A Randomized, Controlled Trial of the Distal Splenorenal Shunt

Abstract

In 1971 a prospective, randomized trial was initiated to determine efficacy of the distal splenorenal shunt in the management of cirrhotic patients who had previously bled from esophageal varices. When entry into the trial was terminated in 1976, 26 patients had received the distal splenorenal shunt (selective) and 29 had undergone a nonselective shunting procedure (18 interposition mesorenal, six interposition mesocaval, and five other nonselective shunts). Three operative deaths occurred in each group. Early postoperative angiography revealed preservation of hepatic portal perfusion in 14 of 16 selective patients (88%), but in only one of 20 nonselective patients (5%; p < .001). Quantitative measures of hepatic function (maximal rate of urea synthesis or MRUS and Child's score) were similar to preoperative values in the selective group but were significantly decreased in nonselective patients on the first postoperative evaluation (p < .001 for MRUS; p < .05 for Child's score). Eighty-seven per cent of selective and 81% of nonselective patients have now been followed for three to six years since surgery. Late postoperative evaluation of 29 survivors (12 selective, 17 nonselective) still shows an advantage to the selective group with respect to MRUS, Child's score, and incidence of hepatopetal portal blood flow, but differences are no longer statistically significant. However, if the seven patients with portal flow (five selective; two nonselective) are compared to the 20 with absent portal flow (seven selective; 13 nonselective), the former group has significantly higher values for MRUS (p < .05) and Child's score (p < .025). No patient with continuing portal perfusion has developed encephalopathy as compared to a 45% incidence of this complication in individuals without portal flow (p < .05). No significant differences between selective and nonselective groups have appeared with respect to total cumulative mortality (ten selective; 38%; eight nonselective, 28%), shunt occlusion (two selective, 10%; five nonselective, 18%), or recurrent variceal hemorrhage (one selective, 4%; two nonselective, 8%). Overall, significantly fewer selective patients have developed postoperative encephalopathy (three selective, 12%; 15 nonselective, 52%; p < .001). Therefore, we conclude that the distal splenorenal shunt, especially when its objective of maintaining hepatic portal perfusion is achieved, results in significantly less morbidity than nonselective shunting procedures.

Venous drainage from the tail of the pancreas to the lienal vein and its relationship with the distal splenorenal shunt selectivity

“…Among them, the distal splenorenal shunt is considered by some authors as a safe, lasting and effective procedure in the control of the hemorrhagic recurrence. It has lesser morbility, lesser loss of portal flow, lesser incidence of portal-systemic encephalopathy, better prognosis and does not compromise the future accomplishment of hepatic transplant, and it also delays the need for it [6][7][8] .…”

“…The distal splenorenal shunt was widely accepted and many studies have been published demonstrating its viability, feasibility, effectiveness, indications, technical difficulties, hemodynamics effects, complications and results [6][7][8][9][10][11][12] .…”

The ECK fistula in animals and humans

“…The claim that hepatopetal portal blood flow is partly retained after such side-to-side procedures has been shown to be untrue if the shunts are of adequate size. 201,208,[216][217][218][219][220][221][222][223][224] Thus, the complications of hepatic failure, including encephalopathy, after the various sideto-side shunts in controlled series have been as common as after end-to-side portacaval shunts. 191,221,225 The mesocaval H-graft operation of Drapanas 226 is no exception, and in addition, the prosthesis used in this procedure has had an exorbitant rate of late thrombosis.…”

“…222,[232][233][234] As demonstrated by Maillard et al, 232 the distal splenorenal shunt carries a high flow that is driven by the splenic arterial input. Undoubtedly this protects the splenorenal anastomosis from thrombosis, but it also gives the selective shunt circuit some of the features of a thirsty and larcenous arteriovenous fistula.…”

“…Undoubtedly this protects the splenorenal anastomosis from thrombosis, but it also gives the selective shunt circuit some of the features of a thirsty and larcenous arteriovenous fistula. However, the consequent loss of portal hepatic perfusion is so gradual after distal splenorenal shunt 222,235 that there is time (months or years) for compensatory physiologic adjustments, including augmentation of the hepatic arterial input. If a high intestinal venous pressure is maintained throughout this time, the absorption of ammonia and other so-called cerebral toxins should be lower than after completely diverting portacaval shunt (see earlier discussion).…”