Matched Control Study of Distal Splenorenal and Portacaval Shunts in the Treatment of Bleeding Esophageal Varices

Ronald W. Busuttil, MD, PhD, Los Angeles, California Barbara Brin, MD, Los Angeles, California Ronald K. Tompkins, MD, Los Angeles, California

Four prospective randomized trials [I-4] have tested the efficacy of therapeutic total portal systemic diversion to prolong life in patients who have bled from gastroesophageal varices. In none of these studies did the survival rate of the surgically treated groups statistically exceed that of the medically treated groups. Although recurrent variceal hemorrhage was prevented in the surgically treated patients, the incidence of hepatic encephalopathy and liver failure was unacceptably high in those patients. In 1967, Warren et al [5] proposed a distal splenorenal shunt as an alternative to total portal systemic diversion in the treatment of cirrhotic patients with bleeding varices. The basic tenet of this operation is selective decompression of the gastroesophageal varices while maintaining portal perfusion of the liver via the superior mesenteric vein. Maintenance of portal perfusion should help prevent the possibility of liver cell injury observed after portacaval anastomosis and the subsequent development of hepatic encephalopathy. Despite reports [6-81 indicating that distal splenorenal shunt does fulfill its goals, considerable controversy remains [9,IO] as to whether this more technically demanding procedure, which is not easily performed in an emergency or in the presence of severe ascites, is indeed superior to a total shunt. To compare the effects of the distal splenorenal shunt procedure to those obtained by total portal systemic diversion in a group of cirrhotic patients with documented variceal hemorrhage, we conducted a matched study of the two operations, and we now report our findings. From the Department of Surgery, UCLA School of Medicine, Los Angeles, California. Reprint requests should be addressed to Ronald W. Busuttil, MD, Department of Surgery, c/o Editor’s Office, UCLA School of Medicine, Los Angeles, CA 90024. Presented at the 50th Annual Meeting of the Pacific Coast Surgical Association, Yosemite National Park, California, February 19-22. 1979.


Material and Methods A group of 17 patients with advanced hepatic cirrhosis of various causes underwent distal splenorenal shunt (DSS) for documented bleeding gastroesophageal varices. This group was matched by a similar number of patients who had received a total portacaval shunt (PCS) for the treatment of bleeding varices. All operations were performed by the residents and full-time attending staff at UCLA Hospital. Patients were matched for age, sex, number of preoperative bleeds, type of cirrhosis, preoperative Child’s classification, associated illnesses, and timing of operation. In the DSS group the ages ranged from 25 to 64 years (mean 46) and in the PCS group, from 19 to 56 years (mean 44). In each group there were 10 men (59 per cent) and 7 women (41 per cent). The origin of the portal hypertension was the same in both groups: Laennec’s cirrhosis in six patients, postnecrotic cirrhosis secondary to hepatitis in eight, biliary cirrhosis in two, and cirrhosis of unknown source in one patient. Fifteen patients in each group underwent elective operations; 2 underwent urgent operations; all had variceal hemorrhage documented by endoscopy, and the average number of bleeds for each group before operation was 2.1. Preoperative risks were assessed by the Child’s classification [Ill, and in both groups there were seven class A, seven class B, and three class C patients. Preoperative ascites was found in five and seven patients in the DSS and PCS groups, respectively. Five among the DSS group evidenced preoperative symptoms of encephalopathy, chiefly confusion. Three patients in the PCS group had similar symptoms of encephalopathy. Preoperative encephalopathy was associated with recent gastrointestinal hemorrhage in these patients. All DSS patients underwent preoperative pan-visceral angiography with venous-phase visualization to delineate the splenic vein and the left renal veins, but angiography was not routinely done in the PCS group. Fourteen of the DSS group had a preoperative liver biopsy, while only 7 in the PCS group underwent this procedure. If acute alcoholic hepatitis with significant piecemeal necrosis and hyaline bodies was revealed in the preoperative liver biopsy, operation was deferred until a repeat biopsy indicated a re-

The American Journal of Surgery

Distal Splenorenal


Figure 7. PhotomicFograph of acute alcoholic hepatitis demonstrating piecemeal necrosis, polymorphonuclear leukocytes, and hyaltne bodies. ( Magnification X 44 0, reduced 32 per cent. )

versa1 of this process (Figure 1). Four patients in the DSS and two in the PCS group were diagnosed as having chronic active hepatitis at the time of operation. The preoperative status of these patients is summarized in Table I. In performing the DSS procedures, the technique described by Warren et al [6] was followed, including a complete portal azygos disconnection (Figure 2). In the PCS group, 14 patients underwent an end-to-side portacaval shunt, one had a side-to-side portacaval shunt, and two underwent interposition H-graft mesocaval shunts.

follow-up. The mean duration of follow-up was 28 months for the DSS group and 57 months for the PCS group. Operative mortality is defined as death during the same period of hospitalization in which the shunt was performed. Two operative deaths occurred in the DSS group (11.7 per cent) and four in t,he PCS group (23.5 per cent) (p >0.05). The two deaths in the DSS group were due to pulmonary sepsis and liver failure in patients who were Child’s C and B risks, respec-


Follow-up study of the survivors was accomplished by personal interview or by telephone questionnaire; information on nonsurvivors was obtained by reviewing their hospital records. No patient was lost to




Preoperative Status of Patients DSS

No. of patients Age (yr) Range Mean Males Females No. of bleeds Follow-up (mo) Elective Urgent Child’s classification A 0




25-64 46 10 7 2.1 4-48 15 2

19-56 44 10 7 2.1 17-96 15 2

7 7

7 7

DSS = patients who underwent distal splenorenal shunt; PCS = patients who underwent total portacaval shunt.

Volume 138, July 1979

'Portal ; Splenlc stump

v *


==--z 4 _,



R gastroepiplolc


Figure 2. Diagrammatic representation of distal sptenorenal shunt. IVC = inferior vena cava; R. = right; S.M.V. = superior mesenteric vein; v. = vein.


Busuttil et al

Figure 3. Venous phase of superior mesenteric artery injection demonstrating hepatopetat flow after distal splenorenal shunt. Note divided stump of splenic vein.

tively. The former patient underwent emergency operation. Three of the four operative deaths in the PCS group stemmed from liver failure. The fourth patient died from cardiac arrest 3 days after an urgent shunting procedure. Two B and two C risk patients were classified in this latter group. Two patients also had chronic active hepatitis. Two patients from the DSS group (13.3 per cent of the group at risk) and seven from the PCS group (53.8 per cent of the group at risk) died after discharge from the hospital (late deaths). The greater number of late deaths in the PCS group is statistically significant (p

Matched control study of distal splenorenal and portacaval shunts in the treatment of bleeding esophageal varices.

Matched Control Study of Distal Splenorenal and Portacaval Shunts in the Treatment of Bleeding Esophageal Varices Ronald W. Busuttil, MD, PhD, Los An...
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