Skip to main content
SpringerLink
Log in

Should both schistosomal and nonschistosomal variceal bleeders be disconnected?

  • Original Scientific Reports
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Splenopancreatic disconnection (SPD) was conceived and implemented as a technical addition to distal splenorenal shunt (DSRS) to maintain its selectivity and preserve portal perfusion. The proposed hemodynamic and metabolic stability of hepatocytes after DSRS-SPD should improve survival. In this nonrandomized study, 145 consecutive (Child A/B) variceal bleeders were electively subjected to selective shunt with DSRS in 93 and DSRS-SPD in 52 patients. The 2 groups were similar before surgery with a mean follow up of 24±12 (DSRS) and 27±14 (DSRS-SPD) months. DSRS-SPD had an operative mortality of 3.8%. Postoperative pancreatitis occurred in 7.7% after DSRS-SPD and 3.2% after DSRS alone, with schistosomal hepatic fibrosis representing 86% of morbid cases. Shunt patency was high and recurrent variceal hemorrhage was low in both groups. Clinical encephalopathy was significantly reduced after DSRS-SPD (p<0.05). The addition of SPD significantly reduced both the incidence of chronic hyperbilirubinemia in the schistosomal patients (p< 0.05) and the difference between the changes in total serum bilirubin in all patients (p=0.001). Portal perfusion was preserved after DSRS-SPD in all of the angiographically-studied patients. The overall survival was 84% after DSRS and 88% after DSRS-SPD. The schistosomal patients showed an incidence of 95% and 96% survival after DSRS and DSRS-SPD, respectively. DSRS-SPD was able to improve survival (92%) better than DSRS (77%) among well-matched nonschistosomal patients. These data show: (1) DSRS-SPD still has low operative mortality and a high patency rate with a low incidence of recurrent variceal hemorrhage, (2) DSRS-SPD maintains portal perfusion, achieves better survival, and reduces the incidence of encephalopathy, especially in patients with nonalcoholic cirrhosis and mixed liver disease, (3) in the schistosomal population, DSRS-SPD reduces the incidence of chronic hyperbilirubinemia but increases the risk of postoperative pancreatitis.

Résumé

La déconnection splénopancréatique (DSP) a été conçue et répandue comme une amélioration technique au shunt splénorénal distal (SSRD) pour maintenir sa sélectivité et préserver la perfusion portale. La stabilité hémodynamique et métabolique des hépatocytes, reconnue dans l'opération combinée SSRD-DSP, devrait augmenter la survie. Dans cette étude non randomisée, il y avait 145 patients consécutifs (Child A/B) avec varices oesophagiennes ayant saigné. Quatre vingt treize patients ont eu un SSRD seul et 52 patients, un SSRD-DSP. Les deux groupes étaient similaires avant la chirurgie. La survie moyenne était de 24±12 mois (SSRD) et de 27±14 mois (SSRD-DSP), respectivement. La mortalité opératoir de SSRD-DSP était de 3.8%. L'incidence de pancréatite post-opératoire était de 7.7% après SSRD-DSP et de 3.2% après SSRD seul chez des patients ayant une fibrose hépatique secondaire à une bilharziose dans 86% des cas. Le pourcentage de perméabilité de l'anastomose était élevé et la récidive hémorragique par varices était basse dans les deux groupes. L'encéphalopathie clinique était significativement moins fréquente après SSRD-DSP (p<0.05). Ajouter une DSP à une SSRD réduisait de façon significative l'incidence de l'hyperbilirubinémie chronique chez le patient avec bilharziose (p<0.05) et la bilirubinémie (p=0.001) dans les deux groupes. La perfusion portale était préservée après SSRD-DSP chez tous les patients ayant eu une angiographie. La survie globale était de 84% après SSPD et de 88% après SSPD-DSP. La survie des patients avec bilharziose était de 95% et de 96%, respectivement, après SSPD et SSPD-DSP. Parmi les patients sans bilharziose dont les caractéristiques étaient comparables aux patients avec bilharziose, la survie était plus longue après SSPD-DSP (92%) qu'après SSPD seul (77%). Ces résultats montrent que: (1) la mortalité opératoire de SSPD-DSP est basse avec un taux de récidive hémorragique par varices également bas, (2) la SSPD-DSP maintient une perfusion portale, augmente la survie et réduit l'incidence de l'encéphalopathie surtout chez les patients avec cirrhose non alcoolique et hépatopathie mixte, (3) dans la bilharziose, la SSPD-DSP réduisait l'incidence d'hyperbilirubinémie chronique mais augmente le risque de pancréatite.

Resumen

La desconexión esplenopancreática (DEP) fue concebida e implementada como un complemento técnico del “shunt” por anastomosis esplenorrenal distal (AERD) para mantener su selectividad y preservar la perfusión portal. Sesupone que la propuesta estabilidad hemodinámica y metabólica de los hepatocitos después de la AERD-DEP debe mejorar la sobrevida. En el presente estudio no randomizado, 145 pacientes consecutivos con sangrado varicoso (Child A/B) fueron electivamente sometidos a “shunt” selectivo con AERD, 93 casos, y a AERD-DEP, 52 casos. Los grupos, que presentaban características similares antes de la cirugía, tuvieron un seguimiento promedio de 24±12 meses (AERD) y 27±14 (AERD-DEP) meses. La AERD-DEP tuvo una mortalidad operatoria de 3.8%. Pancreatitis postoperatoria se desarrolló en 7.7% de los pacientes con AERD-DEP y en 3.2% de los pacientes con AERD solamente; la fibrosis hepática esquistosomiásica representó el 86% de los casos mórbidos. La tasa de permeabilidad del “shunt” se mantuvo alta y la de hemorragia varicosa recurrente apareció baja en los dos grupos. La encefalopatía clínica resultó significativamente reducida después de la AERD-DEP (p<0.05). La adición de la DEP redujo la incidencia tanto de la hiperbilirrubinemia crónica en los pacientes esquistosomiásicos (p<0.05) como los cambios en la bilirrubinemia total en todos los pacientes (p=0.001). La perfusión portal apareció preservada después de la AERD-DEP en la totalidad de los pacientes estudiados mediante angiografía. La tasa global de sobrevida fue 84% después de AERD y de 88% después de AERD-DEP. Los pacientes esquistosomiásicos exhibieron una tasa de sobrevida de 95% y de 96% después de AERD y de AERD-DEP, respectivamente. La AERD-DEP aumentó la sobrevida a 92%, en comparación con 77% para la AERD, en pacientes cuidadosamente apareados. Estos datos demuestran que: (1) la AERD-DEP exhibe una baja mortalidad y una alta tasa de permeabilidad, con baja incidencia de hemorragia varicosa recurrente, (2) la AERD-DEP mantiene la perfusión portal, logra una mejor sobrevida y reduce la incidencia de encefalopatía, especialmente en pacientes con cirrosis no alcohólica y enfermedad hepática mixta, (3) en la población esquistosomiásica, la AERD-DEP reduce la incidencia de hiperbilirrubinemia crónica, pero incrementa el riesgo de pancreatitis postoperatoria.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Warren, W.D., Zeppa, R., Fomon, J.J.: Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann. Surg.166:437, 1967

    Google Scholar 

  2. Maillard, J.N., Flamant, Y., Hay, J.M., Chandler, J.G.: Selectivity of the distal splenorenal shunt. Surgery86:663, 1979

    Google Scholar 

  3. Widrich, W.C., Robbins, A.H., Johnson, W.C., Nabseth, D.C.: Long term follow up of distal splenorenal shunt: Evaluation by arteriography, shuntography, transhepatic portal venography and cinefluorography. Radiology134:341, 1980

    Google Scholar 

  4. Belghiti, J., Grenier, P., Nouel, O.: Long term loss of Warren's shunt selectivity—Angiographic demonstration. Arch. Surg.116: 1121, 1981

    Google Scholar 

  5. Isomatsu, T.: Loss of selectivity of Warren shunt in long term observation. Jpn. J. Surg.3:202, 1983

    Google Scholar 

  6. Henderson, J.M., Gong-Liang, J., Galloway, J., Millikan, W.J., Sones, P.J., Warren, W.D.: Portaprival collaterals following distal splenorenal shunt: Incidence, magnitude and associated portal perfusion changes. Hepatology1:649, 1985

    Google Scholar 

  7. Warren, W.D., Millikan, W.J., Henderson, J.M., Rasheed, M.E., Salam, A.A.: Selective variceal decompression after splenectomy or splenic vein thrombosis with a note on splenopancreatic disconnection. Ann. Surg.199:694, 1984

    Google Scholar 

  8. 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, 1984

    Google Scholar 

  9. Warren, W.D., Millikan, 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, 1986

    Google Scholar 

  10. Henderson, J.M., Warren, W.D., Millikan, W.J., Galloway, J.R., Kawasaki, S., Kutner, M.H.: Distal splenorenal shunt with splenopancreatic disconnection. A 4-year assessment. Ann. Surg.210:332, 1989

    Google Scholar 

  11. Hashimoto, N., Ashida, H., Kotoura, Y., Ishikoway, Y., Utsunomiya, J.: Effect of distal splenorenal shunt versus distal splenorenal shunt and splenopancreatic disconnection. Abstract. 2nd World Congress on Hepato-Pancreato-Biliary Surgery, Netherlands. J.Surg. F.P. 153, 1988

  12. Maffei-Faccioli, A., Gerunda, G.E.: The improved distal splenorenal shunt: The impact of technique details on hemodynamic results. Abstract. 2nd World Congress on Hepato-Pancreato-Biliary Surgery, Netherlands. J. Surg. H.O. 30, 1980

  13. Dunn, M.A., Kamal, R.: Hepatic schistosomiasis. Hepatology1:653, 1981

    Google Scholar 

  14. Groszmann, R.J., Atterbury, C.E.: The pathophysiology of portal hypertension: A basis for classification. Sem. Liver Dis.2:177, 1983

    Google Scholar 

  15. Warren, K.S.: The kinetics of hepatosplenic schistosomiasis. Sem. Liver Dis.4:293, 1984

    Google Scholar 

  16. Ezzat, F.A., Abu-Elmagd, K.M., Aly, I.Y., Aly, M.A., Fathy, O.M., El-Barbary, M.H., Bahgat, O.O., Salam, A.A., Kutner, M.H.: Distal splenorenal shunt for management of variceal bleeding in patients with schistosomal hepatic fibrosis. Ann. Surg.204:566, 1986

    Google Scholar 

  17. Warren, W.D., Millikan, W.J.: Selective transplenic decompression procedure: Changes in technique after 300 cases. Contemp. Surg.18:11, 1981

    Google Scholar 

  18. Ezzat, F.A., Abu-Elmagd, K.M., Sultan, A.A., Aly, M.A., Fathy, O.M., Bahgat, O.O., El-Fiky, A.M., El-Barbary, M.H., Mashhor, N.: Schistosomal vs. nonschistosomal variceal bleeders—Do they respond differently to selective shunt (DSRS)? Ann. Surg.209:489, 1989

    Google Scholar 

  19. Conn, H.O., Brodoff, M.: Emergency esophagoscopy in the diagnosis of upper gastrointestinal hemorrhage: A critical evaluation of its diagnostic accuracy. Gastroenterology47:505, 1964

    Google Scholar 

  20. Nordlinger, B.M., Nordlinger, D.F., Fulenwider, J.T., Millikan, W.J., Sones, P.J., Kutner, M., Steele, R., Bain, R., Warren, W.D.: Angiography in portal hypertension: Clinical significance in surgery. Am. J. Surg.139:132, 1980

    Google Scholar 

  21. Parsons-Smith, B.G., Summerskill, W.H.J., Dawson, A.M., Sherlock, S.: The electroencephalograph in liver disease. Lancet2:867, 1957

    Google Scholar 

  22. Kaplan, K.L., Meier, P.: Nonparametric estimation from incomplete observations. J. Am. Stat. Assoc.53:457, 1958

    Google Scholar 

  23. Matthews, D.E., Farewell, V.T.: Using and Understanding Medical Statistics, S. Karger, Basel, 1985, pp. 55–87

    Google Scholar 

  24. Zar, J.H.: Biostatistical Analysis, 2nd edition, vol. 9, Englewood Cliffs, New Jersey, Prenticehall, Inc., 1984, pp. 138–144

    Google Scholar 

  25. Ezzat, F.A., Abu-Elmagd, K.M., Aly, M.A., Fathy, O.M., El-Ghawlby, N.A., El-Fiky, A.M., El-Barbary, M.H.: Selective shunt versus nonshunt surgery for management of both schistosomal and nonschistosomal variceal bleeders. Ann. Surg.212:97, 1990

    Google Scholar 

  26. Ezzat, F.A., Abu-Elmagd, K.M., El-Ghawlby, N.A., Fathy, O.M., Aly, M.A., El-Fiky, A.M., El-Barbary, M.H.: Variceal bleeders with active chronic liver disease (CALD). Selective decompression or decongestive surgery? AASLD Abstracts. Hepatology10:660, 1989

    Google Scholar 

  27. Aly, I.Y.: Interposition, H graft, mesocaval shunt for treatment of variceal bleeding in schistosomal portal hypertension. M.D. Thesis, Mansoura University, Egypt, 1979

    Google Scholar 

  28. Ezzat, F.A., Fathy, O.M., Sultan, A.A., El-Fiky, A.M., Aly, M.A., El-Barbary, M.H., Bahgat, O.O.: Esophageal transection for management of variceal bleeding. Benha Med. J. (Egypt)3:81, 1986

    Google Scholar 

  29. DaSilva, L.C., Trauss, E., Gayotto, L.C., Meis, S., Macedo. A.L., DaSilva, A.T., Silva, E.F., Lancet C.Mc., Antonelli, R.H., Fermanian, J., Foster, S., Raia, A., Raia, S.: A randomized trial for the study of the elective surgical treatment of portal hypertension in mansonic schistosomiasis. Ann. Surg.204:148, 1986

    Google Scholar 

  30. Henderson, J.M., Warren, W.D.: Selective variceal decompression: Current status and recent advances. Adv. Surg.18:81, 1984

    Google Scholar 

  31. Paquet, K.-J., Mercado, M.A., Koussouris, P., Kalk, J.F.R., Siemens, F., Cuan-Orozco, F.: Improved results with selective distal splenorenal shunt in a highly selected patient population. Ann. Surg.210:184, 1989

    Google Scholar 

  32. McDermott, W.V., Kane, R.A., Vollman, R.W., O'Hara, E.T.: Pseudocyst of the pancreas complicating distal splenorenal shunt. A report of three cases with successful percutaneous drainage. Ann. Surg.193:176, 1981

    Google Scholar 

  33. Mosimann, F.: Acute necrotizing pancreatitis after distal splenorenal shunt: Case report. World J. Surg.7:552, 1983

    Google Scholar 

  34. Erfan, M.: Bilharziasis of the pancreas. J. Egypt Med. Assoc.23:850, 1940

    Google Scholar 

  35. Eck, N.V.: On the question of ligature of the portal vein. Voen Med. J.130:1, 1877 (Translation in Surg. Gynecol. Obstet.96:375, 1953)

    Google Scholar 

  36. Hahn, M., Massen, M., Nencki, M., Pawlow, J.: Die Eck'sche Fistel zwischen der unteren Hohlvene und der Pfortader und ihre Folgen fur den Organismus. Arch. Exp. Pathol. Pharmokol.32:161, 1893

    Google Scholar 

  37. Rous, P., Larimore, L.D.: Relation of the portal blood to liver maintenance: A demonstration of liver atrophy conditional on compensation. J. Exp. Med.31:609, 1920

    Google Scholar 

  38. Starzl, T.E., Francavilla, A., Halgrimson, C.G., Francavilla, F.R., Porter, K.A., Brown, T.H., Putnam, C.W.: The origin, hormonal nature, and action of hepatotrophic substances in portal venous blood. Surg. Gynecol. Obstet.137:179, 1973

    Google Scholar 

  39. Warren, W.D.: Presidential address: Reflections on the early development of portocaval shunts. Ann. Surg.191:519, 1980

    Google Scholar 

  40. Starzl, T.E., Porter, K.A., Francavilla, A.: The Eck fistula in animals and humans. Curr. Prob. Surg.20:688, 1983

    Google Scholar 

  41. Rikkers, L.F., Rudman, D., Galambos, J.T., Fulenwider, J.T., Millikan, W.J., Kutner, M.H., Smith, III, R.B., Salam, A.A., Jones, P.J., Warren, W.D.: A randomized controlled trial of the distal splenorenal shunt. Ann. Surg.188:271, 1978

    Google Scholar 

  42. Millikan, W.J., Warren, W.D., Henderson, J.M., Smith, III, R.B., Salam, A.A., Galambos, J.T., Kutner, M.H., Keen, H.H.: The Emory prospective randomized trial: Selective versus nonselective shunt to control variceal bleeding. Ann. Surg.201:712, 1985

    Google Scholar 

  43. Raia, S., Mies, S., Macedo, A.L.: Surgical treatment of portal hypertension in schistosomiasis. World J. Surg.8:738, 1984

    Google Scholar 

  44. Warren, W.D., Henderson, J.M., Millikan, W.J., Galambos, J.T., Brooks, W.S., Riepe, S.P., Salam, A.A., Kutner, M.H.: Distal splenorenal shunt versus endoscopic sclerotherapy for long term management of variceal bleeding. Ann. Surg.203:454, 1986

    Google Scholar 

  45. Rikkers, L.F., Burnett, D.A., Volentine, G.D., Buchi, K.N., Cormier, R.A.: Shunt surgery versus endoscopic sclerotherapy for long term treatment of variceal bleeding. Ann. Surg.206:261, 1987

    Google Scholar 

  46. Tere's, J., Bordas, J.M., Bravo, D., Visa, J., Grande, L., Garcia-Valdecasas, J.C., Pera, C., Rodes, J: Sclerotherapy vs. distal splenorenal shunt in the elective treatment of variceal hemorrhage: A randomized controlled trial. Hepatology7:430, 1987

    Google Scholar 

  47. Paguet, K.-J., Mercado, M.A., Gad, H.A.: Surgical procedures for bleeding esophagogastric varices when sclerotherapy fails: A prospective study. Am. J. Surg.160:43, 1990

    Google Scholar 

  48. Millikan, W.J., Henderson, J.M., Galloway, J.R., Dodson, T.F., Shires, III, G.T., Stewart, M.: Surgical rescue for failures of cirrhotic sclerotherapy. Am. J. Surg.160:117, 1990

    Google Scholar 

  49. Rikkers, L.F.: Definitive therapy for variceal bleeding: A personal view. Am. J. Surg.160:80, 1990

    Google Scholar 

  50. Henderson, J.M., Millikan, W.J., Galloway, J.R.: The Emory perspective of the distal splenorenal shunt. Am. J. Surg.160:54, 1990

    Google Scholar 

  51. Maffei-Faccioli, A., Gerunda, G.E., Neri, D., Merenda, R., Langrandi, F., Meduri, F.: Selective variceal decompression and its role relative to other therapies. Am. J. Surg.160:60, 1990

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Gastroenterology Unit, Mansoura University School of Medicine, Mansoura, Egypt

    Kareem M. Abu-Elmagd M.D., Farouk A. Ezzat F.R.C.S., Omar M. Fathy M.D., Nabih A. El-Ghawlby M.D., Mohamed A. Aly M.D., Amgad M. El-Fiky M.D., Mohsen H. El-Barbary M.D., Gamal E. El-Ebady M.D. & Nabil G. El-Hak M.D.

Authors
  1. Kareem M. Abu-Elmagd M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Farouk A. Ezzat F.R.C.S.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Omar M. Fathy M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nabih A. El-Ghawlby M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mohamed A. Aly M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Amgad M. El-Fiky M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mohsen H. El-Barbary M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Gamal E. El-Ebady M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nabil G. El-Hak M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Abu-Elmagd, K.M., Ezzat, F.A., Fathy, O.M. et al. Should both schistosomal and nonschistosomal variceal bleeders be disconnected?. World J. Surg. 15, 389–397 (1991). https://doi.org/10.1007/BF01658738

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01658738

Keywords

Search

Navigation