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Role of distal splenorenal shunt for long-term management of variceal bleeding

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Abstract

Distal splenorenal shunt (DSRS) has been studied extensively over the past 25 years to define its role in management of variceal bleeding. The operative technique of the shunt has not changed, but more aggressive attempts at portal-azygos disconnection have been studied for their effect on maintenance of portal perfusion. Control of variceal bleeding is achieved in about 90% of patients. Portal flow to the liver is maintained in >90% of patients with nonalcoholic etiology of portal hypertension and in 50% to 84% of patients with alcoholic cirrhosis depending on the degree of portal-azygos disconnection. Encephalopathy and liver failure do not seem to be accelerated by DSRS but depend on the severity of the underlying liver disease. Reported survival likewise depends on the etiology of portal hypertension and the severity of liver disease: >90% survival can be achieved in portal vein thrombosis and patients with cirrhosis and normal liver function, but 50% to 60% 3-to 5-year survivals are reported for patients with more advanced disease. DSRS offers one treatment modality for management of variceal bleeding that must fit into an overall strategy for these patients. Full evaluation is the key to allow selection of patients for pharmactherapy, sclerotherapy, variceal decompression, or liver transplantation.

Résumé

L'anastomose splénorénale distale (ASRD) a été beaucoup étudiée ces 25 derniéres années afin de définir son intérêt dans le traitement de l'hémorragie par rupture de varices oesophagiennes. La technique opératoire n'a pas changé, mais l'intérêt de la déconnexion porto-azygos a été souligné pour son rôle dans le maintien d'une perfusion portale. Le contrôle de l'hémorragie par rupture des varices est obtenu chez environ 90% des patients. Le débit portal vers le foie est maintenu chez plus de 90% des patients n'ayant pas d'étiologie alcoolique et chez 50–84% des patients ayant une cirrhose alcoolique selon le degré de déconnexion porto-azygos. La survenue d'encéphalopathie ou d'insuffisance hépatique n'est pas accélérée par I'ASRD, mais dépend de la sévérité de la maladie hépatique sous-jacente. La survie dépend également de l'étiologie de l'hypertension portale et de la gravité de la maladie hépatique: Un taux de survie de plus de 90% peut être atteint dans la thrombose portale et dans la cirrhose lorsque la fonction hépatique est conservée, mais des taux de survie à 3 et à 5 ans sont de 50% et de 60% pour les malades ayant une maladie plus avancée. L'ASRD offre une modalité thérapeutique qui doit s'intégrer dans une stratégie globale. Une évaluation complète est la elé de sélection des patients pour les orienter vers la pharmacothérapie, la sclérothérapie, la décompression des varices ou la transplantation.

Resumen

El “shunt” espleno-renal distal (SERD) ha sido estudiado en forma extensa en el curso de los últimos 25 años con miras a definir su papel en el manejo de la hemorragia varicosa. La técnica operatoria de este tipo de “shunt” no ha cambiado, pero se han estudiado procedimentos más agresivos para lograr la desconexión porta-ázigos, en consideración a su efecto sobre el mantenimiento de la perfusión portal. Se logra el control de la hemorragia varicosa en aproximadamente el 90% de los pacientes, se mantiene el flujo hacia el hígado en más del 90% de los pacientes con hipertensión portal de etiología alcohólica, y en un 50–84% de los pacientes con cirrosis alcohólica, dependiendo del grado de desconexión porta-ázigos. La encefalopatía y la falla hepática no parecen ser aceleradas por el SERD, pero dependen de la severidad de la enfermedad hepática subyacente.

La sobrevida, igualmente, depende de la etiología de la HTP y de la gravedad de la enfermedad hepática: se pueden lograr sobrevidas del más del 90% en casos de trombosis de la vena porta y en pacientes con cirrosis y función hepática normal pero se reportan tasas de sobrevida a 3–5 años de apenas 50–60% en los pacientes con enfermedad hepática más avanzada.

El SERD representa una modalidad terapéutica en el manejo de la hemorragia varicosa que debe estar debidamente ubicada dentro de la estrategia global que se adopte en estos pacientes.

La evaluación total y comprensiva es la clave en el proceso de selección de los pacientes para farmacoterapia, escleroterapia, descompresión portal o trasplante hepático.

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Henderson, J.M. Role of distal splenorenal shunt for long-term management of variceal bleeding. World J. Surg. 18, 205–210 (1994). https://doi.org/10.1007/BF00294402

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Keywords

  • Liver Disease
  • Portal Vein
  • Portal Hypertension
  • Portal Vein Thrombosis
  • Variceal Bleeding