Abstract
Background
A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective, and durable procedures to treat variceal bleeding in patients with low operative risk and good liver function.
Discussion
In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) and a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or transjugular intrahepatic portosystemic shunt insertion fails to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) should be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.
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References
Wolff M, Kalff JC, Textor J, Hirner A (1999) Portosystemische Shuntchirurgie und transjugulärer Stent (TIPS) in Deutschland. Chirurg 70:447–452
D'Amico G, Magliaro L, Bosch J (1995) Treatment of portal hypertension: a meta-analytic review. Hepatology 22:332–254
DeFranchis R (2001) Portal hypertension III. Proceedings of the third Baveno International Consensus Workshop. Blackwell, Oxford
Burroughs AK, Vangeli M (2002) Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis. Scand J Gastroenterol 37:249–252
Roesch J, Keller FS (2001) Transjugular intrahepatic portosystemic shunt: present status, comparison with endoscopic therapy and shunt surgery, and future prospectives. World J Surg 25:337–346
Grace ND, Groszmann R, Garcia-Tsao G, Burroughs AK, Pagliaro L, Makuch R (1996) Portal hypertension and variceal bleeding: a report of a single topic symposium. Hepatology 28:868–880
Shiffman ML, Jeffers L, Hoofnagle JH, Tralka TS (1995) The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications. Hepatology 22:1591–1596
Isaakson B, Jeppsson B, Bengtsson F, Hannesson P, Herlin P, Bengmark S (1995) Mesocaval shunt or repeated sclerotherapy: effects on rebleeding and encephalopathy. Surgery 117:498–504
Orozco H, Mercado MA (2000) The evolution of portal hypertension surgery. Lessons from 1000 operations and 50 years' experience. Arch Surg 135:1389–1393
Henderson JM, Nagle A, Curtas S, Geisinger M, Barnes D (2000) Surgical shunts and TIPS for variceal decompression in the 1990s. Surgery 128:540–547
Hillebrand DJ, Kojouri K, Cao S, Runyon BA, Ojogho O, Conception W (2000) Small-diameter portacaval H-graft shunt: a paradigm shift back to surgical shunting in the management of variceal bleeding in patients with preserved liver function. Liver Transpl 6:459–465
Banares R, Casado M, Rodriguez-Laiz JM, Camunez F, Matilla A, Echenagusia A, Simo G, Piqueras B, Clemente G, Cos E (1998) Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. Am J Gastroenterol 93:75–79
Rikkers LF, Jin G (1994) Surgical management of acute variceal hemorrhage. World J Surg 18:193–199
Chalasani N, Clarc WS, Martin LG, Kamean J, Khan MA, Patel NH, Boyer TD (2000) Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 118:138–144
Orloff ML, Orloff MS, Rambotti M, Girard B (1992) Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Long-term results of emergency shunt in 94 patients with bleeding varices. Ann Surg 216:256–268
Orloff MJ, Bell RH, Orloff MS, Hardison WGM, Greenburg AG (1994) Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices. Hepatology 20:863–872
Jenkins RL, Gedaly R, Pomposelli JJ, Pomfret EA, Gordon F, Lewis WD (1999) Distal splenorenal shunt. Role, indications, and utility in the era of liver transplantation. Arch Surg 134:416–420
Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'Amico G, Dickson ER, Kim WR (2001) A model to predict survival in patients with end-stage liver disease. Hepatology 33:464–470
Rosemurgy AS, Serafini FM, Zweibel BR, Black TJ, Kudryk BT, Nord HJ, Goode SE (2000) Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomised prospective trial. J Gastrointest Surg 4:589–597
Soybel DI (1997) TIPS versus surgical decompression of portal hypertension. Gastroenterology 112:1768–1770
Rosemurgy AS, Bloomston M, Zervos EE, Goode SE, Pencev D, Zweibel B, Black TJ (1997) Transjugular intrahepatic portosystemic shunt versus H-graft portacaval shunt in the management of bleeding varices: a cost-benefit analysis. Surgery 122:794–800
Zacks SL, Sandler RS, Biddle AK, Mauro MA, Brown RS (1999) Decision-analysis of transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt for portal hypertension. Hepatology 29:1399–1405
Helton WS, Maves R, Wicks K, Johansen K (2001) Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients. Arch Surg 136:17–20
Khaitiyar JS, Luthra SK, Prasad N, Ratnakar N, Daruwala DK (2000) Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt A comparative study. Hepatogastroenterology 47:492–497
Sarfeh IJ, Rypins EB (1994) Partial versus total portacaval shunt in alcoholic cirrhosis: results of a prospective, randomized clinical trial. Ann Surg 219:353–361
Henderson MB (1994) Role of distal splenorenal shunt for long-term management of variceal bleeding. World J Surg 18:205–210
Rikkers LF, Jin G, Langnas AN, Shaw BW Jr (1997) Shunt surgery in the era of liver transplantation. Ann Surg 226:51–57
Collins C, Ong J, Rypins EB, Sarfeh IJ (1998) Partial portacaval shunt for variceal hemorrhage. Longitudinal analysis of effectiveness. Arch Surg 133:590–593
Paquet KJ, Lazar A, Koussouris P, Hotzel B, Gad HA, Kuhn R, Kalk JF (1995) Mesocaval interposition shunt with small-diameter polytetrafluoroethylene grafts in sclerotherapy failure. Br J Surg 82:199–203
Wong LL, Lorenzo C, Limm WM, Wong LM (2002) Splenorenal shunt: an ideal procedure in the pacific. Arch Surg 137:1125–1129
Gawish Y, El-Hammadi HA, Kotb M, Awad AT, Anwar M (2000) Devascularization procedure and DSRS: a controlled randomized trial on selected haemodynamic portal flow pattern in schistosomal portal hypertension with variceal bleeding. Int Surg 85:325–330
Mitra SK Rao KLN, Narasinham KL, Dilawari JB, Batra YK, Chawla Y, Thapa BR, Nagi B, Walia BNS (1993) Side-to-side lienorenal shunt without splenectomy in non-cirrhotic portal hypertension in children. J Pediatr Surg 28:898–802
Slakey DP, Klein AS, Venbrux AC, Cameron JL (2001) Budd-Chiari syndrome: current management options. Ann Surg 233:522–527
Denninger MH, Chait Y, Casadevall N, Hillaire S, Guillin MC, Bezeaud A, Erlinger S, Briere J, Valla D (2000) Cause of portal or hepatic venous thrombosis in adults: the role of multiple concurrent factors. Hepatology 31:587–591
Perello, A, Garcia-Pagan JC, Gilabert R, Suarez Y, Moitinho E, Cervantes F, Reverter JC, Escorsell A, Bosch J, Rodes J (2002) TIPS is a useful long-term derivative therapy for patients with Budd-Chiari syndrome uncontrolled by medical therapy. Hepatology 35:132–139
Janssen HLA, Wijnhoud A, Haagsma EB, van Uum SHM, van Nieuwkerk CMJ, Adang RP, Chamuleau RAFM, van Hattum J, Vleggaar FP, Hansen BE, Rosendaal FR, van Hoek B (2001) Extrahepatic portal vein thrombosis: aetiology and determinants of survival. Gut 49:720–724
Valla DC, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. J Hepatol 32:865–871:2000
Sarin SK, Agarwal SR (2002) Extrahepatic portal vein obstruction. Semin Liver Dis 22:43–58
Shiyansky J, Roberts E, Superina RA (1999) Distal splenorenal shunts for the treatment of severe thrombocytopenia from portal hypertension in children. J Gastrointest Surg 3:659–663
Sarin SK, Bansal A, Sasan S, Nigam A (1992) Portal vein obstruction in children leads to growth retardation. Hepatology 15:229–233
Sarin SK, Lahoti D, Saxena SP, Murthi NS, Makwane UK (1992) Prevalence, classification and natural history of gastric varices: long-term follow-up study in 568 patients with portal hypertension. Hepatology 16:1343–1349
Ganguly S, Sarin SK, Bhatia V (1995) The prevalence and spectrum of colonic lesions in patients with cirrhotic and non-cirrhotic portal hypertension. Hepatology 21:1226–1231
Merkel C, Bolognesi M, Bellon S, Sacerdoti D, Bianco S, Amodio P, Gatta A (1992) Long-term follow-up study of adult patients with non-cirrhotic obstruction of the portal system: comparison with cirrhotic patients. J Hepatol 15:299–303
Condat B, Pessione F, Denninger MH, Hillaire S, Valla D (2000) Recent portal or mesenteric venous thrombosis: increased recognition and frequent recalization on anticoagulant therapy. Hepatology 32:466–470
Tuerler A, Wolff M, Dorlars D, Hirner A (2001) Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate. Gastrointest Endosc 53:228–230
Bismuth H, Franco D, Alagille D (1980) Portal diversion for portal hypertension in children. The first ninety patients. Ann Surg 192:18–24
Alvarez F, Bernard O, Brunelle F, Hadchouel P, Odievre M, Alagille D (1983) Portal obstruction in children. II. Results of surgical portasystemic shunts. J Pediatr 103:18–24
Kato T, Romero R, Koutouby R, Mittal NK, Thompson JF, Schleien CL, Tsakis AG (2000) Portosystemic shunting in children during the era of endoscopic therapy: improved postoperative growth parameters. J Pediatr Gastroenterol Nutr 30:419–425
Orloff MJ, Orloff MS, Girard B, Orloff SL (2002) Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt. J Am Coll Surg 194:717–730
Pande GK, Reddy VM, Kar P, Sahni P, Berry M, Tandon BN, Nundy S (1987) Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow-up. BMJ 295:1115–1117
Prasad SA, Gupta S, Kohli V, Pande GK, Sahni P, Nundy S (1994) Proximal splenorenal shunts for extrahepatic portal venous obstruction in children. Ann Surg 219:193–196
Alagille D, Carlier JC, Chiva M, Ziade R, Ziade M, Moy F (1986) Long term neuropsychological outcome in children undergoing portal-systemic shunts for portal vein obstruction without liver disease. J Pediatr Gastroenterol Nutr 5:861–866
Mohapatra MK, Mohapatra AK, Acharya SK, Sahni P, Nundy S (1992) Encephalopathy in patients with extrahepatic obstruction after lienorenal shunts. Br J Surg 79:1103–1105
Voorhees AB, Price JB (1974) Extrahepatic portal hypertension. A retrospective analysis of 127 cases and associated clinical implications. Arch Surg 108:338–341
de Ville de Goyet J, Alberti D, Clapuyt P, Otte JB (1999) Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension. J Pediatr Surg 33:597–601
Kreft, B, Strunk H, Flacke S, Wolff M, Conrad R, Gieseke J, Pauleit D, Bachmann R, Hirner A, Schild HH (2000) Detection of thrombosis in the portal venous system: comparison of contrast enhanced MR angiography with intraarterial digital subtraction angiography. Radiology 216:86–92
Cooley DA (1963) Side-to-side splenorenal anastomosis with splenic preservation for portal hypertension. Surg Gynecol Obstet 116:627–629
Warren WD, Henderson JM, Millikan WJ, Galambos JT, Bryan FC (1988) Management of variceal bleeding in patients with noncirrhotic portal vein thrombosis. Ann Surg 207:623–634
Maksoud JG, Miles S (1982) Distal splenorenal shunt in children. Ann Surg 195:401–405
Gauthier F, DeDreuzy O, Valayer J, Montupet PH (1989) H-type shunt with autologous venous graft for treatment of portal hypertension in children. J Pediatr Surg 29:1041–1043
Inokuchi K, Sugimachi K (1990) The selective shunt for variceal bleeding: a personal perspective. Am J Surg 160:48–53
Rahmani O, Wolpert LM, Drezner AD (2002) Distal inferior mesenteric veins to renal vein shunt for treatment of bleeding anorectal varices: case report and review of literature. J Vasc Surg 36:1264–1266
El-Khishen MA, Henderson JM, Millikan WJ, Kutner MH, Warren WD (1885) Splenectomy is contraindicated for thrombocytopenia secondary to portal hypertension. Surg Gynecol Obstet 160:233–238
Klempnauer J, Grothues F, Bektas H, Pichlmayr R (1997) Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis. Br J Surg 84:129–132
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Wolff, M., Hirner, A. Current state of portosystemic shunt surgery. Langenbecks Arch Surg 388, 141–149 (2003). https://doi.org/10.1007/s00423-003-0367-5
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DOI: https://doi.org/10.1007/s00423-003-0367-5