The Fate of Esophageal Varices Following Selective Distal Splenorenal Shunt DUANE G. HUTSON, M.D., RAUL PEREIRAS, M.D., ROBERT ZEPPA, M.D., JOE U. LEVI, M.D., EUGENE R. SCHIFF, M.D., PAT FINK, R.N.
Esophagographic evaluation of the fate of esophageal varices after distal splenorenal shunt was obtained. The radiologistobserver was blinded as to the surgical status of the films under study. The results indicate that varices are likely to persist after surgery. However, the sizes of the varices are clearly diminished following selective distal splenorenal shunt. The incidence of postoperative bleeding has been low, 3.7% (2/54) or one episode for each 441 months of postoperative survival.
From the University of Miami Affiliated Hospitals, Department of Surgery, P.O. Box 520875, Miami, Florida 33152
radiographic examinations were conducted at a time when the patients were not bleeding. Code numbers were assigned to the films and all other identifying characteristics were obliterated. The major problem in this endeavor was to mask the metallic clips seen on most of the postoperative films. This was solved by painting over each clip on the postoperative films and in similar locations on the preoperative films (Fig. 1). This served to conceal the surgical status of the patient whose films were being assessed. Subsequently, all of the films were read by one radiologist and the varices were graded on a 04+ scale. Representative examples of x-ray films reflecting the evaluations are seen in Figs. 2 and 3.
THE PERSISTENCE of esophageal varices following portal-systemic decompression is well documented. Palmer has reported the incidence of such persistence to be 27% after portacaval shunt and 83% after conventional splenorenal shunt.6 These observations were made endoscopically, the technique considered to be the most precise method for evaluation of esophageal varices. The disadvantages ofesophagoscopy for long term assessments in our experience are: 1) it is an invasive test and, 2) patient acceptance under the doctorine of informed consent is low. For these reasons, this retrospective, non-randomized but blinded study presents the results of Results radiological assessment of the fate of esophageal varices Analysis of the grades awarded to the x-rays by the after the construction of selective distal splenorenal radiologist revealed 5 patients (19%) in whom the shunts. varices were unchanged for the entire period ranging from 1-4 years after surgery (Table 1). In one of the 5 Methods patients the varices were thought to be one grade larger X-ray films of barium studies of the esophagus of 26 in the second postoperative year, although this patient patients who were followed from one to 4 years after has not bled during this interval. In 4 patients (15%) surgery were considered adequate for this study. All of the complete disappearance of the varices was recorded and in the remainder of the group, 17 (65%) the varices were noted to be smaller in size but definitely identifiable as Presented at the Annual Meeting of the Southern Surgical Associapersistent (Fig. 4). tion, December 8- 10, 1975, The Homestead, Hot Springs, Virginia. At one after distal splenorenal shunt the x-ray year Supported in part by Clinical Research Center Program (RR261) of the Division of Research Resources NIH. films of 18 patients in the group of 26 were available for 496
DISTAL SPLENORENAL SHUNT
FIGS. Ia and b. (left) Typical postoperative radiograph showing multiple clips. (right) Clips marked out with black paint. All of the films of each patient were painted in locations similar to the postoperative studies.
study. Another two patients were noted to show no decrease in variceal size during the one year interval. However, even at this time, a difference is noted in the distribution of the numbers of patients in each grade cell (Table 2). Eighteen of the 26 preoperative patients were graded 3+ or 4+ whereas 9 of the 18 patients evaluated at one year after surgery were considered to have none or 1+ varices. The percentage occupancy of each grade cell is demonstrated in Fig. 5
FIGs. 2a and b. (left) Grade 1 + varices. (right) Two views of 2+ varices.
wherein an obvious distinction between the preoperative and postoperative groups may be seen. More than 70% of the postoperative patients are found in the cells 0 to 2+ whereas almost 90% of the preoperative patients occupy the cells identified as grades 2+ to 4+. Discussion The accuracy of esophagography for the diagnosis of esophageal varices continues to be questioned.1'2 As a
HUTSON AND OTHERS
Surg. May 1976
FIGS. 3a and b. (left) Grade 3+ varices. (right) Grade 4+ varices which extend to the thoracic inlet.
rule, it seems that esophagoscopy will demonstrate varices in 90%o of the instances while conventional esophagography may result in the correct diagnosis in 70% of similar cases.5 8 However, the accuracy of endoscopy per se is not perfect since observer variability may apTABLE 1. Time After Distal Shiunt
1 2 3 4 5 6t 7 8 9 10 11 12* 13* 14 15 16* 17 18* 19 20 21 22 23 24 25 26
4+ 2+ 4+ 2+ 4+ 2+ 4+ 4+ 2+ 4+ 3+ 1+ 2+ 3+ 4+ 3+ 4+ 3+ 3+ 4+ 4+ 4+ 3+ 3+ 1+ 2+
3+ 0 2+
0 1+ 1+ 1+ 1+ 2+ 2+ 3+ 3+ 1+ 2+
1+ 3+ 1+
2+ 0 1+
Varices graded: 0 (none), 1+, 2+, 3+, 4+ No observation. * Varices unchanged. t Varices worse.
obtain sufficient data for analysis. The data presented suggest that the distal splenorenal 4 yrs shunt has a beneficial effect on the size of esophageal varices as has been demonstrated for other shunt opera1+ tions. However, in 85% of patients some degree of 1+ persistence of varices was noted. This finding is also similar to those reported after conventional shunt therapy, although the techniques of evaluation have differed. For the most part, the other studies have used esophagoscopy for which the observers were not blinded as to the patients' therapies. In this manner, Dagradi has concluded that varices do not disappear after portacaval shunt "except in rare instances." His esophagoscopic evaluation did reveal a reduction in the caliber and extent of varices after shunt therapy, a finding similar to that seen on esophagography in this study.4 Perhaps the most important point at issue is the sig3+ 1+ nificance of persistent varices with regard to the risk of 3+ subsequent variceal hemorrhage. Palmer has considered that spontaneous fluctuation in variceal size is of sufficient magnitude to preclude the usefulness of the persistence of 1+ varices as the criterion for judging the success of portal decompression. He has written that: "prevention of variceal bleeding remains the best test of shunt effectiveness."7 In our series of 54 consecutive patients followed from one to 51 months after elective distal splenorenal shunt, only two bleeding episodes have occurred. This t
proach 30%. In this study, comparative
not considered and the relative merits of different techniques of evaluation were not studied since it seemed more important to blind the observer as to the fact of the patient's therapy. In addition, patient acceptance of the evaluation was deemed more important in order to
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Vol. 183 * No.
FIGS. 4a and b. (left) "Wall to wall" varices extending above aortic arch. (right) Striking reduction on postoperative films.
TABLE 2. Comparative Analysis of Grade Evaluations
0 1+ 2+ 3+
0 2 6 7 11 26
I Yr Postop
Grade 0 1+
2+ 3+ 4+
PRE-OP YEAR POST-OP 1
No. Pts. 3 6 4 3 2 18
--------- _ _
18/26 patients were in grades 3+ and 4+ preoperatively, compared to 13/18 patients in grades 0 to 2+.
represents two occurrences in 883 patient-months of study. Precise identification of bleeding from varices was not obtained in either patient, however, it has been attributed to variceal origin since no other site for bleeding could be demonstrated.
References 1. Brick, 1. B. and Palmer, E. D.: Comparison of Esophagoscopic and Roentgenologic Diagnosis of Esophageal Varices in Cirrhosis of the Liver. Am. J. Roentgenol. Radium Ther. Nucl. Med., 73:387, 1955. 2. Conn, H. O., Mitchell, J. R. and Brodoff, M. G.: A Comparison of the Radiologic and Esophagoscopic Diagnosis of Esophageal Varices. N. Engl. J. Med., 265:160, 1961. 3. Conn, H. O., Smith, H. W. and Brodoff, M. G.: Observer Variation in the Endoscopic Diagnosis of Esophageal Varices. N. Engl. J. Med., 372:830, 1965. 4. Dagradi, A. E., Stempien, S. J. and Tan, D. T. D.: Endoscopic
Study of the Cirrhotic Patient Before and Following Portacaval
5 ---0 0
3 GRADE VARICES
FIG. 5. Change in percentage distribution of patients in grade cells 0 to 4+ postoperatively as compared to preoperative assessment.
HUTSON AMND OTHERS
Shunt for Bleeding Varices. Am. J. Gastroenterol., 53:425. 1970. 5. Feist, J. H. and Riley, R.: Diagnosis of Esophageal Varices. Radiology, 93:861, 1969. 6. Palmer, E. D.: Reassessment of the Fate of Esophageal Varices Following Portal Decompression in Cirrhosis. Am. J. Gastroenterol., 46:38, 1966.
DR. SESHADRI RAJu (Jackson, Mississippi): In Jackson we thus far share the enthusiasm of Dr. Zeppa for this distal splenorenal shunt, and we hope that its apparent superiority over the other shunt procedures will become firmly established. Nevertheless, it has some drawbacks. It is technically a somewhat difficult operation, often time consuming, and may require fair amounts of blood. It is certainly not the procedure for the surgeon who does only an occasional shunt, moreover, for the same reasons, it is not an ideal emergency
procedure. (Slide) The anatomical feature which makes this operation tedious is the multiple pancreatic branches of the splenic vein. Thus, we looked for, and have devised, a modification which we think will minimize or obviate several of these objections I stated. In a recent patient, we excised a portion of the autogenous jugular vein, and simply used it as a jump graft between the splenic vein and the renal vein. The splenic vein was tied proximal to the jump graft. In effect, therefore, this is a Warren shunt, except that the modification provides certain distinct advantages. Firstly, one has to clear only 4-cm segment of splenic vein, and we don't have to mobilize the whole length of the splenic vein, as in the original Warren procedure. This makes the technical exercise much easier. Furthermore, you have to clear only the superifical aspects of the splenic vein, leaving the deep pancreatic branches intact in the 4 cm segment. You clear the splenic vein just enough to place a partial occlusion clamp to sew the jump graft in. As I said, this maneuver significantly reduces the operating time and blood loss. (Slide) You can see the jump graft here: (indicating) the splenic vein has been tied off. This is the renal vein and these are the numerous pancreatic branches of the splenic vein. (Slide) This shows the jump graft in position. You can see that the internal jugular vein is fairly large; in fact, slightly larger than the splenic vein.
(Slide) The jump graft effectively reduces distal splenic pressure, while maintaining the portal pressure intact, the primary principle of this operation. (Slide) The next slide shows the postoperative contrast study. This is an arterial injection, venous phase. You can see the jump graft and the renal vein; you can even see part of the vena cava, opacified due to the nicely functioning shunt. DR. GEORGE JOHNSON, JR. (Chapel Hill): The treatment of these unfortunate patients with bleeding esophageal varices is in a state of flux at the present time. The long-term results of the portacaval shunt as they are presently being reported are not very promising. Although the long-term results of the ablative operation, championed by Dr. Nathan Womack, are promising, the immediate mortality and recurrent episodes of bleeding are certainly distressing. Of the twenty-six patients that we have had the opportunity of examining the status of their esophageal varices following an ablative operation, 27%, compared to the 8% just reported, have had complete disappearance of their varices. On the other hand, in 46% there was no change, and in only 19% did the size of the varices decrease. In 7% the varices actually increased in size following the ablative procedure. It is our present feeling that the ablative operation should be restricted as a primary operation to good-risk patients with severe hypersplenism. Currently, the primary operation used at our institution is the interposition mesocaval shunt, popularized and championed by the late
Ann. Surg. *
7. Palmer, E. D.: Course of Esophageal Varices in Cirrhosis, in the Absence of Portal Decompression. Gastroenterologia, 107:337, 1967.
8. Peternel, W. W., Dagradi, A. E., et al.: Clinical Investigation of the Portacaval Shunt. Ill. The Diagnosis of Esophageal Varices. JAMA, 202: 107, 1967.
Dr. Ted Drapanas. It is certainly appealing in its relative technical simplicity. Although we have performed several distal splenorenal shunts as described by Zeppa and Warren, and are satisfied with the results, we find it to be a tedious procedure that should be performed by a select group of surgeons. If, however, the operation will allow liver perfusion, and yet decompress the varices, is associated with a low morbidity and mortality, and episodes of recurrent bleeding, then most of us who are operating upon these patients would be willing to spend the time and effort necessary to perform this procedure. The data just presented support increasing utilization. We shall, therefore, look forward to hearing increasing reports of long-term evaluation of the selective distal splenorenal shunt, not only from Zeppa and Warren, but also from other centers utilizing this procedure. I would like to ask Dr. Zeppa if the increase in the size of the varices can be correlated with portal pressure, or other hemodynamic or clinical data. This study is important, because the distal splenorenal shunt has apparently decompressed the varices, as Zeppa predicted, without significantly lowering portal vein pressure. I must admit that I have been a skeptic.
DR. ROBERT B. SMITH, Ill (Decatur, Georgia): We wish to emphasize that the selective distal splenorenal shunt under discussion is a multiple step operative procedure that involved not only decompression of the distal stump of the splenic vein, but also, very importantly, portal-azygous disconnection by ligation of the coronary vein and the right gastroepiploic vein. Without these important steps, this operation amounts to little more than a remote total shunt. Nabseth recently reported an experience in which he deliberately failed to ligate the associated veins, and observed a significant incidence of rebleeding and encephalopathy among his patients. Others have had similar results when inadvertently the ligations were not performed. In our experience with more than 50 distal splenorenal shunts over the last four years at Emory, no patient has died of rebleeding if the shunt remained patent. We also have noted persistence of the varices on endoscopy and G.I. Series following operation, just as is the case with total shunts. We assume that the protective effect of the distal shunt relates to reduced pressure in the regional veins, and even though the varicosities may persist anatomically, these patients have no greater incidence of bleeding than with total shunts.
DR. WILLIAM SCOTT, JR. (Nashville): Some of us had an opportunity to hear Dr. Sandblom's colleague, formerly at Lund, now at Boras, Sweden, Dr. Carl-Axel Ekman, comment on his use of the Warren shunt in some 40 patients. He continued to study these patients, and found that a large number of them apparently had encephalopathy, and he has stopped doing the procedure, and has reverted to-or continued to use-the end-to-side portacaval shunt. I don't know any more about this than what I heard in Sweden, but do want to have comments from Dr. Zeppa. and perhaps Dr. Warren. DR. W. DEAN WARREN. (Atlanta): From my conversations with Dr. Bengmark, it is my understanding that they have utilized the procedure in those patients primarily with chronic active hepatitis. If one takes this tack, there are going to be many patients who go ahead and die of progressive hepatitis and ultimately hepatic failure. If one calls that encephalopathy, which is what Dr. Bengmark was speaking about, then there will be many instances of hepatic encepha-