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. 1986 Oct;204(4):346–355. doi: 10.1097/00000658-198610000-00002

Splenopancreatic disconnection. Improved selectivity of distal splenorenal shunt.

W D Warren, W J Millikan Jr, J M Henderson, K M Abu-Elmagd, J R Galloway, G T Shires 3rd, W O Richards, A A Salam, M H Kutner
PMCID: PMC1251296  PMID: 3532968

Abstract

Distal splenorenal shunt (DSRS) improves survival from variceal bleeding in nonalcoholic cirrhotics but not in alcoholic subjects. The metabolic response after DSRS is also different in alcoholic and nonalcoholic cirrhotics. Portal perfusion, quality of blood perfusing the liver, cardiac output, and liver blood flow do not change in nonalcoholics. In alcoholics, portal perfusion is frequently lost (60%), quality of blood perfusing the liver decreases, and cardiac output and liver blood flow increase. It is proposed that portal flow is lost in alcoholics via pancreatic and colonic collaterals after surgery. Elimination of this sump by adding complete dissection of the splenic vein and division of the splenocolic ligament to DSRS (splenopancreatic disconnection, SPD) could preserve portal perfusion, decrease shunt loss of hepatotrophic factor, and improve survival in alcoholic cirrhotics. This report compares data 1 year after surgery in two groups of cirrhotics: group I (8 nonalcoholic; 16 alcoholic) had DSRS without SPD; group II (17 nonalcoholic; 11 alcoholic) received DSRS + SPD. Methods: Portal perfusion grade, cardiac output (CO), liver blood flow (f), hepatic function (GEC), and hepatic volume (vol) were measured before and 1 year after surgery. Shunt loss of hepatotrophic factor was estimated by insulin response (change in plasma concentration over 10 minutes: AUC) after arginine stimulation. Results: Groups I and II were similar before surgery. Metabolically, nonalcoholics remained stable after both DSRS and DSRS + SPD. After standard DSRS, alcoholics lost portal perfusion (75%, p less than 0.05), CO, and f increased (p less than 0.05), and quality of blood perfusing the liver was decreased (GEC/f: p less than 0.05). DSRS + SPD preserved portal perfusion better (p less than 0.05) in alcoholic cirrhotics than did DSRS alone. After DSRS + SPD, the metabolic response in alcoholics resembled that of nonalcoholics. CO, f, and GEC/f remained stable. These data show: DSRS + SPD preserves postoperative portal perfusion in alcoholic cirrhotics better than DSRS alone. Metabolic response to DSRS + SPD is similar in alcoholic and nonalcoholic cirrhotics. Because portal perfusion and metabolic integrity are preserved after DSRS + SPD, its use in alcoholic cirrhotics should improve survival.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Cello J. P., Grendell J. H., Crass R. A., Trunkey D. D., Cobb E. E., Heilbron D. C. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and variceal hemorrhage. N Engl J Med. 1984 Dec 20;311(25):1589–1594. doi: 10.1056/NEJM198412203112501. [DOI] [PubMed] [Google Scholar]
  2. Feigenbaum H. Clinical applications of echocardiography. Prog Cardiovasc Dis. 1972 May;14(6):531–558. doi: 10.1016/0033-0620(72)90007-2. [DOI] [PubMed] [Google Scholar]
  3. Galambos J. T., Warren W. D., Rudman D., Smith R. B., 3rd, Salam A. A. Selective and total shunts in the treatment of bleeding varices. A randomized controlled trial. N Engl J Med. 1976 Nov 11;295(20):1089–1095. doi: 10.1056/NEJM197611112952001. [DOI] [PubMed] [Google Scholar]
  4. Henderson J. M., Heymsfield S. B., Horowitz J., Kutner M. H. Measurement of liver and spleen volume by computed tomography. Assessment of reproducibility and changes found following a selective distal splenorenal shunt. Radiology. 1981 Nov;141(2):525–527. doi: 10.1148/radiology.141.2.6974875. [DOI] [PubMed] [Google Scholar]
  5. Henderson J. M., Kutner M. H., Bain R. P. First-order clearance of plasma galactose: the effect of liver disease. Gastroenterology. 1982 Nov;83(5):1090–1096. [PubMed] [Google Scholar]
  6. Henderson J. M., Millikan W. J., Jr, Wright-Bacon L., Kutner M. H., Warren W. D. Hemodynamic differences between alcoholic and nonalcoholic cirrhotics following distal splenorenal shunt--effect on survival? Ann Surg. 1983 Sep;198(3):325–334. doi: 10.1097/00000658-198309000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Inokuchi K., Beppu K., Koyanagi N., Nagamine K., Hashizume M., Sugimachi K. Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation. Ann Surg. 1984 Dec;200(6):711–717. doi: 10.1097/00000658-198412000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Johnston G. W., Rodgers H. W. A review of 15 years' experience in the use of sclerotherapy in the control of acute haemorrhage from oesophageal varices. Br J Surg. 1973 Oct;60(10):797–800. doi: 10.1002/bjs.1800601011. [DOI] [PubMed] [Google Scholar]
  9. MacDougall B. R., Westaby D., Theodossi A., Dawson J. L., Williams R. Increased long-term survival in variceal haemorrhage using injection sclerotherapy. Results of a controlled trial. Lancet. 1982 Jan 16;1(8264):124–127. doi: 10.1016/s0140-6736(82)90378-6. [DOI] [PubMed] [Google Scholar]
  10. Millikan W. J., Jr, Warren W. D., Henderson J. M., Smith R. B., 3rd, Salam A. A., Galambos J. T., Kutner M. H., Keen J. H. The Emory prospective randomized trial: selective versus nonselective shunt to control variceal bleeding. Ten year follow-up. Ann Surg. 1985 Jun;201(6):712–722. doi: 10.1097/00000658-198506000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Mitchell K. J., MacDougall B. R., Silk D. B., Williams R. A prospective reappraisal of emergency endoscopy in patients with portal hypertension. Scand J Gastroenterol. 1982 Nov;17(8):965–968. [PubMed] [Google Scholar]
  12. Nordlinger B. M., Nordlinger D. F., Fulenwider J. T., Millikan W. J., Sones P. J., Kutner M., Steele R., Bain R., Warren W. D. Angiography in portal hypertension: clinical significance in surgery. Am J Surg. 1980 Jan;139(1):132–141. doi: 10.1016/0002-9610(80)90242-1. [DOI] [PubMed] [Google Scholar]
  13. Novis B. H., Duys P., Barbezat G. O., Clain J., Bank S., Terblanche J. Fibreoptic endoscopy and the use of the Sengstaken tube in acute gastrointestinal haemorrhage in patients with portal hypertension and varices. Gut. 1976 Apr;17(4):258–263. doi: 10.1136/gut.17.4.258. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Paquet K. J. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices -- a prospective controlled randomized trial. Endoscopy. 1982 Jan;14(1):4–5. doi: 10.1055/s-2007-1021560. [DOI] [PubMed] [Google Scholar]
  15. Potts J. R., 3rd, Henderson J. M., Millikan W. J., Jr, Sones P., Warren W. D. Restoration of portal venous perfusion and reversal of encephalopathy by balloon occlusion of portal systemic shunt. Gastroenterology. 1984 Jul;87(1):208–212. [PubMed] [Google Scholar]
  16. Rikkers L. F., Rudman D., Galambos J. T., Fulenwider J. T., Millikan W. J., Kutner M., Smith R. B., 3rd, Salam A. A., Sones P. J., Jr, Warren W. D. A randomized, controlled trial of the distal splenorenal shunt. Ann Surg. 1978 Sep;188(3):271–282. doi: 10.1097/00000658-197809000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Terblanche J., Northover J. M., Bornman P., Kahn D., Silber W., Barbezat G. O., Sellars S., Campbell J. A., Saunders S. J. A prospective controlled trial of sclerotherapy in the long term management of patients after esophageal variceal bleeding. Surg Gynecol Obstet. 1979 Mar;148(3):323–333. [PubMed] [Google Scholar]
  18. Terblanche J., Yakoob H. I., Bornman P. C., Stiegmann G. V., Bane R., Jonker M., Wright J., Kirsch R. Acute bleeding varices: a five-year prospective evaluation of tamponade and sclerotherapy. Ann Surg. 1981 Oct;194(4):521–530. doi: 10.1097/00000658-198110000-00015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Tygstrup N. Determination of the hepatic elimination capacity (Lm) of galactose by single injection. Scand J Clin Lab Invest Suppl. 1966;18:118–125. [PubMed] [Google Scholar]
  20. Warren W. D., Henderson J. M., Millikan W. J., Galambos J. T., Brooks W. S., Riepe S. P., Salam A. A., Kutner M. H. Distal splenorenal shunt versus endoscopic sclerotherapy for long-term management of variceal bleeding. Preliminary report of a prospective, randomized trial. Ann Surg. 1986 May;203(5):454–462. doi: 10.1097/00000658-198605000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Warren W. D., Millikan W. J., Jr, Henderson J. M., Rasheed M. E., Salam A. A. Selective variceal decompression after splenectomy or splenic vein thrombosis. With a note on splenopancreatic disconnection. Ann Surg. 1984 Jun;199(6):694–702. doi: 10.1097/00000658-198406000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Warren W. D., Millikan W. J., Jr, Henderson J. M., Wright L., Kutner M., Smith R. B., 3rd, Fulenwider J. T., Salam A. A., Galambos J. T. Ten years portal hypertensive surgery at Emory. Results and new perspectives. Ann Surg. 1982 May;195(5):530–542. doi: 10.1097/00000658-198205000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Warren W. D., Rudman D., Millikan W., Galambos J. T., Salam A. A., Smith R. B., 3rd The metabolic basis of portasystemic encephalopathy and the effect of selective vs nonselective shunts. Ann Surg. 1974 Oct;180(4):573–579. doi: 10.1097/00000658-197410000-00022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Zeppa R., Hensley G. T., Levi J. U., Bergstresser P. R., Hutson D. G., Sr, Livingstone A. S., Schiff E. R., Fink P. The comparative survivals of alcoholics versus nonalcoholics after distal splenorenal shunt. Ann Surg. 1978 May;187(5):510–514. doi: 10.1097/00000658-197805000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]

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