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Surgical Treatment: Selective Shunt Surgery

  • Hiroshi YoshidaEmail author
  • Hiroshi Makino
  • Tadashi Yokoyama
  • Hiroshi Maruyama
  • Atsushi Hirakata
  • Junji Ueda
  • Hideyuki Takata
  • Yasuhiro Mamada
  • Nobuhiko Taniai
  • Eiji Uchida
Chapter

Abstract

A number of surgical procedures have been developed for the management of esophagogastric varices. They can be broadry classified into shunting and nonshunting procedures. There are two types of shunting procedure, namely nonselective and selective. Nonselective shunts, such as portacaval or mesocaval shunts, effectively reduce the incidence of variceal bleeding, but they carry a high risk of postoperative encephalopathy as a result of hyperammonemia. Selective shunts such as the distal splenorenal shunt (DSRS) or left gastric venous caval shunt were developed to preserve portal blood flow through the liver and reduce esophagogastric variceal pressure. The DSRS effectively prevents rebleeding, but it still carries a risk of postoperative encephalopathy. In order to prevent both postoperative encephalopathy and bleeding, we have improved the DSRS procedure by additionally performing splenopancreatic disconnection and gastric transection.

In conclusion, endoscopic treatments have been developed recently and are performed widely performed for esophagogastric varices; however, surgery in the form of DSRS is also useful for managing esophagogastric varices in patients with idiopathic portal hypertension in the absence of severe liver pathologies.

Keywords

Distal splenorenal shunt Esophagogastric varices Portal hypertension Selective shunt 

References

  1. 1.
    Yoshida H, Mamada Y, Taniai N, Tajiri T. New methods for the management of esophageal varices. World J Gastroenterol. 2007;13:1641–5.CrossRefGoogle Scholar
  2. 2.
    Yoshida H, Mamada Y, Taniai N, Tajiri T. New methods for the management of gastric varices. World J Gastroenterol. 2006;12:5926–31.CrossRefGoogle Scholar
  3. 3.
    Yoshida H, Mamada Y, Taniai N, et al. Treatment modalities for bleeding esophagogastric varices. J Nippon Med Sch. 2012;79:19–30.CrossRefGoogle Scholar
  4. 4.
    Yoshida H, Mamada Y, Taniai N, Tajiri T. New trends in surgical treatment for portal hypertension. Hepatol Res. 2009;39:1044–51.CrossRefGoogle Scholar
  5. 5.
    Inokuchi K, Kobayashi M, Kusaba A, Ogawa Y, Saku M, Shiizaki T. New selective decompression of esophageal varices. By a left gastric venous-caval shunt. Arch Surg. 1970;100:157–62.CrossRefGoogle Scholar
  6. 6.
    Belghiti J, Grenier P, Nouel O, Nahum H, Fekete F. Long-term loss of Warren’s shunt selectivity. Angiographic demonstration. Arch Surg. 1981;116:1121–4.CrossRefGoogle Scholar
  7. 7.
    Shields R. Small-diameter PTFE portosystemic shunts: portocaval vs mesocaval. HPB Surg. 1998;10:413–4.CrossRefGoogle Scholar
  8. 8.
    Mercado MA, Morales-Linares JC, Granados-Garcia J, Gomez-Mendez TJ, Chan C, Orozco H. Distal splenorenal shunt versus 10-mm low-diameter mesocaval shunt for variceal hemorrhage. Am J Surg. 1996;171:591–5.CrossRefGoogle Scholar
  9. 9.
    Paquet KJ, Lazar A, Koussouris P, et al. Mesocaval interposition shunt with small-diameter polytetrafluoroethylene grafts in sclerotherapy failure. Br J Surg. 1995;82:199–203.CrossRefGoogle Scholar
  10. 10.
    Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967;166:437–55.CrossRefGoogle Scholar
  11. 11.
    Rikkers LF, Rudman D, Galambos JT, et al. A randomized, controlled trial of the distal splenorenal shunt. Ann Surg. 1978;188:271–82.CrossRefGoogle Scholar
  12. 12.
    Tajiri T, Onda M, Yoshida H, et al. Long-term results of modified distal splenorenal shunts for the treatment of esophageal varices. Hepatogastroenterology. 2000;47:720–3.PubMedGoogle Scholar
  13. 13.
    Stipa S, Balducci G, Ziparo V, Stipa F, Lucandri G. Total shunting and elective management of variceal bleeding. World J Surg. 1994;18:200–4.CrossRefGoogle Scholar
  14. 14.
    Klein AS, Fair JH, Cameron JL. Suprarenal mesocaval shunt. Surg Gynecol Obstet. 1991;173:319–22.PubMedGoogle Scholar
  15. 15.
    Sato Y, Hatakeyama K. Left gastric venous caval direct shunt in esophagogastric varices. Hepatogastroenterology. 2002;49:1251–2.PubMedGoogle Scholar
  16. 16.
    Inokuchi K, Beppu K, Koyanagi N, Nagamine K, Hashizume M, Sugimachi K. Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation. Ann Surg. 1984;200:711–7.CrossRefGoogle Scholar
  17. 17.
    Inokuchi K. Selective decompression of esophageal varices by a left gastric venacaval shunt. Surg Annu. 1978;10:215–36.PubMedGoogle Scholar
  18. 18.
    Henderson JM, Warren WD, Millikan WJ, Galloway JR, Kawasaki S, Kutner MH. Distal splenorenal shunt with splenopancreatic disconnection. A 4-year assessment. Ann Surg. 1989;210:332–9; discussion 9–41.CrossRefGoogle Scholar
  19. 19.
    Tajiri T, Onda M, Yoshida H, Mamada Y, Taniai N, Yamashita K. Comparison of the long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices. Hepatogastroenterology. 2000;47:1619–21.PubMedGoogle Scholar
  20. 20.
    Rikkers LF. Definitive therapy for variceal bleeding: a personal view. Am J Surg. 1990;160:80–5.CrossRefGoogle Scholar
  21. 21.
    Inokuchi K, Beppu K, Koyanagi N, et al. Fifteen years’ experience with left gastric venous caval shunt for esophageal varices. World J Surg. 1984;8:716–21.CrossRefGoogle Scholar
  22. 22.
    Inokuchi K, Kobayashi M, Ogawa Y, Saku M, Nagasue N. Results of left gastric vena caval shunt for esophageal varices: analysis of one hundred clinical cases. Surgery. 1975;78:628–36.PubMedGoogle Scholar
  23. 23.
    Inokuchi K. A selective portacaval shunt. Lancet. 1968;2:51–2.CrossRefGoogle Scholar
  24. 24.
    Millikan WJ Jr, Warren WD, Henderson JM, et al. The Emory prospective randomized trial: selective versus nonselective shunt to control variceal bleeding. Ten year follow-up. Ann Surg. 1985;201:712–22.CrossRefGoogle Scholar
  25. 25.
    Rikkers LF, Jin G. Variceal hemorrhage: surgical therapy. Gastroenterol Clin N Am. 1993;22:821–42.Google Scholar
  26. 26.
    Rikkers LF, Sorrell WT, Jin G. Which portosystemic shunt is best? Gastroenterol Clin N Am. 1992;21:179–96.Google Scholar
  27. 27.
    Henderson JM, El Khishen MA, Millikan WJ Jr, Sones PJ, Warren WD. Management of stenosis of distal splenorenal shunt by balloon dilation. Surg Gynecol Obstet. 1983;157:43–8.PubMedGoogle Scholar
  28. 28.
    Warren WD, Millikan WJ Jr, Henderson JM, et al. Splenopancreatic disconnection. Improved selectivity of distal splenorenal shunt. Ann Surg. 1986;204:346–55.CrossRefGoogle Scholar
  29. 29.
    Katoh H, Shimozawa E, Kojima T, Tanabe T. Modified splenorenal shunt with splenopancreatic disconnection. Surgery. 1989;106:920–4.PubMedGoogle Scholar
  30. 30.
    Galambos JT, Warren WD, Rudman D, Smith RB III, Salam AA. Selective and total shunts in the treatment of bleeding varices. A randomized controlled trial. N Engl J Med. 1976;295:1089–95.CrossRefGoogle Scholar
  31. 31.
    Warren WD, Rudman D, Millikan W, Galambos JT, Salam AA, Smith RB III. The metabolic basis of portasystemic encephalopathy and the effect of selective vs nonselective shunts. Ann Surg. 1974;180:573–9.CrossRefGoogle Scholar
  32. 32.
    Yoshida H, Mamada Y, Taniai N, et al. Shunting and nonshunting procedures for the treatment of esophageal varices in patients with idiopathic portal hypertension. Hepatogastroenterology. 2010;57:1139–44.PubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Hiroshi Yoshida
    • 1
    Email author
  • Hiroshi Makino
    • 2
  • Tadashi Yokoyama
    • 2
  • Hiroshi Maruyama
    • 2
  • Atsushi Hirakata
    • 2
  • Junji Ueda
    • 2
  • Hideyuki Takata
    • 2
  • Yasuhiro Mamada
    • 1
  • Nobuhiko Taniai
    • 3
  • Eiji Uchida
    • 1
  1. 1.Department of SurgeryNippon Medical SchoolTokyoJapan
  2. 2.Department of SurgeryNippon Medical School Tama Nagayama HospitalTokyoJapan
  3. 3.Department of SurgeryNippon Medical School Musashi Kosugi HospitalTokyoJapan

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