faciles; aucun malade n'a pr6sent6 de symptomes ou d'anomalie biologique d'alt6ration fonctionnelle h6patique. Un seul malade e s t mort d'h6morragie massive ~t la troisi~me semaine postop6ratoire. Aucun des 12 survivants n'a pr6sent6 de r6cidive d'h6morragie digestive. La dissection des veines spl6nique et r6nale par voie post6rieure, r6trop6riton6ale, est techniquement ais6e. Cette voie d'abord peut ~tre la seule utilisable chez les malades op6r6s ant6rieurement sur les voies biliaires ou le tube digestif et qui pr6sentent d'importantes adh6rences intrap6riton6ales. Le shunt spl6nor6nal s61ectif par voie r6trop6riton6ale est une th6rapeutique pr6ventive efficace des h6morragies gastro-oesophagiennes chez le malade cirrhotique.
World J. Surg., Vol. 2, No. 5, September 1978
2. 3. 4. 5.
1. Warren, W.D., Zeppa, R., Fomon, J.J.: Selective trans-splenic decompression of gastroesophageal vari-
ces by distal splenorenal shunt. Ann. Surg. 166:473, 1967 Warren, W.D., Salam, A.A., Hutson, D., Zeppa, R.: Selective distal sphenorenal shunt. Technique and results of operation. Arch. Surg. 108:306, 1974 Stoney, R.J., Mehigan, J.T., Olcott, C.: Retroperitoneal approach for portasystemic decompression. Arch. Surg. 110:1347, 1975 Gil-Vernet, J.M., Caralps, A.: Renal autotransplantation in the treatment of renovascular hypertension. Lancet 1:1081, 1976 Salam, A.A., Warren, W.D., LePage, J.R., Viamonte, M.R., Hutson, D., Zeppa, R.: Hemodynamic contrasts between selective and total portal-systemic decompression. Ann. Surg. 173:827, 1971 Vang, J., Simert, G., Hansson, J.A., Thylen, U., Bengmark, S.: Results of a modified distal splenorenal shunt for portal hypertension. Ann. Surg. 185:224, 1977 Nabshet, D.C., Widrich, W.C., O'Hara, E.T., Johnson, W.C.: Flow and pressure characteristics of the portal system before and after splenorenal shunts. Surgery 78:739, 1975 Reichle, F.A.: Portal hemodynamics after distal splenorenal (Warren) shunt. Ann. Surg. 176:195, 1972
Invited Commentary Stig Bengmark, M.D., Ph.D. University of Lund, Lund, Sweden The authors have demonstrated that it is possible, and in some cases advantageous and technically easier, to perform a distal splenorenal shunt by the retroperitoneal approach. The method was introduced in 1974 by Stoney and coworkers, who used a side-to-end splenorenal shunt. The present writers have used end-to-side and end-to-end anastomoses as is usually routine with the anterior approach. One possible disadvantage with this technique, mentioned by the authors, is that it does not allow performance of portal-azygos disconnection. I am personally quite convinced that the portalazygos disconnection is not of great importance. In our postoperative studies following portal-azygos disconnection, we learned from angiography and sclerotherapy that it is impossible to establish portal-azygos disconnection of a permanent nature. Within a few weeks, new collaterals were formed that connect the high pressure system within the portal tree with the low pressure system in the azygos vein.
The writers do not mention the length of followup and there are reasons to believe that the observation time of their material was short. This might explain why the authors did not observe any hepatic encephalopathy. Their statement: "This operation has a markedly lower incidence of hepatic encephalopathy as compared to total (conventional) portosystemic shunting procedures" is probably premature. In 1977 we published our experience with 25 distal splenorenal shunts without portal-azygos disconnection performed during the years 19701973 (see authors' reference no. 6). After a median observation time of 43 months, 10 of 20 patients were dead. The chief cause of death was liver failure. Encephalopathy was common, although generally of minor degree. We do not believe that distal splenorenal anastomosis, using the same shunt procedure as the authors but with an anterior approach, has any advantage over the traditional porto-systemic type of shunt.