency, elective, and prophylactic situations.

Keywords

Portal Hypertension Hepatic Encephalopathy Primary Biliary Cirrhosis Esophageal Varix Idiopathic Portal Hypertension 
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

Entre juin 1969 et février 1987, 78 patients avec des varices oesogastriques ont subi une anastomose splénorénale distale (ASRD). L'intervention a été réalisée en urgence dans 9 cas, à froid dans 40, et à titre prophylactique chez 29 patients. Cinquante deux hommes et 26 femmes ont été opérés. L'âge moyen des patients était 53 ans, les extrêmes 16 et 76 ans; trente sept patients étaient alcooliques. L'antigène de surface d'hépatite B n'était positif que chez 14.1% des patients. Les causes de l'hypertension portale était la cirrhose du foie chez 67 patients, l'hépatite chronique chez 5, l'hypertension portale idiopathique chez 4, la cirrhose biliaire primitive chez un, et la stéatose chez un. Selon la classification de Child, 52 patients étaient classés A, 18, B, et 8, C. Les anastomoses ont été pratiquées en urgence seulement lorsque le traitement médical conservateur n'avait pas réussi à arrêter le signement. Les interventions à titre prophylactique ont été réalisées chez des patients classés Child A ou B avec des varices à risques c'est-à-dire ayant plus de 5 mm de diamètre et/ou présentant des signes de rupture imminente comme les tâches de cerise rouge. Quarante deux patients ont eu une ASRD selon la technique originale de Warren; les 36 autres ont en une ASRD par l'intermédiaire d'une prothèse en polytétrafluoroéthylène. La mortalité opératoire était de 11.1% chez les patients opérés en urgence, 2.5% chez ceux opérés à froid, et 3.4% chez les patients opérés à titre prophylactique. Respectivement, la mortalité globale opératoire et périopératoire était de 3.8% et 7.7%. Le taux de perméabilité de l'anastomose était de 94.1%; l'incidence de récidive hémorragique, de 3.8%. L'encéphalopathie hépatique, au plus modéré en intensité, était observée chez 14.7% des 75 patients survivant à l'intervention. Les taux de survie à 1, 2, et 3 ans chez les patients opérés en urgence était de 77.8% pour chaque groupe. Les taux de survie à 1, 2, 3, 5, et 10 ans des patients opérés à froid était de 86.9, 75.1, 71.3, 55.2, et 29.4%, respectivement. Le taux de survie à 5, 10, et 15 ans des patients opérés à titre prophylactique était de 85.5% pour chaque groupe. Le pronostic à long terme était moins bon lorsqu'il s'agissait de patients de classe C de Child et chez les alcooliques.

Compte tenu des résultats de cette étude rétrospective, nous concluons que l'ASRD est une intervention fiable dans le traitement des varices oesogastriques en rapport avec l'hypertension portale et qu'elle peut être effectuée avec sécurité en urgence, à froid et à titre prophylactique.

Resumen

Entre junio de 1969 y febrero de 1987 se practicaron derivaciones esplenorrenales distales en 78 pacientes con diagnóstico de várices esofagogástricas. Las operaciones fueron de urgencia en 9 casos, electivas en 40, y profilácticas en 29. El grupo estaba compuesto por 52 hombres y 26 mujeres, con edades que oscilaron entre 16 y 76 años, con un promedio de 53 años. Treinta y siete pacientes eran alcohólicos; el antígeno de superficie para hepatitis B fue positivo solamente en el 14.1%. Las causas de la hipertensión portal fueron: cirrosis hepática en 67, hepatitis crónica en 5, hipertensión portal idiopática en 4, cirrosis biliar primaria en 1, e hígado graso en 1. Cincuenta y dos pacientes fueron clasificados en la categoría A de la escala de Child, 18 en la categoría B, y 8 en la categoría C. Las derivaciones de emergencia fueron efectuadas sólo cuando no se logró controlar la hemorragia con terapia conservadora. Las operaciones profilácticas fueron realizadas en aquellos pacientes que clasificaron como clases A o B en la escala de Child y varices de alto riesgo, en pacientes con varices mayores de 5 mm de diámetro y/o várices con signos de color rojo, tales como manchas de color cereza. En 42 pacientes se hizo la derivación original de Warren, pero en los 36 restantes se hizo una derivación esplenorrenal distal modificada con interposición de un puente de politetrafluoroetileno. Las tasas de mortalidad operatoria fueron de 11.1% en las operaciones de emergencia, 2.5% en las operaciones electivas, y 3.4% en las operaciones profilácticas. Las tasas globales de mortalidad operatoria y hospitalaria fueron de 3.8% y 7.7%, respectivamente. La tasa de permeabilidad de la derivación fue de 94.1% y la incidencia de sangrado récurrente de las varices esofágicas fue de 3.8%. Se observé encefalopatía hepática de grado medio a moderado, en 14.7% de 75 pacientes, excluyendo 3 muertes operatorias. La tasa de supervivencia a 1, 2, y 3 años del grupo en que se practicó cirugia de emergencia, fueron todas de 77.8%. La tasa de supervivencia a 1,2, 3, 5, y 10 años de los pacientes en que se practicó cirugía electiva fue de 86.9%, 75.1%, 71.3%, 55.2%, y 29.4%, respectivamente. Las tasas de supervivencia a 5, 10, y 15 años del grupo en que se practicó cirugfa profiláctica fueron todas de 85.5%. El pronóstico a largo plazo apareció significativamente peor en los pacientes en la categoria C de Child y en los alcohólicos.

A la luz de los resultados de esta evaluación retrospectiva se puede concluŕ que la derivación distal esplenorrenal es un método operatorio confiable para el tratamiento de várices esofagogástricas asociadas a hipertensión portal y que puede ser practicado en forma segura en situaciones de emergencia, así como en cirugía electiva y profiláctica.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Jackson, F.C., Perrin, E.B., Smith, A.G., Dagradi, A.E., Nadal, H.M.: A clinical investigation of the portacaval shunt. II. Survival analysis of the prophylactic operation. Am. J. Surg.115:22, 1968Google Scholar
  2. 2.
    Resnick, R.H., Chalmers, T.C., Ishihara, A.M., Garceau, A.J., Callow, A.D., Schimmel, E.M., O'Hara, E.T., The Boston Inter-Hospital Liver Group: A controlled study of the prophylactic portacaval shunt. A final report. Ann. Intern. Med.70:675, 1969Google Scholar
  3. 3.
    Conn, H.O., Lindenmuth, W.W., May, C.J., Ramsby, G.R.: Prophylactic portacaval anastomosis. A tale of two studies. Medicine51:27, 1972Google Scholar
  4. 4.
    Orloff, M.J.: Emergency portacaval shunt: A comparative study of shunt, varix ligation and nonsurgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Ann. Surg.166:456, 1967Google Scholar
  5. 5.
    Orloff, M.J., Bell, Jr., R.H., Hyde, P.V., Skivolocki, W.P.: Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcoholic cirrhosis. Ann. Surg.192:325, 1980Google Scholar
  6. 6.
    Balasegaram, M., Damodaran, A.: Emergency shunt surgery for bleeding oesophagogastric varices. Aust. N.Z. J. Surg.40:152, 1970Google Scholar
  7. 7.
    Edmondson, H.T., Jackson, F.C., Juler, G.L., Sigel, B., Perrin, E.B.: Clinical investigation of the portacaval shunt: IV. A report of early survival from the emergency operation. Ann. Surg.173:372, 1971Google Scholar
  8. 8.
    Rikkers, L.F., Rudman, D., Galambos, J.T., Fulenwider, J.T., Millikan, W.J., Kutner, M., Smith, III, R.B., Salamn, A.A., Jones, Jr., P.J., Warren, W.D.: A randomized, controlled trial of the distal splenorenal shunt. Ann. Surg.188:271, 1978Google Scholar
  9. 9.
    Busuttil, R.W., Brin, B., Tompkins, R.K.: Matched control study of distal splenorenal and portacaval shunts in the treatment of bleeding esophageal varices. Am. J. Surg.138:62, 1979Google Scholar
  10. 10.
    Langer, B., Rothstein, L.E., Stone, R.M., Taylor, B.R., Patel, S.C., Blendis, L.M., Colapinto, R.F.: A prospective randomized trial of the selective distal splenorenal shunt. Surg. Gynecol. Obstet.150:45, 1980Google Scholar
  11. 11.
    Inokuchi, K., Kobayashi, M., Ogawa, Y., Saku, M., Nagasue, N., Iwaki, A.: Results of left gastric vena caval shunt for esophageal varices: Analysis of one hundred clinical cases. Surgery78:628, 1975Google Scholar
  12. 12.
    Warren, W.D., Zeppa, R., Fomon, J.J.: Selective transsplenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann. Surg.166:437, 1967Google Scholar
  13. 13.
    Japanese Research Society for Portal Hypertension: The general rules for recording endoscopic findings on esophageal varices. Jpn. J. Surg.10:84, 1980Google Scholar
  14. 14.
    Beppu, K., Inokuchi, K., Koyanagi, N., Nakayama, S., Sakata, H., Kitano, S., Kobayashi, M.: Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest. Endosc.27:213, 1981Google Scholar
  15. 15.
    Nagasue, N., Ogawa, Y., Hirose, S., Yukaya, H.: Bilateral gastric venous decompression by a modified Warren shunt. Br. J. Surg.72:199, 1985Google Scholar
  16. 16.
    Nagasue, N., Ogawa, Y., Yukaya, H., Hirose, S.: Modified distal splenorenal shunt with expanded polytetrafluoroethylene interposition. Surgery98:870, 1985Google Scholar
  17. 17.
    Sherlock, S.: Hepatic encephalopathy. In Disease of the Liver and Biliary System, Oxford, Blackwell Scientific Publ., 1985, pp. 91–107Google Scholar
  18. 18.
    Warren, W.D., Millikan, Jr., W.J., Henderson, J.M., Wright, L., Kutner, M., Smith, III, R.B., Fulenwider, J.T., Salam, A.A., Galambos, J.T.: Ten years portal hypertensive surgery at Emory. Results and new perspectives. Ann. Surg.195:530, 1982Google Scholar
  19. 19.
    Gibson, P.R., McInnes, I.E., Rosengarten, D.S., Jakobovits, A.W., Coventry, D.A., Dudley, F.J.: The distal lienorenal shunt: Perioperative experience with 30 patients. Aust. N.Z. J. Surg.51:336, 1981Google Scholar
  20. 20.
    Potts, III, J.R., Henderson, J.M., Millikan, Jr., W.J., Warren, W.D.: Emergency distal splenorenal shunts for variceal hemorrhage refractory to nonoperative control. Am. J. Surg.148:813, 1984Google Scholar
  21. 21.
    Peterson, K., Giles, G.R.: Distal splenorenal (Warren) shunt in the management of actively bleeding oesophageal varices. Br. J. Surg.73:618, 1986Google Scholar
  22. 22.
    Maillard, J.N., Flamant, Y.M., Hay, J.M., Chandler, J.G.: Selectivity of the distal splenorenal shunt. Surgery86:663, 1979Google Scholar
  23. 23.
    Widrich, W.C., Robbins, A.H., Johnson, W.C., Nabseth, D.C.: Long-term follow up of distal splenorenal shunts: Evaluation by arteriography, shuntography, transhepatic portal venography and cinefluorography. Radiology134:341, 1980Google Scholar
  24. 24.
    Inokuchi, K., Beppu, K., Koyanagi, N., Nagamine, K., Hashizume, M., Sugimachi, K.: Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation. Ann. Surg.200:711, 1984Google Scholar
  25. 25.
    Warren, W.D., Millikan, Jr., W.J., Henderson, J.M., Abu-Elmagd, K.M., Galloway, J.R., Shires, III, G.T., Richards, W.O., Salam, A.A., Kutner, M.H.: Splenopancreatic disconnection: Improved selectivity of distal splenorenal shunt. Ann. Surg.204:346, 1986Google Scholar
  26. 26.
    Malt, R.A., Abbott, W.M., Warshaw, A.L., van der Salm, T.J., Smead, W.L.: Randomized trial of emergency mesocaval and portacaval shunts for bleeding esophageal varices. Am. J. Surg.135:584, 1978Google Scholar
  27. 27.
    Osborne, D.R., Hobbs, K.E.F.: The acute treatment of haemorrhage from oesophageal varices: A comparison of oesophageal transection and staple gun anastomosis with mesocaval shunt. Br. J. Surg.68:734, 1981Google Scholar
  28. 28.
    Wanamaker, S.R., Cooperman, M., Carey, L.C.: Use of the EEA stapling instrument for control of bleeding esophageal varices. Surgery94:620, 1983Google Scholar
  29. 29.
    Terblanche, J., Bornman, P.C., Kahn, D., Jonker, M.A., Campbell, J.A.H., Wright, J., Kirsch, R.: Failure of repeated injection sclerotherapy to improve long-term survival after oesophageal variceal bleeding. Lancet2:1328, 1983Google Scholar
  30. 30.
    The Copenhagen Esophageal Varices Sclerotherapy Project: Sclerotherapy after first variceal hemorrhage in cirrhosis: A randomized multicenter trial. N. Engl. J. Med.311:1594, 1984Google Scholar
  31. 31.
    Paquet, K.J.: Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices. A prospective controlled randomized trial. Endoscopy14:4, 1982Google Scholar
  32. 32.
    Witzel, L., Wilbergs, E., Merki, H.: Prophylactic endoscopic sclerotherapy of oesophageal varices. A prospective controlled study. Lancet1:773, 1985Google Scholar
  33. 33.
    Koch, H., Henning, H., Grimm, H., Soehendra, N.: Prophylactic sclerosing of esophageal varices. Results of a prospective controlled study. Endoscopy18:40, 1986Google Scholar
  34. 34.
    Inokuchi, K., Cooperative Study Group of Portal Hypertension of Japan: Prophylactic portal nondecompression surgery in patients with esophageal varices. An interim report. Ann. Surg.200:61, 1984Google Scholar
  35. 35.
    The Italian Liver Cirrhosis Project: Reliability of endoscopy in the assessment of variceal features. J. Hepatol.4:93, 1987Google Scholar

Copyright information

© Société Internationale de Chirurgie 1989

Authors and Affiliations

  • Naofumi Nagasue
    • 1
    • 2
  • Hitoshi Kohno
    • 1
    • 2
  • Yuichiro Ogawa
    • 1
    • 2
  • Hirofumi Yukaya
    • 1
    • 2
  • Ryuichiro Tamada
    • 1
    • 2
  • Yukiharu Sasaki
    • 1
    • 2
  • Yu-Chung Chang
    • 1
    • 2
  • Teruhisa Nakamura
    • 1
    • 2
  1. 1.Second Department of SurgeryShimane Medical UniversityIzumoJapan
  2. 2.Department of SurgeryHiroshima Red Cross and Atomic Bomb HospitalHiroshimaJapan

Personalised recommendations