Abstract
Ninety patients with cirrhosis undergoing elective distal splenorenal shunt (DSRS) for variceal bleeding between January, 1977 and September, 1988 comprised the study group. In 63 cases, the original technique of Warren was used and, in 15, the modified Britton procedure was employed. Twelve patients had a DSRS plus splenopancreatic disconnection. Thirtyfour had alcoholic cirrhosis and 56 had nonalcoholic cirrhosis. Intraoperative portal pressure remained high after the shunt (29.4 cm H 2O)even if its initial value was probably decreased by the loss of the splenic flow. Splenic pressure was reduced to 21 cm H 2 O. The hepatic artery diameter enlarged even after selective shunt (from 6.5 to 7.1 mm). The persistence of a high portal pressure allowed for the preservation of hepatopedal portal flow in 87% of cases. Disconnection between the high-pressure mesenteric area and the low-pressure splenic area seemed to be ideal in only 17% of cases. Fifty-five percent of cases had the early development of minimal or moderate portomesenteric gastrosplenic (PM-GS) collateral pathways. In 33%, the PM-GS collaterals were generally abundant and often allowed visualization of the splenic and caval veins during the venous phase of the superior mesenteric arteriograms. In this group, portal flow was generally highly reduced and even abolished. The incidence of portal thrombosis was 11%. Early angiographic checks after DSRS did not show a different hemodynamic behavior between alcoholics and nonalcoholics. Splenopancreatic disconnection seems to prevent the development of collaterals and the loss of portal perfusion after shunt surgery.
Résumé
Quatre-vingt dix patients cirrhotiques ont été opérés d'une dérivation splénorénale distale (DSRD) pour hémorragie digestive par varices oesophagiennes entre Janvier, 1977 et Septembre, 1988. La technique originale de Warren a été employée dans 63 cas et celle modifiée par Britton dans 15. Douze patients ont eu une DSRD associée à une déconnection spléno-pancréatique. La cirrhose était d'origine alcoolique dans 34 cas et non alcoolique dans 56 cas. La pression résiduelle dans la veine porte après création de shunt restait haute (29.4 cm d'H2O) même lorsque sa valeur initiale s'était un peu abaissée en raison de la dimunition du débit splénique. Le diamètre de l'artère hépatique a augmenté de 6.5 mm à 7.1 mm, même après shunt électif. La persistance d'une pression porte élèvée a asssuré un flux hépatopète dans 87% des cas. La déconnection des régimes à haute pression (mésentérique) et à basse pression (splénique) n'apparaissait comme idéale que dans 17% des cas. Des collatérales porto-mésentériques gastro-spléniques, minimes ou modérées, se sont développées assez rapidement chez 55% des patients. Chez 33% des patients, les collatérales étaient généralement larges et permettaient l'opacification de la veine splénique et de la veine cave inférieure pendant la phase veineuse de l'artériographie mésentérique supérieure. Dans ce groupe, le débit porte était réduit voire même aboli. L'incidence de thrombose porte était de 11%. Les contrôles angiographiques précoces après DSRD n'ont pas montré de différence hémodynamique entre les patients alcooliques et ceux qui ne l'étaient pas. La déconnection splénopancréatique semble pouvoir empêcher le développement des collatérales et la perte de perfusion porte après les dérivations chirurgicales.
Resumen
El grupo de estudio comprende los pacientes cirróticos sometidos a derivación (“shunt”) esplenorrenal distal (SERD) por hemorragia varicosa entre enero de 1977 y septiembre de 1988. En 63 casos se utilizó la técnica original de Warren y en 15 el procedimiento modificado de Britton. Doce pacientes recibieron el SERD más desconexión esplenopancreática. Treinta y cuatro casos presentaban cirrosis alcohólica y 56 cirrosis no alcohólica. La presión portal intraoperatoria permaneció elevada después de realizar el “shunt” (29.4 cm H2O) aún en aquellos casos en que el valor inicial apareció disminuido posiblemente por la pérdida del flujo esplénico. La presión esplénica se redujo a 21 cm H2O. El diámetro de la arteria hepática aumentó aün después del “shunt” selectivo (de 6.5 a 7.1 mm). La persistencia de una alta presión portal logró la preservación del flujo portal hepático en 87% de los casos. La desconexión entre el area mesentérica de alta presión y el area esplénica de baja presión pareció ser ideal en solo 17% de los casos. Cincuenta y cinco por ciento de los casos desarrolló precozmente colaterales portomesentericas gastroesplénicas (PM-GE) mínimas o moderadas. En 33% las colaterales PM-GE aparecieron abundantes y con frecuencia permitieron la visualización de las venas esplénicas y cavas en la fase venosa de los arteriogramas de mesentérica superior. En este grupo el flujo portal generalmente resultó muy disminuido y aún abolido. La incidencia de trombosis portal fue 11%. Los controles angiográficos después de SERD no mostraron un comportamiento diferente entre los alcohólicos y no alcohólicos. La desconexión esplenopancreática parece prevenir el desarrollo de colaterales y la pérdida de perfusión portal después de una cirugía derivativa (“shunt”).
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Spina, G.P., Santambrogio, R., Opocher, E. et al. Early hemodynamic changes following selective distal splenorenal shunt for portal hypertension: Comparison of surgical techniques. World J. Surg. 14, 115–121 (1990). https://doi.org/10.1007/BF01670559
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DOI: https://doi.org/10.1007/BF01670559