Dig Dis 1992;10(suppl 1): 74-83
Antonino Cavallari Emilio De Raffele Roberto Bellusci Romano Bragaglia Bruno Nardo Marco Vivarelli Alfonso Recordare
Bleeding Esophageal Varices: Today's Role of Portosystemic Shunts
Istituto di Clinica Chirurgica II c Cattcdra di Anatomía Chirurgica, Université di Bologna, Bologna, Italia
Abstract
Portosystemic shunt Portal hypertension Hepatic cirrhosis Hepatoportal hemodynamics
Current options in the management of bleeding esophageal varices and portal hyper tension are emergency or elective injection sclerotherapy, portosystemic shunts, mainly after failure of sclerotherapy, and liver trans plantation, an emerging treatment for both portal hypertension and the underlying liver disease. In recent years, interest in procedures such as portoazygous devascularization and esophageal transection has subsided. Pharma
cological therapy as the sole mode of treat ment is still controversial and at present should be considered complementary to other management modalities [ 1]. Improved results in clinical liver trans plantation have opened up new frontiers in the field of portal hypertension although only selected cirrhotics with bleeding gastroesoph ageal varices may benefit. Bearing this in mind, the management of bleeding esopha-
Anionino Cavallari. MD Professor of Surgical Anatomy Istituto di Clinica Chirurgica 11 Policlinico S. Orsola Via Massarenti. 9.1-40138. Bologna (Italy)
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KeyWords
Emergency portosystemic shunting has once again become a significant option in the management of bleeding esophageal varices and portal hypertension. The decision to perform such a shunt and the choice of shunt procedure requires a rational assessment of the pathophysiology and hepatoportal hemody namics of the patient’s disease and the manner in which it is anticipated that the selected procedure may alter portal flow. Since shunt surgery may interfere with hepatic transplanta tion, the patient’s suitability as a future transplant recipient must also be considered in choosing a shunt procedure. Fur thermore, if a shunt is to be performed on an emergency basis to control acute bleeding, this procedure must be done before the patient’s condition deteriorates sufficiently to represent a prohibitive surgical risk.
10], However these observations are scanty, and the fact than no randomized study has ever fully demonstrated a significantly longer survival rate after a portosystemic shunt than after sclerotherapy [31]. selective shunt [11. 12], or esophageal transection [13] should be stressed. In conclusion, the outcome in cir rhotics submitted to portosystemic shunting is extremely variable. It is therefore necessary to review the various hemodynamic parame ters which may play a role in the onset of encephalopathy and liver failure after sur gery. The severe architectural derangements commonly observed in cirrhotic livers pro duce marked changes in hepatic microcircula tion [14] resulting in a significant blood flow reduction within the sinusoids. Collagen de Hepatoportai Hemodynamics and posits within sinusoids and the space of Disse Portosystemic Shunts produce a progressive capillarization of sinu Classic experiments have shown that non soids [15. 16] and the formation of extensive cirrhotic animals submitted to portacaval anastomoses between afferent and efferent shunt develop progressive liver failure. In a vessels of the liver, with an increasing impair similar way. patients with portal hypertension ment of exchange between sinusoidal blood but no parenchymal damage who undergo and hepatocytes. Two patterns of intrahepatic portosystemic connection show a tendency to shunting have been described: the intra-acimanifest encephalopathy. A randomized clin nar intrahepatic shunts, found early in alco ical trial by Da Silva et al. [6] in patients with holic cirrhosis and much later in non-alco hepatosplenic schistosomiasis and bleeding holic liver disease [17], and septal or extraaciesophageal varices has shown that encepha nar intrahepatic shunts [14, 18] characteristic lopathy is significantly more frequent and of post-hepatic cirrhosis [19] but quite com severe after proximal splenorenal shunt mon in very advanced cirrhosis of any etio (26%) than after selective shunt (7%) while no logy. The degree of intrahepatic shunting pro encephalopathy was observed after esophago gastric dcvascularization with splenectomy gresses with the liver disease, with a peak in the very advanced forms [19], where shunts [ 6], In cirrhotics, liver damage and extensive have also been clearly displayed by percuta intrahepatic hemodynamic derangement pre neous transhcpatic portography [20]. On the sent a completely different pathophysiologi other hand, intrahepatic shunting seems to be cal pattern. It has been reported that in pa well correlated with the parallel reduction in tients with total portosystemic shunts, angio portal sinusoidal blood flow observed in the graphic or surgical occlusion of the shunt is advanced stages of cirrhosis [21], These effective in restoring hepatopedal flow and changes in the microcirculation, along with reversing incapacitating encephalopathy [7- the presence of the extrahepatic shunts, con
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geal varices should not preclude future liver transplantation in patients who are or maybecome transplant candidates. This is why injection sclerotherapy is at present consid ered the best treatment in most patients with variceal hemorrhage. However, recent reports show renewed in terest in portosystemic shunting [2-5]. The portacaval shunt is gaining ground again. However, the decision to perform a shunt should not rely on an emotional drive to sal vage a patient, as often happens, but should be based on a rational assessment of various parameters, especially hcpatoportal hemody namics.
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venous pressure gradients in the prevention of encephalopathy after portosystemic shunting has been questioned by others [33]. The hepatic artery plays a very important role in keeping a high total blood supply to the cirrhotic liver, because of the reciprocal rela tionship between hepatic arterial and portal blood flow. In cirrhotics, the presence of a hypertrophied hepatic artery is a common finding [34, 35] generally associated with a better prognosis [36]. After total portosys temic shunting, hepatic artery flow frequently increases. The magnitude of this increase has been directly related to post-shunt morbidity, mortality, and encephalopathy in experimen tal and clinical studies [32, 35, 37], Increased arterial diameter is also found after selective splenorenal shunting [26, 38] and some au thors maintain that the augmented arterial blood supply to the liver might be the most important protective factor against encepha lopathy after selective shunting [38, 39], Nev ertheless, in a recent study, Rypins et al. [40] failed to demonstrate a significant increase in hepatic arterial perfusion after interposition of a small-diameter portacaval H-graft even though an elevated arterial blood supply ap peared to protect against encephalopathy and liver failure in shunted patients with retro grade portal flow [40]. The importance of hepatic portal perfu sion in cirrhotics has not been widely investi gated. mainly because spontaneous inversion of portal flow is rare [41], although probably underestimated [42], In recent studies, se lective portal vein angiography has suggested that the direction of superior mesenteric ve nous flow might play an important role in maintaining liver function, since encephalop athy has been significantly more frequent in patients with large spontaneous gastrorenal and splenorenal shunts with mainly hepatofugal mesenteric venous flow [43],
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tribute to the functional failure of the cir rhotic parenchyma, with a reduced first-pass removal of hormones and metabolites from the splanchnic venous district and a decrease in hepatic clearance of substances from the systemic circulation [17, 22], The complex relationship between deranged microcircula tion, spontaneous intra- and extrahepatic por tosystemic shunting and clinical outcome of patients with a surgical shunt has not yet been fully investigated. Experimental and clinical data suggest that encephalopathy arising after total portal de compression might be, in part, due to the sud den decrease in mesenteric venous hyperten sion. The hyperdynamic, low-pressure portal flow into the systemic circulation causes an augmented intestinal absorption of nitroge nous substances which overwhelms the detox ifying capacity of the cirrhotic liver [23, 24], The selective shunt separates the gastrosplcnic and the portomesenteric venous districts. This selectively decompresses the gastro esophageal varices even in the presence of a high portal pressure which causes prograde portal flow [25], Although the portal perfu sion of the liver is progressively lost, the per sistent mesenteric venous hypertension [26, 27] should result in a lower incidence of post operative encephalopathy [23, 28]. The same mechanism has been advocated to explain the lower encephalopathy rate observed after cali brated portacaval anastomoses in some noncontrolled studies [29, 30], The maintenance of a pressure gradient between the portal and the caval side of the anastomosis has been clearly demonstrated in most patients even when reversal of portal flow develops [31]. Moreover, a definite relationship between mesenteric venous hypertension and in creased hepatic arterial blood flow after por tacaval shunting has recently been demon strated in animals [32], However, controversy is still lively since the role of high mesenteric
portal hypertension without reversing portal flow in most patients. After shunting with 10 and 8 mm H-grafts and portal collateral abla tion. prograde portal perfusion was observed in 46 and 82% of patients respectively, with no significant change in flow patterns at fol low-up studies [52], The incidence of enceph alopathy after surgery was 35% in patients with reversed portal streams, compared with 9% in patients with hepatic portal perfusion [52], The survival rates after partial shunt were also significantly better in cirrhosis in whom prograde flow was maintained over time [53].
Portosystemic Shunts in Variceal Bleeding
Emergency endoscopic sclerotherapy is currently the treatment of choice for actively bleeding varices. One or two sessions achieve definite control of hemorrhage in over 90% of patients [5], Nevertheless, recent studies have renewed interest in emergency portosystemic shunts. The elevated perioperative mortality, especially when surgery is performed as a 'last resort', actually does not differ much from that of conservative medical treatment in this setting [54. 55]. In bleeding cirrhotics, the severity of the underlying liver disease seems to be the main factor influencing prognosis. It is highly unlikely that patients with severe liver failure will benefit much from any type of treatment [3,4], We would like to stress the importance of an early shunt procedure whenever sclero therapy fails, before the patient's condition deteriorates to such an extent that surgery would have a prohibitive risk of mortality [4], All patients whose variceal bleeding has not stopped after one or two sessions of sclero therapy should be referred to the surgeon, to avoid the 65-90% mortality rate reported for
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Total portosystemic shunts cause radical changes in hepatic hemodynamics, the most important being complete diversion of portal flow from the liver [44] which is commonly considered the key factor in progressive he patic failure. The importance of maintaining hepatopedal portal perfusion after distal splenorenal shunt has not been fully clarified. Due to the formation of new collaterals [45] and the dila tation of the anastomosis [26. 46], the distal splenorenal shunt loses its selectivity in most patients [26. 38. 47. 48], especially those with alcoholic cirrhosis [49], The portal vein diam eter decreases progressively and so does its flow, up to almost complete diversion of the superior mesenteric venous blood toward the shunt [39. 47] or to portal vein thrombosis [50], However, the long-term outcome of pa tients with distal splenorenal shunt and hepatopedal or hepatofugal portal blood flow has never been fully assessed, since there are no data on the incidence of encephalopathy, liver failure and mortality in these two patient pop ulations. Therefore the association between portal flow inversion after selective shunt and the onset of encephalopathy remains mainly circumstantial. This is why some authors be lieve that the lower incidence of encephalopa thy and liver failure after selective shunts might be related to factors other than mainte nance of prograde portal perfusion, such as persistent mesenteric venous hypertension [23, 28], increased hepatic arterial perfusion [26, 39], or the gradual, rather than abrupt, diversion of blood away from the liver [47, 51]. The introduction of the small-diameter (810 mm) portacaval H-graft shunt, first de scribed by Sarfeh et al. [52] has facilitated evaluation of the possible role of hepatic por tal perfusion after portosystemic shunting. This type of shunt creates a partial portal decompression, since it uniformly reduces
Table 1. Prospective randomized trials comparing portosystemic shunts (PSS) and endoscopic sclerotherapy (EST) in the treatment of bleeding esophageal varices
Reference
Patients
Rebleeding
Severe rebleeding after EST
PSS
EST
PSS
EST
patients
mortality operated without operation
sur vivors
Warren et ai. [60] 1986
35 (DSRS)
36
1(3%)
19(53%)*
11 (36%)
1
I01
9
Teres et al. [59] 1987
42 (DSRS)
48
6(14%) 18(37%)*
9(19%)
4
3:
3
Rikkers et al. [58] 1987
23 (DSRS) 4 (TS)
30
5(19%) 17(57%)*
10(33%)
6
43
2
Cello et al. [3] 1987
325 (PCS)
325
0
7 (40%)
0
74
6
DSRS = distal splenorenal shunt; TS = total shunt: PCS = portacaval shunt. * The difference was statistically significant. 7 DSRS. 2 TS, I devascularization + splenectomy. 2 PCS. 1 esophageal transection. 2 PCS, I mesocaval interposition shunt. 1 devascularization + splenectomy. 3 DSRS. 3 PCS, I splenectomy. All patients were Child C.
Child B and C patients after sclerotherapy failure [56], The portacaval shunt may be the best option for patients unfit for liver trans plantation. since mesocaval and splenorenal shunts have exhibited a higher rate of throm bosis in follow-up studies. Although injection sclerotherapy is cur rently the most widespread mode of treat ment for patients who have previously bled from varices, sclerotherapy has not signifi cantly improved long-term survival com pared with medical treatment in four of the five controlled trials reported in the literature [5. 57], Careful follow-up is required because of the high rate of recurrent hemorrhage [57] and because varices recur within 1 or 2 years after eradication in most patients [5], For this
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reason, sclerotherapy is likely to be less useful in patients who live far from specialized cen ters or in those who show a low treatment compliance [58]. Early referral to surgical units should also be considered for patients who have experienced repeated bleeding dur ing sclerosing therapy and for those cirrhotics whose varices are difficult to eradicate. In 2040% of sclerosed patients, the recurrent hem orrhage will be so severe as to require an emergency shunt or cause death (table 1) [3. 58-60]. The combined use of sclerotherapy and shunt surgery for failed variceal sclerosis has given excellent results in the Atlanta se ries. significantly better than the selective splenorenal shunt alone [60].
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1 2 3 4 5
12(75)*
a
b Fig. 1. Pulsed Doppler of an intrahepatic portal branch in 2 cirrhotic patients with portal hypertension and esophageal bleeding varices, a Slow prograde portal venous flow (stagnant flow), b The Doppler shift below the zero line indicates a reversed portal venous flow.
The recently introduced small-diameter portacaval interposition shunt seems to be quite promising. The procedure is easy to carry out. and in most cases it maintains a hepatopedal flow over time [52], Moreover, in some non-controlled studies, this tech nique results in less encephalopathy and lon ger survival rates than total shunts [40. 53], Nevertheless, the high rate of post-operative thrombosis [52] requires further investigation to better evaluate the technical limits and the long-term hemodynamics of this procedure.
Portosystemic Shunts and Liver Transplantation
The onset of variceal bleeding refractory to conventional therapies in patients with ad vanced liver disease constitutes a well-defined indication for liver transplantation (fig. 2) About 30-50% of liver transplant candidates have a history of bleeding esophageal varices and about 10-15% may require portosys temic shunt procedures to control variceal
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For those cirrhotics who need surgery, the choice of the ideal portosystemic shunt is dif ficult. and we believe that no single procedure can be applied to all cases. A total diversion is indicated in patients with stagnant or re versed portal flow at angiography or echodoppler examination (fig. I). This event is quite rare in unselccted cirrhotics, but it has been demonstrated at angiography in 10-20% of variceal bleeders considered for a shunt [12.61.62], Some authors maintain that the etiology of the liver disease should be a major discrimi nating factor in the choice of shunt. A se lective shunt is usually reserved for posthepatic cirrhotics, while in patients with alco holic liver disease the selective shunt does not seem to give better results than a total shunt [49, 63], When the three randomized trials comparing selective and portacaval shunts in post-alcoholic cirrhotics are considered to gether. patients with total shunts had a signifi cantly lower incidence of rebleeding episodes, with comparable encephalopathy and sur vival rates [12, 64, 65],
bleeding before arriving at transplantation [66. 67], Liver transplantation should be consid ered for cirrhotics under 55-65 years of age with advanced liver disease and a history' of variceal hemorrhage, but it may eventually become the ultimate management of today's younger patients with bleeding varices and well-compensated cirrhosis. In all of these cir rhotics. the treatment of esophago-gastric hemorrhage should not hamper a subsequent liver transplant. In this perspective, endo scopic sclerotherapy should be considered the procedure of choice, reserving portosystemic shunting for when sclerotherapy fails [6668], If a shunt procedure is required for those cirrhotics awaiting a liver transplant in the
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near future, a mesocaval shunt is advisable since this shunt avoids dissection of the porta hepatis and can be easily dismantled during the liver transplant [66. 68]. For those pa tients in whom a longer compensation of the liver disease is foreseen, a selective shunt may represent the best option because of the lower incidence of encephalopathy and liver failure. In this case too, the anastomosis is con structed far away from the hepatic hilum. but an extensive devascularization, recently ad vised by some authors [48, 69], may increase the difficulty of transplant hepatectomv [66]. The shunt closure, to ensure a normal portal perfusion to the graft, may be extremely diffi cult because of dense adhesions [70]: the UCLA group instead maintains that the shunt does not need to be dismantled [68]. The
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Fig. 2. Portosystemic shunts performed at our institution from 1984 to August 1989. compared with the increasing number of liver transplanta tions for hepatic cirrhosis and severe portal hypertension (OLT). A pro gressive reduction of distal splenorenal shunts (DSRS) and elective total shunts (ETS) can be observed, while the number of emergency total shunts (EmTS) remained constant over time.
small-diameter portacaval H-graft shunt may represent a valid alternative for cirrhotics with bleeding esophageal varices who are or may become transplant candidates, since it facilitates dissection of porta hepatis and can be easily removed at the end of the trans plant.
In conclusion, we would like to point out the renewed interest in portosystemic shunts, almost abandoned in the last decade. At present the portacaval shunt may still repre sent in some selected cases, the procedure of choice to prevent recurrent hemorrhage from esophageal varices.
References
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64 Langer B. Taylor BR. MacKenzie PR. et al: Further report of a pro spective randomized trial compar ing distal splenorenal shunt with end-to-side portacaval shunt. Gas troenterology 1985.88:424-429. 65 Harley HAJ. Morgan T. Redcker AG. et al: Results of a randomized trial of end-lo-side portacaval shunt and distal splenorenal shunt in alco holic liver disease and variceal bleeding. Gastroenterology 1986:91: 802-809.
Antonino Cavallari Emilio De Raffele Roberto Bellusci Romano Bragaglia Bruno Nardo Marco Vivarelli Alfonso Recordare
Bleeding Esophageal Varices: Today's Role of Portosystemic Shunts
Istituto di Clinica Chirurgica II c Cattcdra di Anatomía Chirurgica, Université di Bologna, Bologna, Italia
Abstract
Portosystemic shunt Portal hypertension Hepatic cirrhosis Hepatoportal hemodynamics
Current options in the management of bleeding esophageal varices and portal hyper tension are emergency or elective injection sclerotherapy, portosystemic shunts, mainly after failure of sclerotherapy, and liver trans plantation, an emerging treatment for both portal hypertension and the underlying liver disease. In recent years, interest in procedures such as portoazygous devascularization and esophageal transection has subsided. Pharma
cological therapy as the sole mode of treat ment is still controversial and at present should be considered complementary to other management modalities [ 1]. Improved results in clinical liver trans plantation have opened up new frontiers in the field of portal hypertension although only selected cirrhotics with bleeding gastroesoph ageal varices may benefit. Bearing this in mind, the management of bleeding esopha-
Anionino Cavallari. MD Professor of Surgical Anatomy Istituto di Clinica Chirurgica 11 Policlinico S. Orsola Via Massarenti. 9.1-40138. Bologna (Italy)
© 1992 S. Kargcr AG. Basel 0257-2753/92/ 0107-0074S2.75/0
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KeyWords
Emergency portosystemic shunting has once again become a significant option in the management of bleeding esophageal varices and portal hypertension. The decision to perform such a shunt and the choice of shunt procedure requires a rational assessment of the pathophysiology and hepatoportal hemody namics of the patient’s disease and the manner in which it is anticipated that the selected procedure may alter portal flow. Since shunt surgery may interfere with hepatic transplanta tion, the patient’s suitability as a future transplant recipient must also be considered in choosing a shunt procedure. Fur thermore, if a shunt is to be performed on an emergency basis to control acute bleeding, this procedure must be done before the patient’s condition deteriorates sufficiently to represent a prohibitive surgical risk.
10], However these observations are scanty, and the fact than no randomized study has ever fully demonstrated a significantly longer survival rate after a portosystemic shunt than after sclerotherapy [31]. selective shunt [11. 12], or esophageal transection [13] should be stressed. In conclusion, the outcome in cir rhotics submitted to portosystemic shunting is extremely variable. It is therefore necessary to review the various hemodynamic parame ters which may play a role in the onset of encephalopathy and liver failure after sur gery. The severe architectural derangements commonly observed in cirrhotic livers pro duce marked changes in hepatic microcircula tion [14] resulting in a significant blood flow reduction within the sinusoids. Collagen de Hepatoportai Hemodynamics and posits within sinusoids and the space of Disse Portosystemic Shunts produce a progressive capillarization of sinu Classic experiments have shown that non soids [15. 16] and the formation of extensive cirrhotic animals submitted to portacaval anastomoses between afferent and efferent shunt develop progressive liver failure. In a vessels of the liver, with an increasing impair similar way. patients with portal hypertension ment of exchange between sinusoidal blood but no parenchymal damage who undergo and hepatocytes. Two patterns of intrahepatic portosystemic connection show a tendency to shunting have been described: the intra-acimanifest encephalopathy. A randomized clin nar intrahepatic shunts, found early in alco ical trial by Da Silva et al. [6] in patients with holic cirrhosis and much later in non-alco hepatosplenic schistosomiasis and bleeding holic liver disease [17], and septal or extraaciesophageal varices has shown that encepha nar intrahepatic shunts [14, 18] characteristic lopathy is significantly more frequent and of post-hepatic cirrhosis [19] but quite com severe after proximal splenorenal shunt mon in very advanced cirrhosis of any etio (26%) than after selective shunt (7%) while no logy. The degree of intrahepatic shunting pro encephalopathy was observed after esophago gastric dcvascularization with splenectomy gresses with the liver disease, with a peak in the very advanced forms [19], where shunts [ 6], In cirrhotics, liver damage and extensive have also been clearly displayed by percuta intrahepatic hemodynamic derangement pre neous transhcpatic portography [20]. On the sent a completely different pathophysiologi other hand, intrahepatic shunting seems to be cal pattern. It has been reported that in pa well correlated with the parallel reduction in tients with total portosystemic shunts, angio portal sinusoidal blood flow observed in the graphic or surgical occlusion of the shunt is advanced stages of cirrhosis [21], These effective in restoring hepatopedal flow and changes in the microcirculation, along with reversing incapacitating encephalopathy [7- the presence of the extrahepatic shunts, con
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geal varices should not preclude future liver transplantation in patients who are or maybecome transplant candidates. This is why injection sclerotherapy is at present consid ered the best treatment in most patients with variceal hemorrhage. However, recent reports show renewed in terest in portosystemic shunting [2-5]. The portacaval shunt is gaining ground again. However, the decision to perform a shunt should not rely on an emotional drive to sal vage a patient, as often happens, but should be based on a rational assessment of various parameters, especially hcpatoportal hemody namics.
76
venous pressure gradients in the prevention of encephalopathy after portosystemic shunting has been questioned by others [33]. The hepatic artery plays a very important role in keeping a high total blood supply to the cirrhotic liver, because of the reciprocal rela tionship between hepatic arterial and portal blood flow. In cirrhotics, the presence of a hypertrophied hepatic artery is a common finding [34, 35] generally associated with a better prognosis [36]. After total portosys temic shunting, hepatic artery flow frequently increases. The magnitude of this increase has been directly related to post-shunt morbidity, mortality, and encephalopathy in experimen tal and clinical studies [32, 35, 37], Increased arterial diameter is also found after selective splenorenal shunting [26, 38] and some au thors maintain that the augmented arterial blood supply to the liver might be the most important protective factor against encepha lopathy after selective shunting [38, 39], Nev ertheless, in a recent study, Rypins et al. [40] failed to demonstrate a significant increase in hepatic arterial perfusion after interposition of a small-diameter portacaval H-graft even though an elevated arterial blood supply ap peared to protect against encephalopathy and liver failure in shunted patients with retro grade portal flow [40]. The importance of hepatic portal perfu sion in cirrhotics has not been widely investi gated. mainly because spontaneous inversion of portal flow is rare [41], although probably underestimated [42], In recent studies, se lective portal vein angiography has suggested that the direction of superior mesenteric ve nous flow might play an important role in maintaining liver function, since encephalop athy has been significantly more frequent in patients with large spontaneous gastrorenal and splenorenal shunts with mainly hepatofugal mesenteric venous flow [43],
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tribute to the functional failure of the cir rhotic parenchyma, with a reduced first-pass removal of hormones and metabolites from the splanchnic venous district and a decrease in hepatic clearance of substances from the systemic circulation [17, 22], The complex relationship between deranged microcircula tion, spontaneous intra- and extrahepatic por tosystemic shunting and clinical outcome of patients with a surgical shunt has not yet been fully investigated. Experimental and clinical data suggest that encephalopathy arising after total portal de compression might be, in part, due to the sud den decrease in mesenteric venous hyperten sion. The hyperdynamic, low-pressure portal flow into the systemic circulation causes an augmented intestinal absorption of nitroge nous substances which overwhelms the detox ifying capacity of the cirrhotic liver [23, 24], The selective shunt separates the gastrosplcnic and the portomesenteric venous districts. This selectively decompresses the gastro esophageal varices even in the presence of a high portal pressure which causes prograde portal flow [25], Although the portal perfu sion of the liver is progressively lost, the per sistent mesenteric venous hypertension [26, 27] should result in a lower incidence of post operative encephalopathy [23, 28]. The same mechanism has been advocated to explain the lower encephalopathy rate observed after cali brated portacaval anastomoses in some noncontrolled studies [29, 30], The maintenance of a pressure gradient between the portal and the caval side of the anastomosis has been clearly demonstrated in most patients even when reversal of portal flow develops [31]. Moreover, a definite relationship between mesenteric venous hypertension and in creased hepatic arterial blood flow after por tacaval shunting has recently been demon strated in animals [32], However, controversy is still lively since the role of high mesenteric
portal hypertension without reversing portal flow in most patients. After shunting with 10 and 8 mm H-grafts and portal collateral abla tion. prograde portal perfusion was observed in 46 and 82% of patients respectively, with no significant change in flow patterns at fol low-up studies [52], The incidence of enceph alopathy after surgery was 35% in patients with reversed portal streams, compared with 9% in patients with hepatic portal perfusion [52], The survival rates after partial shunt were also significantly better in cirrhosis in whom prograde flow was maintained over time [53].
Portosystemic Shunts in Variceal Bleeding
Emergency endoscopic sclerotherapy is currently the treatment of choice for actively bleeding varices. One or two sessions achieve definite control of hemorrhage in over 90% of patients [5], Nevertheless, recent studies have renewed interest in emergency portosystemic shunts. The elevated perioperative mortality, especially when surgery is performed as a 'last resort', actually does not differ much from that of conservative medical treatment in this setting [54. 55]. In bleeding cirrhotics, the severity of the underlying liver disease seems to be the main factor influencing prognosis. It is highly unlikely that patients with severe liver failure will benefit much from any type of treatment [3,4], We would like to stress the importance of an early shunt procedure whenever sclero therapy fails, before the patient's condition deteriorates to such an extent that surgery would have a prohibitive risk of mortality [4], All patients whose variceal bleeding has not stopped after one or two sessions of sclero therapy should be referred to the surgeon, to avoid the 65-90% mortality rate reported for
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Total portosystemic shunts cause radical changes in hepatic hemodynamics, the most important being complete diversion of portal flow from the liver [44] which is commonly considered the key factor in progressive he patic failure. The importance of maintaining hepatopedal portal perfusion after distal splenorenal shunt has not been fully clarified. Due to the formation of new collaterals [45] and the dila tation of the anastomosis [26. 46], the distal splenorenal shunt loses its selectivity in most patients [26. 38. 47. 48], especially those with alcoholic cirrhosis [49], The portal vein diam eter decreases progressively and so does its flow, up to almost complete diversion of the superior mesenteric venous blood toward the shunt [39. 47] or to portal vein thrombosis [50], However, the long-term outcome of pa tients with distal splenorenal shunt and hepatopedal or hepatofugal portal blood flow has never been fully assessed, since there are no data on the incidence of encephalopathy, liver failure and mortality in these two patient pop ulations. Therefore the association between portal flow inversion after selective shunt and the onset of encephalopathy remains mainly circumstantial. This is why some authors be lieve that the lower incidence of encephalopa thy and liver failure after selective shunts might be related to factors other than mainte nance of prograde portal perfusion, such as persistent mesenteric venous hypertension [23, 28], increased hepatic arterial perfusion [26, 39], or the gradual, rather than abrupt, diversion of blood away from the liver [47, 51]. The introduction of the small-diameter (810 mm) portacaval H-graft shunt, first de scribed by Sarfeh et al. [52] has facilitated evaluation of the possible role of hepatic por tal perfusion after portosystemic shunting. This type of shunt creates a partial portal decompression, since it uniformly reduces
Table 1. Prospective randomized trials comparing portosystemic shunts (PSS) and endoscopic sclerotherapy (EST) in the treatment of bleeding esophageal varices
Reference
Patients
Rebleeding
Severe rebleeding after EST
PSS
EST
PSS
EST
patients
mortality operated without operation
sur vivors
Warren et ai. [60] 1986
35 (DSRS)
36
1(3%)
19(53%)*
11 (36%)
1
I01
9
Teres et al. [59] 1987
42 (DSRS)
48
6(14%) 18(37%)*
9(19%)
4
3:
3
Rikkers et al. [58] 1987
23 (DSRS) 4 (TS)
30
5(19%) 17(57%)*
10(33%)
6
43
2
Cello et al. [3] 1987
325 (PCS)
325
0
7 (40%)
0
74
6
DSRS = distal splenorenal shunt; TS = total shunt: PCS = portacaval shunt. * The difference was statistically significant. 7 DSRS. 2 TS, I devascularization + splenectomy. 2 PCS. 1 esophageal transection. 2 PCS, I mesocaval interposition shunt. 1 devascularization + splenectomy. 3 DSRS. 3 PCS, I splenectomy. All patients were Child C.
Child B and C patients after sclerotherapy failure [56], The portacaval shunt may be the best option for patients unfit for liver trans plantation. since mesocaval and splenorenal shunts have exhibited a higher rate of throm bosis in follow-up studies. Although injection sclerotherapy is cur rently the most widespread mode of treat ment for patients who have previously bled from varices, sclerotherapy has not signifi cantly improved long-term survival com pared with medical treatment in four of the five controlled trials reported in the literature [5. 57], Careful follow-up is required because of the high rate of recurrent hemorrhage [57] and because varices recur within 1 or 2 years after eradication in most patients [5], For this
78
reason, sclerotherapy is likely to be less useful in patients who live far from specialized cen ters or in those who show a low treatment compliance [58]. Early referral to surgical units should also be considered for patients who have experienced repeated bleeding dur ing sclerosing therapy and for those cirrhotics whose varices are difficult to eradicate. In 2040% of sclerosed patients, the recurrent hem orrhage will be so severe as to require an emergency shunt or cause death (table 1) [3. 58-60]. The combined use of sclerotherapy and shunt surgery for failed variceal sclerosis has given excellent results in the Atlanta se ries. significantly better than the selective splenorenal shunt alone [60].
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1 2 3 4 5
12(75)*
a
b Fig. 1. Pulsed Doppler of an intrahepatic portal branch in 2 cirrhotic patients with portal hypertension and esophageal bleeding varices, a Slow prograde portal venous flow (stagnant flow), b The Doppler shift below the zero line indicates a reversed portal venous flow.
The recently introduced small-diameter portacaval interposition shunt seems to be quite promising. The procedure is easy to carry out. and in most cases it maintains a hepatopedal flow over time [52], Moreover, in some non-controlled studies, this tech nique results in less encephalopathy and lon ger survival rates than total shunts [40. 53], Nevertheless, the high rate of post-operative thrombosis [52] requires further investigation to better evaluate the technical limits and the long-term hemodynamics of this procedure.
Portosystemic Shunts and Liver Transplantation
The onset of variceal bleeding refractory to conventional therapies in patients with ad vanced liver disease constitutes a well-defined indication for liver transplantation (fig. 2) About 30-50% of liver transplant candidates have a history of bleeding esophageal varices and about 10-15% may require portosys temic shunt procedures to control variceal
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For those cirrhotics who need surgery, the choice of the ideal portosystemic shunt is dif ficult. and we believe that no single procedure can be applied to all cases. A total diversion is indicated in patients with stagnant or re versed portal flow at angiography or echodoppler examination (fig. I). This event is quite rare in unselccted cirrhotics, but it has been demonstrated at angiography in 10-20% of variceal bleeders considered for a shunt [12.61.62], Some authors maintain that the etiology of the liver disease should be a major discrimi nating factor in the choice of shunt. A se lective shunt is usually reserved for posthepatic cirrhotics, while in patients with alco holic liver disease the selective shunt does not seem to give better results than a total shunt [49, 63], When the three randomized trials comparing selective and portacaval shunts in post-alcoholic cirrhotics are considered to gether. patients with total shunts had a signifi cantly lower incidence of rebleeding episodes, with comparable encephalopathy and sur vival rates [12, 64, 65],
bleeding before arriving at transplantation [66. 67], Liver transplantation should be consid ered for cirrhotics under 55-65 years of age with advanced liver disease and a history' of variceal hemorrhage, but it may eventually become the ultimate management of today's younger patients with bleeding varices and well-compensated cirrhosis. In all of these cir rhotics. the treatment of esophago-gastric hemorrhage should not hamper a subsequent liver transplant. In this perspective, endo scopic sclerotherapy should be considered the procedure of choice, reserving portosystemic shunting for when sclerotherapy fails [6668], If a shunt procedure is required for those cirrhotics awaiting a liver transplant in the
80
near future, a mesocaval shunt is advisable since this shunt avoids dissection of the porta hepatis and can be easily dismantled during the liver transplant [66. 68]. For those pa tients in whom a longer compensation of the liver disease is foreseen, a selective shunt may represent the best option because of the lower incidence of encephalopathy and liver failure. In this case too, the anastomosis is con structed far away from the hepatic hilum. but an extensive devascularization, recently ad vised by some authors [48, 69], may increase the difficulty of transplant hepatectomv [66]. The shunt closure, to ensure a normal portal perfusion to the graft, may be extremely diffi cult because of dense adhesions [70]: the UCLA group instead maintains that the shunt does not need to be dismantled [68]. The
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Fig. 2. Portosystemic shunts performed at our institution from 1984 to August 1989. compared with the increasing number of liver transplanta tions for hepatic cirrhosis and severe portal hypertension (OLT). A pro gressive reduction of distal splenorenal shunts (DSRS) and elective total shunts (ETS) can be observed, while the number of emergency total shunts (EmTS) remained constant over time.
small-diameter portacaval H-graft shunt may represent a valid alternative for cirrhotics with bleeding esophageal varices who are or may become transplant candidates, since it facilitates dissection of porta hepatis and can be easily removed at the end of the trans plant.
In conclusion, we would like to point out the renewed interest in portosystemic shunts, almost abandoned in the last decade. At present the portacaval shunt may still repre sent in some selected cases, the procedure of choice to prevent recurrent hemorrhage from esophageal varices.
References
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