Sclerotherapy vs. Distal splenorenal shunt in the elective treatment of variceal hemorrhage: A randomized controlled trial

Abstract

One hundred and twelve consecutive Child Class A and B cirrhotic patients were included in a prospective controlled trial aimed at investigating the efficacy and safety of endoscopic sclerotherapy vs. distal splenorenal shunt in the elective treatment of hemorrhage from esophagogastric varices. Fifty-seven patients were randomly allocated to splenorenal shunt and 55 to endoscopic sclerotherapy. Since only 4 of the 55 patients assigned to endoscopic sclerotherapy had to be excluded after randomization and before treatment as compared to 14 of the 57 patients assigned to splenorenal shunt, it is suggested that the applicability of endoscopic sclerotherapy is greater than that of splenorenal shunt. One patient in each group died within 30 days of the procedure and two in the endoscopic sclerotherapy group were lost to follow-up just after discharge. Variceal rebleeding during follow-up occurred in 37.5% (18/48) of patients in the endoscopic sclerotherapy group and in 14.3% of those in the splenorenal shunt group (6/42) (p less than 0.02), whereas hepatic encephalopathy was more frequent in patients submitted to splenorenal shunt (10/42, 24%) than in those treated by endoscopic sclerotherapy (4/48, 8%) (p less than 0.05). The therapeutic modality was the only variable with independent predictive value for rebleeding during follow-up, whereas for hepatic encephalopathy, the therapeutic modality, and the presence of encephalopathy related to the bleeding episode each showed independent predictive value. Early and long-term mortality, did not differ between the two therapeutic groups, being the 2-year survival was 71% for splenorenal shunt and 68% for endoscopic sclerotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Long–Term Effects of Distal Splenorenal Shunt on Hepatic Hemodynamics and Liver Function in Patients With Cirrhosis: Importance of Reversal of Portal Blood Flow

“…The main limitation of the retroperitoneal approach is the impossibility of performing portal-azygos disconnection, which has being considered a very important component of the Warren operation in achieving the goals of maintaining portal perfusion. However, the clinical results obtained with this modified DSRS are quite similar to those reported with the Warren shunt in prospective series or in controlled studies vs. endoscopic sclerotherapy (11,12,25).…”

“…In this technique, the shunt is constructed from a retroperitoneal approach that does not allow portal-azygos disconnection. Nonetheless, the results obtained with this operation in large series of patients are similar to those reported using the standard DSRS (11,12).This hernodynamic study investigated a group of patients who underwent retroperitoneal DSRS more than 2 yr earlier. It assesses whether this operation can help maintain hepatic portal perfusion over a long-term follow-up.…”

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

“…It has become clear that selective shunts lose their selectivity with time, leading to a decline in portal flow toward the liver and thus the inherent risks for hepatic encephalopathy and declining liver function. 21,22 In our series, prograde portal flow was maintained, and there were no treatment failures beyond 3 months after the SDPHG shunt procedure.…”

Bleeding Esophageal Varices: Today’s Role of Portosystemic Shunts

“…In 20-40% of sclerosed patients, the recurrent hem orrhage will be so severe as to require an emergency shunt or cause death (table 1) [3. [58][59][60]. The combined use of sclerotherapy and shunt surgery for failed variceal sclerosis has given excellent results in the Atlanta se ries.…”