Experience With Interposition Mesocaval Shunt for Management of Variceal Bleeding Horst S. Filtzer, MD; Riccardo Rossi, MD; Francis G. Wolfort, MD
\s=b\We present an experience with 20 patients undergoing interposition mesocaval shunts for decompression of esophageal varices. There were 14 men and six women, ranging in age from 32 to 80 years. Two patients were classified as good risks, nine as moderate risks, and nine as poor risks. There were ten elective operations, seven urgent operations, and three emergency procedures. An operative mortality of 10% was noted in the entire group, with one late death due to shunt occlusion. All deaths occurred in the emergency group. A shunt patency of 88% and minimal problems with postoperative hepatic encephalopathy were noted. The interposition mesocaval shunt is judged to be a safe, technically easy procedure that is currently a satisfactory solution to the problem of hemorrhage from esophageal varices.
(Arch Surg 112:593-595, 1977)
portosystemic venous shunts have been designed to relieve portal hypertension and esophageal variceal bleeding. Portosystemic shunts reduce the likelihood of variceal bleeding. The ideal procedure, consid¬ ering mortality, technical feasibility, and effective decom¬ pression of the portal circulation, however, still remains in
Multiple doubt.
Encouraging results with mesocaval interposition grafts have been reported.'-' Still, some believe that this opera¬ tion is not superior to the standard portacaval shunt.7"' It has been suggested that the mesocaval shunt has fewer technical difficulties,' -7 and that it can be carried out more easily than other portosystemic procedures. The technical advantages and the experience reported by Drapanas in 1972- made us consider this procedure a satisfactory solution for the treatment of variceal hemor¬ rhage in a community hospital of 200 beds, where this type of case load is apt to be small. Therefore, the Cambridge Hospital experience, consisting of 20 cases over the period from 1973 through 1976, is presented here. for publication Nov 29, 1976. From the Harvard Medical School and the Department of Surgery, Cambridge Hospital, Cambridge, Mass. Reprint requests to Department of Surgery, Cambridge Hospital, 1493 Cambridge St, Cambridge, MA 02139 (Dr Filtzer).
Accepted
SUBJECTS AND METHODS A retrospective study of 20 patients with portal hypertension who underwent interposition mesocaval shunt procedures between September 1973 and October 1976 was undertaken. These cases represent all patients treated for variceal hemorrhage except for three, who underwent portacaval shunting and are therefore excluded from this series. Preoperatively, the patients were divided into three groups, according to the criteria of Turcotte et al.* There were nine patients in group C, considered to be at poor risk; nine patients in group B, considered to be a moderate risk; and two in group A, considered to be good-risk patients. There were six women and 14 men. The mean age was 55.8 years, with a range from 32 to 80 years (Table 1). All patients experienced at least one episode of massive variceal bleeding, with an average of two and a range from one to three. The average number of units of blood needed preoperatively in their last hemorrhage was 9.7, with a range of from three to 34. Only one patient was operated on for ascites that resulted in perforation of an incisional hernia and an uncontrollable ascitic
leak. The
diagnosis of variceal hemorrhage was made by endoscopy in patients. In six patients, frank bleeding from the varices was observed. Variceal hemorrhage was thought to be present by inference if there was clear-cut bleeding from the area of the cardioesophageal junction with the endoscope retroflexed and no evidence of diffuse gastritis, gastric, or duodenal ulcer noted. Eight patients underwent angiography. In four, vasopressin infusion catheters were left in the superior mesenteric artery for infusion therapy, while in the others, arterial hemorrhage from the stomach and duodenum was ruled out. An upper gastrointes¬ tinal x-ray series was performed in 11 patients, with confirmation 18
of the presence of varices in every
case.
Preoperatively, a Sengstaken-Blakemore tube was used in six patients and intra-arterial vasopressin infusion through the superior mesenteric artery in four patients. Ten other patients stopped bleeding with the aid of nasogastric suction and blood replacement alone. The operative technique was similar to the one used by Drapaand Drapanas et al.4 The superior mesenteric vein was identified in the root of the small bowel mesentery, and by tunnelling directly through the right mesocolon, the inferior vena cava was exposed. The grafts used were of knitted Dacron, with a diameter between 18 and 22 mm. An elective shunt was defined as one done two weeks after the episode of bleeding, on the same hospital admission or on a subsequent admission, without interval bleeding. Emergency nas-
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Table
gm/100
ml
mg/100
3.2
1/32/M 2/72/M
3/48/Ft
8/76/MJ 9/56/F 10/80/F 11/58/M 12/39/M 13/58/M 14/51/M 15/48/M 16/39/M 17/61/F 18/67/M 19/49/M 20/80/F
,
and Late Mortality Classification
20
3+ 2+ 2+
and 3-
Female Male
6
by Child
8 14
Operative 2
(22%) 2(10%)
Late
1 1
(11%) (5%)
shunts were performed because of massive bleeding nonrespon¬ sive to medical therapy, or because of recurrent bleeding after vasopressin infusion or the Sengstaken-Blakemore tube was discontinued. An urgent shunt was defined as one performed within 48 hours of controlling massive bleeding but with evidence of a slowly decreasing hematocrit level and slow, persistent bleeding. Operative mortality was defined as death during the same hospital admission or within 30 days of surgery.
RESULTS
The mean follow-up time was 16.3 months, with a range of from two to 36 months and a total follow-up time of 325.3 months. Ten patients were operated on electively, seven urgently, and three as an emergency.
Operative Mortality Two patients died in the postoperative period (10%), at the 14th and 30th day. Both were considered poor-risk patients and were operated on as an emergency. Bronchopneumonia and tachyarrhythmia in one, and progressive hepatic failure in another, were responsible for death. No deaths occurred in the elective or urgent group (Table 2). Late
No 2+
2+ 2+ 1 +
1 + No No
3+ No 2+ 2+ No No No 2+
tense abdomen.
Mortality
No. of
Total
No 3+ 3+ No 2+
Child Class
,
2—Operative
Patients
3+ 3+ 3+ 3+ No 1 +
No
,
Child Classitication
2+
3.0 3.1 3.0 2.0
Encephalopathyf
Nutrition Good Poor Poor Poor Poor Good Good Poor Good Good Poor Excellent Poor Poor Excellent Good Good Poor Good Good
1.5
*1 + indicates clinically evident; 2+ moderate distention, f1 + indicates asterixis; 2 + arousable; 3 + coma. {Operative mortality.
Table
Ascites
ml
3.0 3.5 3.4 3.0 3.1 1.2 2.0 3.4 0.4 0.9 2.7 0.9 3.0 3.1
2.6 2.6 2.9 3.0 3.2 3.5 2.5 3.2 3.8 3.0 4.2 2.8 2.7 4.3 2.9 3.2 2.8 3.5 3.1
4/51/M 5/80/M 6/45/F 7/45/M
Risk Factors
Bilirubin,
Albumin,
Patient/Age, yr/Sex
1.—Preoperative
Mortality
One patient in the Child class C group died at seven months postoperatively after undergoing the interposition mesocaval shunt. Shunt occlusion was demonstrated on
and a splenorenal shunt was constructed. However, the patient died of progressive hepatic failure six weeks following his second procedure. No mortality has occurred in patients of the moderate or good-risk group.
angiography
Hemodynamic Studies The average requirement of blood during surgery was 2.8 units, with a range of 0 to 9; the average requirement in the postoperative period was 3.3 units. Twelve of the 20 patients had measurements of portal blood pressure made during the procedure. The average preoperative portal blood pressure was 365 mm of water, and the pressure following shunting was 167 mm of water, a decrease of 45.7%. Shunt
Two
Patency
had massive variceal bleeding at 2Vi and seven months following mesocaval shunt, respectively. Both patients had occluded grafts, demonstrated by inferior vena cavogram in one and by superior mesenteric and celiac angiogram in the other. One of these patients died, and the other is alive and well with a splenorenal shunt. Seven other patients underwent angiographie follow-up studies, revealing an open graft in all of them. If the lack of bleeding and absence of varices on a barium swallow is considered to represent shunt patency, the patency rate in the patients who survived the operative period is 88.8%.
patients
Metabolic Effects
Preoperative encephalopathy was classified from 1+ to according to severity (Table 1). Postoperatively, three patients (17.5%) have clinically significant encephalopathy requiring protein restriction in two and intermittent lactulose therapy in another. Two of these patients are 80 years old, and the other is 67 years of age. The remaining 3+
,
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clinically detectable encephalopathy dietary protein restriction. Analysis of bilirubin, SGOT, lactic dehydrogenase, and alkaline phosphatase levels showed a postoperative tenden¬ cy to rise, with a gradual return to preoperative levels on the sixth and seventh postoperative day. patients
and
are
free of
are on no
Ascites
Ascites was also graded from 1+ to 3+ according to severity. In the survivor group of 14 patients with preoper¬ ative ascites, none had clinically detectable ascites in their latest follow-up examination. COMMENT
Since 1951, when Reynolds and Southwick" reported on the use of the azygos vein as an interposition mesocaval graft, autogenous grafts with larger caliber have been introduced. Theron1" used a superficial femoral vein and Stipa et al" and Thompson and Read12 have used jugular veins. Lord and associates," Giles and associates,' Drapanas,- and Drapanas et al4 have advised the use of prosthetic materials. In 1972, Drapanas- reported 25 patients with mesocaval interposition shunts using a large knitted Dacron prosthe¬ sis. His shunt patency was over 90%, the operative mortality was 8%, and the portal decompression effective (pressure drop exceeding 50%) and the incidence of enceph¬ alopathy low. The procedure was apparently significantly easier, technically, to perform than others.
Our own operative mortality has been 10%, with a late mortality of 5%. This is somewhat higher than that reported by Drapanas- and Drapanas et al.' Our patients tended to have a median age eight years higher than that reported by Drapanas et al in 1975,4 and 80% of our patients had ascites. All of our deaths occurred in the poor-risk patients undergoing emergency shunt operations. The decrease of portal blood pressure following shunt operation
45.7% (365 mm to 167 mm of water), and our estimated shunt patency rate was 88%, both somewhat lower than that reported by Drapanas et al· of 51% and 95%, respec¬ tively. Of two patients who had demonstrated occluded grafts, one is still alive with a splenorenal shunt. All patients in our series with preoperative ascites became clinically free of it in the postoperative period. Good results in the treatment of intractable ascites with interposition mesocaval shunt have been reported by Peracchia." Our results are not quite as good as the ones reported by Drapanas- and Drapanas et al.4 They are, however, in a range acceptable at present for the management of massive variceal bleeding. We consider this operation to be the ideal procedure until prospective randomized studies comparing different types of portosystemic shunts eluci¬ date the procedure of choice. Holyoke et al'7' have recently evaluated the anatomy of the superior mesenteric vein in order to decrease technical complications. This procedure has to be considered effective until other theoretically better methods like coronary-caval1" and distal splenorenal shunt17 prove themselves superior to this operation. was
References 1. Thompson B, Read RC: Proceedings: Interposition "H" grafting for portal hypertension. Arch Surg 108:502-506, 1974. 2. Drapanas T: Interposition mesocaval shunt for treatment of portal hypertension. Ann Surg 176:435-448, 1972. 3. Giles GR, Brennan TG, Losanski MS: Interposition Teflon mesenteric caval shunt for bleeding esophageal varices. Br J Surg 60:649-652, 1973. 4. Drapanas T, Lacecero J, Dowling JB: Hemodynamics of the interposition mesocaval shunt. Ann Surg 181:523-533, 1975. 5. Malt RA: Emergency and elective operation for bleeding esophageal varices. Surg Clin North Am 54:561-571, 1974. 6. Hermann RE: Shunt operations for portal hypertension. Surg Clin
North Am 55:1073-1087, 1975. 7. Gliedmann ML, Margulies M: The side-to-end superior mesenteric vein-inferior cava shunt for portal hypertension. Surgery 56:473, 1964. 8. Turcotte JG, Wallin WV, Child CG III: End-to-side vs side-to-side portocaval shunts in patients with hepatic cirrhosis. Am J Surg 117:108-116, 1969. 9. Reynolds JT, Southwick HW: Portal hypertension: Use of venous grafts when side-to-side anastomosis is impossible. Arch Surg 62:789,
1951. 10. Theron P: Portacaval shunt operations with special reference to the use of vein grafts. S Afr Med J 27:73, 1953. 11. Stipa S, Thau A, Cavallaro A, et al: A technique for mesentericocaval shunt. Surg Gynecol Obstet 137:285-287, 1973. 12. Thompson BW, Read RC: Use of autogenous jugular vein for interposition grafting in portal hypertension. South Med J 66:818-822, 1973. 13. Lord JW, Rossi G, Daliana M, et al: Portosplenic shunts in the management of massive hemorrhage from esophageal varices due to cirrhosis of the liver. Am J Surg 121:241-248, 1971. 14. Peracchia A: Interposition mesocaval shunt for intractable cirrhotic ascites. Ateneo Parmese [Acta Biomed] 46:101-111, 1975. 15. Holyoke EA, Davis WC, Harry RD: Surgical anatomy of the mesocaval shunt. Surgery 78:526-530, 1975. 16. Inokuchi K, Kabayashi MD, Ogaya Y, et al: Results of left gastric vena caval shunt for esophageal varices: Analysis of 100 clinical cases. Surgery 78:628-636, 1975. 17. Warren WD, Salam AA, Smith RB: Selective distal splenorenal shunt: Technique and results of operation. Arch Surg 108:306-314, 1974.
Editorial Comment One must applaud the authors both for their fine clinical resutts with the interposition mesocaval shunt and for their appropriately conservative evaluation of the ultimate usefulness of this opera¬ tion. Like others, their operative mortality is quite low, especially considering the fact that one half of the operations were urgent or emergencies, and 18 of the 20 patients were in the Child class or C. They have also observed the effective control of ascites, as might be anticipated since this is a functional side-to-side porto¬ systemic shunt. Given the physiologic nature of the shunt, and especially considering that 13 patients had preoperative encephalopathy, the postoperative incidence of encephalopathy is pleasantly and, to
incomprehensibly low. The authors are hesitant to state that this is the operation of choice for bleeding esophageal varices. Many now believe that the distal splenorenal shunt will become the procedure of choice, but, with massive ascites as a contraindication to that operation, at least eight of these patients would not have been candidates in any case. The present results reaffirm that, whatever its other merits, the interposition mesocaval shunt can be performed expeditiously and with very acceptable results in relatively poor-risk patients and even under urgent circumstances. Gardner W. Smith, MD Baltimore me,
Downloaded From: http://archsurg.jamanetwork.com/ by a Georgetown University Medical Center User on 05/26/2015
\s=b\We present an experience with 20 patients undergoing interposition mesocaval shunts for decompression of esophageal varices. There were 14 men and six women, ranging in age from 32 to 80 years. Two patients were classified as good risks, nine as moderate risks, and nine as poor risks. There were ten elective operations, seven urgent operations, and three emergency procedures. An operative mortality of 10% was noted in the entire group, with one late death due to shunt occlusion. All deaths occurred in the emergency group. A shunt patency of 88% and minimal problems with postoperative hepatic encephalopathy were noted. The interposition mesocaval shunt is judged to be a safe, technically easy procedure that is currently a satisfactory solution to the problem of hemorrhage from esophageal varices.
(Arch Surg 112:593-595, 1977)
portosystemic venous shunts have been designed to relieve portal hypertension and esophageal variceal bleeding. Portosystemic shunts reduce the likelihood of variceal bleeding. The ideal procedure, consid¬ ering mortality, technical feasibility, and effective decom¬ pression of the portal circulation, however, still remains in
Multiple doubt.
Encouraging results with mesocaval interposition grafts have been reported.'-' Still, some believe that this opera¬ tion is not superior to the standard portacaval shunt.7"' It has been suggested that the mesocaval shunt has fewer technical difficulties,' -7 and that it can be carried out more easily than other portosystemic procedures. The technical advantages and the experience reported by Drapanas in 1972- made us consider this procedure a satisfactory solution for the treatment of variceal hemor¬ rhage in a community hospital of 200 beds, where this type of case load is apt to be small. Therefore, the Cambridge Hospital experience, consisting of 20 cases over the period from 1973 through 1976, is presented here. for publication Nov 29, 1976. From the Harvard Medical School and the Department of Surgery, Cambridge Hospital, Cambridge, Mass. Reprint requests to Department of Surgery, Cambridge Hospital, 1493 Cambridge St, Cambridge, MA 02139 (Dr Filtzer).
Accepted
SUBJECTS AND METHODS A retrospective study of 20 patients with portal hypertension who underwent interposition mesocaval shunt procedures between September 1973 and October 1976 was undertaken. These cases represent all patients treated for variceal hemorrhage except for three, who underwent portacaval shunting and are therefore excluded from this series. Preoperatively, the patients were divided into three groups, according to the criteria of Turcotte et al.* There were nine patients in group C, considered to be at poor risk; nine patients in group B, considered to be a moderate risk; and two in group A, considered to be good-risk patients. There were six women and 14 men. The mean age was 55.8 years, with a range from 32 to 80 years (Table 1). All patients experienced at least one episode of massive variceal bleeding, with an average of two and a range from one to three. The average number of units of blood needed preoperatively in their last hemorrhage was 9.7, with a range of from three to 34. Only one patient was operated on for ascites that resulted in perforation of an incisional hernia and an uncontrollable ascitic
leak. The
diagnosis of variceal hemorrhage was made by endoscopy in patients. In six patients, frank bleeding from the varices was observed. Variceal hemorrhage was thought to be present by inference if there was clear-cut bleeding from the area of the cardioesophageal junction with the endoscope retroflexed and no evidence of diffuse gastritis, gastric, or duodenal ulcer noted. Eight patients underwent angiography. In four, vasopressin infusion catheters were left in the superior mesenteric artery for infusion therapy, while in the others, arterial hemorrhage from the stomach and duodenum was ruled out. An upper gastrointes¬ tinal x-ray series was performed in 11 patients, with confirmation 18
of the presence of varices in every
case.
Preoperatively, a Sengstaken-Blakemore tube was used in six patients and intra-arterial vasopressin infusion through the superior mesenteric artery in four patients. Ten other patients stopped bleeding with the aid of nasogastric suction and blood replacement alone. The operative technique was similar to the one used by Drapaand Drapanas et al.4 The superior mesenteric vein was identified in the root of the small bowel mesentery, and by tunnelling directly through the right mesocolon, the inferior vena cava was exposed. The grafts used were of knitted Dacron, with a diameter between 18 and 22 mm. An elective shunt was defined as one done two weeks after the episode of bleeding, on the same hospital admission or on a subsequent admission, without interval bleeding. Emergency nas-
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Table
gm/100
ml
mg/100
3.2
1/32/M 2/72/M
3/48/Ft
8/76/MJ 9/56/F 10/80/F 11/58/M 12/39/M 13/58/M 14/51/M 15/48/M 16/39/M 17/61/F 18/67/M 19/49/M 20/80/F
,
and Late Mortality Classification
20
3+ 2+ 2+
and 3-
Female Male
6
by Child
8 14
Operative 2
(22%) 2(10%)
Late
1 1
(11%) (5%)
shunts were performed because of massive bleeding nonrespon¬ sive to medical therapy, or because of recurrent bleeding after vasopressin infusion or the Sengstaken-Blakemore tube was discontinued. An urgent shunt was defined as one performed within 48 hours of controlling massive bleeding but with evidence of a slowly decreasing hematocrit level and slow, persistent bleeding. Operative mortality was defined as death during the same hospital admission or within 30 days of surgery.
RESULTS
The mean follow-up time was 16.3 months, with a range of from two to 36 months and a total follow-up time of 325.3 months. Ten patients were operated on electively, seven urgently, and three as an emergency.
Operative Mortality Two patients died in the postoperative period (10%), at the 14th and 30th day. Both were considered poor-risk patients and were operated on as an emergency. Bronchopneumonia and tachyarrhythmia in one, and progressive hepatic failure in another, were responsible for death. No deaths occurred in the elective or urgent group (Table 2). Late
No 2+
2+ 2+ 1 +
1 + No No
3+ No 2+ 2+ No No No 2+
tense abdomen.
Mortality
No. of
Total
No 3+ 3+ No 2+
Child Class
,
2—Operative
Patients
3+ 3+ 3+ 3+ No 1 +
No
,
Child Classitication
2+
3.0 3.1 3.0 2.0
Encephalopathyf
Nutrition Good Poor Poor Poor Poor Good Good Poor Good Good Poor Excellent Poor Poor Excellent Good Good Poor Good Good
1.5
*1 + indicates clinically evident; 2+ moderate distention, f1 + indicates asterixis; 2 + arousable; 3 + coma. {Operative mortality.
Table
Ascites
ml
3.0 3.5 3.4 3.0 3.1 1.2 2.0 3.4 0.4 0.9 2.7 0.9 3.0 3.1
2.6 2.6 2.9 3.0 3.2 3.5 2.5 3.2 3.8 3.0 4.2 2.8 2.7 4.3 2.9 3.2 2.8 3.5 3.1
4/51/M 5/80/M 6/45/F 7/45/M
Risk Factors
Bilirubin,
Albumin,
Patient/Age, yr/Sex
1.—Preoperative
Mortality
One patient in the Child class C group died at seven months postoperatively after undergoing the interposition mesocaval shunt. Shunt occlusion was demonstrated on
and a splenorenal shunt was constructed. However, the patient died of progressive hepatic failure six weeks following his second procedure. No mortality has occurred in patients of the moderate or good-risk group.
angiography
Hemodynamic Studies The average requirement of blood during surgery was 2.8 units, with a range of 0 to 9; the average requirement in the postoperative period was 3.3 units. Twelve of the 20 patients had measurements of portal blood pressure made during the procedure. The average preoperative portal blood pressure was 365 mm of water, and the pressure following shunting was 167 mm of water, a decrease of 45.7%. Shunt
Two
Patency
had massive variceal bleeding at 2Vi and seven months following mesocaval shunt, respectively. Both patients had occluded grafts, demonstrated by inferior vena cavogram in one and by superior mesenteric and celiac angiogram in the other. One of these patients died, and the other is alive and well with a splenorenal shunt. Seven other patients underwent angiographie follow-up studies, revealing an open graft in all of them. If the lack of bleeding and absence of varices on a barium swallow is considered to represent shunt patency, the patency rate in the patients who survived the operative period is 88.8%.
patients
Metabolic Effects
Preoperative encephalopathy was classified from 1+ to according to severity (Table 1). Postoperatively, three patients (17.5%) have clinically significant encephalopathy requiring protein restriction in two and intermittent lactulose therapy in another. Two of these patients are 80 years old, and the other is 67 years of age. The remaining 3+
,
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clinically detectable encephalopathy dietary protein restriction. Analysis of bilirubin, SGOT, lactic dehydrogenase, and alkaline phosphatase levels showed a postoperative tenden¬ cy to rise, with a gradual return to preoperative levels on the sixth and seventh postoperative day. patients
and
are
free of
are on no
Ascites
Ascites was also graded from 1+ to 3+ according to severity. In the survivor group of 14 patients with preoper¬ ative ascites, none had clinically detectable ascites in their latest follow-up examination. COMMENT
Since 1951, when Reynolds and Southwick" reported on the use of the azygos vein as an interposition mesocaval graft, autogenous grafts with larger caliber have been introduced. Theron1" used a superficial femoral vein and Stipa et al" and Thompson and Read12 have used jugular veins. Lord and associates," Giles and associates,' Drapanas,- and Drapanas et al4 have advised the use of prosthetic materials. In 1972, Drapanas- reported 25 patients with mesocaval interposition shunts using a large knitted Dacron prosthe¬ sis. His shunt patency was over 90%, the operative mortality was 8%, and the portal decompression effective (pressure drop exceeding 50%) and the incidence of enceph¬ alopathy low. The procedure was apparently significantly easier, technically, to perform than others.
Our own operative mortality has been 10%, with a late mortality of 5%. This is somewhat higher than that reported by Drapanas- and Drapanas et al.' Our patients tended to have a median age eight years higher than that reported by Drapanas et al in 1975,4 and 80% of our patients had ascites. All of our deaths occurred in the poor-risk patients undergoing emergency shunt operations. The decrease of portal blood pressure following shunt operation
45.7% (365 mm to 167 mm of water), and our estimated shunt patency rate was 88%, both somewhat lower than that reported by Drapanas et al· of 51% and 95%, respec¬ tively. Of two patients who had demonstrated occluded grafts, one is still alive with a splenorenal shunt. All patients in our series with preoperative ascites became clinically free of it in the postoperative period. Good results in the treatment of intractable ascites with interposition mesocaval shunt have been reported by Peracchia." Our results are not quite as good as the ones reported by Drapanas- and Drapanas et al.4 They are, however, in a range acceptable at present for the management of massive variceal bleeding. We consider this operation to be the ideal procedure until prospective randomized studies comparing different types of portosystemic shunts eluci¬ date the procedure of choice. Holyoke et al'7' have recently evaluated the anatomy of the superior mesenteric vein in order to decrease technical complications. This procedure has to be considered effective until other theoretically better methods like coronary-caval1" and distal splenorenal shunt17 prove themselves superior to this operation. was
References 1. Thompson B, Read RC: Proceedings: Interposition "H" grafting for portal hypertension. Arch Surg 108:502-506, 1974. 2. Drapanas T: Interposition mesocaval shunt for treatment of portal hypertension. Ann Surg 176:435-448, 1972. 3. Giles GR, Brennan TG, Losanski MS: Interposition Teflon mesenteric caval shunt for bleeding esophageal varices. Br J Surg 60:649-652, 1973. 4. Drapanas T, Lacecero J, Dowling JB: Hemodynamics of the interposition mesocaval shunt. Ann Surg 181:523-533, 1975. 5. Malt RA: Emergency and elective operation for bleeding esophageal varices. Surg Clin North Am 54:561-571, 1974. 6. Hermann RE: Shunt operations for portal hypertension. Surg Clin
North Am 55:1073-1087, 1975. 7. Gliedmann ML, Margulies M: The side-to-end superior mesenteric vein-inferior cava shunt for portal hypertension. Surgery 56:473, 1964. 8. Turcotte JG, Wallin WV, Child CG III: End-to-side vs side-to-side portocaval shunts in patients with hepatic cirrhosis. Am J Surg 117:108-116, 1969. 9. Reynolds JT, Southwick HW: Portal hypertension: Use of venous grafts when side-to-side anastomosis is impossible. Arch Surg 62:789,
1951. 10. Theron P: Portacaval shunt operations with special reference to the use of vein grafts. S Afr Med J 27:73, 1953. 11. Stipa S, Thau A, Cavallaro A, et al: A technique for mesentericocaval shunt. Surg Gynecol Obstet 137:285-287, 1973. 12. Thompson BW, Read RC: Use of autogenous jugular vein for interposition grafting in portal hypertension. South Med J 66:818-822, 1973. 13. Lord JW, Rossi G, Daliana M, et al: Portosplenic shunts in the management of massive hemorrhage from esophageal varices due to cirrhosis of the liver. Am J Surg 121:241-248, 1971. 14. Peracchia A: Interposition mesocaval shunt for intractable cirrhotic ascites. Ateneo Parmese [Acta Biomed] 46:101-111, 1975. 15. Holyoke EA, Davis WC, Harry RD: Surgical anatomy of the mesocaval shunt. Surgery 78:526-530, 1975. 16. Inokuchi K, Kabayashi MD, Ogaya Y, et al: Results of left gastric vena caval shunt for esophageal varices: Analysis of 100 clinical cases. Surgery 78:628-636, 1975. 17. Warren WD, Salam AA, Smith RB: Selective distal splenorenal shunt: Technique and results of operation. Arch Surg 108:306-314, 1974.
Editorial Comment One must applaud the authors both for their fine clinical resutts with the interposition mesocaval shunt and for their appropriately conservative evaluation of the ultimate usefulness of this opera¬ tion. Like others, their operative mortality is quite low, especially considering the fact that one half of the operations were urgent or emergencies, and 18 of the 20 patients were in the Child class or C. They have also observed the effective control of ascites, as might be anticipated since this is a functional side-to-side porto¬ systemic shunt. Given the physiologic nature of the shunt, and especially considering that 13 patients had preoperative encephalopathy, the postoperative incidence of encephalopathy is pleasantly and, to
incomprehensibly low. The authors are hesitant to state that this is the operation of choice for bleeding esophageal varices. Many now believe that the distal splenorenal shunt will become the procedure of choice, but, with massive ascites as a contraindication to that operation, at least eight of these patients would not have been candidates in any case. The present results reaffirm that, whatever its other merits, the interposition mesocaval shunt can be performed expeditiously and with very acceptable results in relatively poor-risk patients and even under urgent circumstances. Gardner W. Smith, MD Baltimore me,
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