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. 1982 May;195(5):530–541. doi: 10.1097/00000658-198205000-00002

Ten Years Portal Hypertensive Surgery at Emory: Results and New Perspectives

W Dean Warren, William J Millikan Jr, J Michael Henderson, Lisa Wright, Michael Kutner, Robert B Smith III, J Timothy Fulenwider, Atef A Salam, John T Galambos
PMCID: PMC1352553  PMID: 7073351

Abstract

Five hundred four Shunt procedures have been done at Emory University Hospitals between 1971 and 1981 to decompress bleeding esophageal varices. This paper reviews how far the experiences of a prospective randomized study (55 patients) of distal splenorenal shunts against total shunts is supported by the nonrandomized experience (449 patients), and outlines our current methods of management dictated by this experience. The overall operative mortality for 348 selective shunts is 4.1% and for 156 nonselective shunts, 14.1%. The five-year survival following Selective shunt is 59%, and following nonselective shunt is 49%: more than half the selective shunt patients are alive, in contrast to the median survival of 44.5 months for patients having nonselective shunts. Following Selective shunt, the survival in nonalcoholic patients is significantly better than the median survival of alcoholic patients of 57 months. Encephalopathy, reported at three years after surgery in the randomized patients was significantly (p < 0.001) lower after selective shunt (12%) compared to nonselective shunt (52%): in the same population at seven years, all patients with patent nonselective shunts have clinical or subclinical encephalopathy, but only 30% of the selective shunt patients have subclinical encephalopathy. Shunt patency, immediately after surgery, is 93% following selective shunt, with only two documented late thromboses: nine of nine patients, at a mean of seven years, retain patency in the randomized study. Shunt occlusion increases with time after interposition nonselective shunts: seven of 13 are occluded at a mean follow-up of seven years in the randomized study. Portal venous perfusion is retained in 93% of patients seven to ten days after selective shunt, but in no patient with a patent nonselective shunt. Late portal perfusion is maintained in nine of the eleven patients in the randomized group studied at a mean of seven years after selective shunt. Restoration of portal perfusion has led to clearing of encephalopathy and improvement in hepatic function in six patients. The following conclusions are made: (1) selective shunts can be done with low operative mortality, and long-term patency with excellent control of bleeding; (2) hepatic portal venous perfusion has been maintained after selective shunt for ten years, and this is vital for preventing encephalopathy and maintaining hepatic function; (3) long-term survival after selective shunt is better than any reported series for nonselective shunt; and (4) selective shunts are the operative procedure of choice for variceal decompression and nonselective shunts should rarely be performed for elective decompression.

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Selected References

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

  1. Belghiti J., Grenier P., Nouel O., Nahum H., Fekete F. Long-term loss of Warren's shunt selectivity. Angiographic demonstration. Arch Surg. 1981 Sep;116(9):1121–1124. doi: 10.1001/archsurg.1981.01380210009002. [DOI] [PubMed] [Google Scholar]
  2. Bigley H. A., Jr, Chenault O. W., Jr Chylous ascites following retroperitoneal lymphadenectomy. J Urol. 1975 Dec;114(6):948–950. doi: 10.1016/s0022-5347(17)67183-0. [DOI] [PubMed] [Google Scholar]
  3. CALLOW A. D., LLOYD J. B., ISHIHARA A., PONSDOMENECH E., O'HARA E. T., CHALMERS T. C., GARCEAU A. J. INTERIM EXPERIENCE WITH A CONTROLLED STUDY OF PROPHYLACTIC PORTACAVAL SHUNT. Surgery. 1965 Jan;57:123–130. [PubMed] [Google Scholar]
  4. CONN H. O., LINDENMUTH W. W. PROPHYLACTIC PORTACAVAL ANASTOMOSIS IN CIRRHOTIC PATIENTS WITH ESOPHAGEAL VARICES: A PROGRESS REPORT OF A CONTINUING STUDY. N Engl J Med. 1965 Jun 17;272:1255–1263. doi: 10.1056/NEJM196506172722402. [DOI] [PubMed] [Google Scholar]
  5. Conn H. O., Resnick R. H., Grace N. D., Atterbury C. E., Horst D., Groszmann R. J., Gazmuri P., Gusberg R. J., Thayer B., Berk D. Distal splenorenal shunt vs. portal-systemic shunt: current status of a controlled trial. Hepatology. 1981 Mar-Apr;1(2):151–160. doi: 10.1002/hep.1840010211. [DOI] [PubMed] [Google Scholar]
  6. Fischer J. E., Bower R. H., Atamian S., Welling R. Comparison of distal and proximal splenorenal shunts: a randomized prospective trial. Ann Surg. 1981 Oct;194(4):531–544. doi: 10.1097/00000658-198110000-00016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Galambos J. T., Hersh T., Fulenwider J. T., Ansley J. D., Rudman D. Hyperalimentation in alcoholic hepatitis. Am J Gastroenterol. 1979 Nov;72(5):535–541. [PubMed] [Google Scholar]
  8. 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]
  9. Gerron G. G., Ansley J. D., Isaacs J. W., Kutner M. H., Rudman D. Technical pitfalls in measurement of venous plasma NH3 concentration. Clin Chem. 1976 May;22(5):663–666. [PubMed] [Google Scholar]
  10. Habashi A. H. Trans-splenic decompression of oesophageal varices by selective distal splenorenal shunt. J Egypt Med Assoc. 1977;60(1-2):23–38. [PubMed] [Google Scholar]
  11. Langer B., Patel S. C., Stone R. M., Colapinto R. F., Phillips M. J., Fisher M. M. Selection of operation in patients with bleeding esophageal varices. Can Med Assoc J. 1978 Feb 18;118(4):369–372. [PMC free article] [PubMed] [Google Scholar]
  12. Langer B., Rotstein L. E., Stone R. M., Taylor B. R., Patel S. C., Blendis L. M., Colapinto R. F. A prospective randomized trial of the selective distal splenorenal shunt. Surg Gynecol Obstet. 1980 Jan;150(1):45–48. [PubMed] [Google Scholar]
  13. Maillard J. N., Flamant Y. M., Hay J. M., Chandler J. G. Selectivity of the distal splenorenal shunt. Surgery. 1979 Nov;86(5):663–671. [PubMed] [Google Scholar]
  14. Malt R. A., Nabseth D. C., Orloff M. J., Stipa S. Occasional notes. Portal hypertension, 1979. N Engl J Med. 1979 Sep 13;301(11):617–618. doi: 10.1056/NEJM197909133011124. [DOI] [PubMed] [Google Scholar]
  15. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep. 1966 Mar;50(3):163–170. [PubMed] [Google Scholar]
  16. Martin E. W., Jr, Molnar J., Cooperman M., Pace W. G., Thomford N. R., Carey L. C. Observations on fifty distal splenorenal shunts. Surgery. 1978 Sep;84(3):379–383. [PubMed] [Google Scholar]
  17. Mosimann R., Loup P. Efficacy and risks of the distal splenorenal shunt in the treatment of bleeding esophageal varices. Am J Surg. 1977 Feb;133(2):163–168. doi: 10.1016/0002-9610(77)90072-1. [DOI] [PubMed] [Google Scholar]
  18. Nabseth D. C. The distal splenorenal shunt: an enigma. Am J Surg. 1981 May;141(5):579–580. doi: 10.1016/0002-9610(81)90054-4. [DOI] [PubMed] [Google Scholar]
  19. 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]
  20. Orloff M. J., Bell R. H., Jr, Hyde P. V., Skivolocki W. P. Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcoholic cirrhosis. Ann Surg. 1980 Sep;192(3):325–340. doi: 10.1097/00000658-198009000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Reichle F. A., Fahmy W. F., Golsorkhi M. Prospective comparative clinical trial with distal splenorenal and mesocaval shunts. Am J Surg. 1979 Jan;137(1):13–21. doi: 10.1016/0002-9610(79)90004-7. [DOI] [PubMed] [Google Scholar]
  22. Reynolds T. B., Donovan A. J., Mikkelsen W. P., Redeker A. G., Turrill F. L., Weiner J. M. Results of a 12-year randomized trial of portacaval shunt in patients with alcoholic liver disease and bleeding varices. Gastroenterology. 1981 May;80(5 Pt 1):1005–1011. [PubMed] [Google Scholar]
  23. 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]
  24. Rikkers L., Jenko P., Rudman D., Freides D. Subclinical hepatic encephalopathy: detection, prevalence, and relationship to nitrogen metabolism. Gastroenterology. 1978 Sep;75(3):462–469. [PubMed] [Google Scholar]
  25. Rypins E. B., Fajman W., Sarper R., Henderson J. M., Kutner M. H., Tarcan Y. A., Galambos J. T., Warren W. D. Radionuclide angiography of the liver and spleen. Noninvasive method for assessing the ratio of portal venous to total hepatic blood flow and portasystemic shunt patency. Am J Surg. 1981 Nov;142(5):574–579. doi: 10.1016/0002-9610(81)90429-3. [DOI] [PubMed] [Google Scholar]
  26. Rypins E. B., Henderson J. M., Fulenwider J. T., Moffitt S., Galambos J. T., Warren W. D., Rudman D. A tracer method for measuring rate of urea synthesis in normal and cirrhotic subjects. Gastroenterology. 1980 Jun;78(6):1419–1424. [PubMed] [Google Scholar]
  27. Silver D., Puckett C. L., McNeer J. F., McLeod M. E., Sabiston D. C., Jr Evaluation of selective transsplenic decompression of gastroesophageal varices. Am J Surg. 1974 Jan;127(1):30–34. doi: 10.1016/0002-9610(74)90007-5. [DOI] [PubMed] [Google Scholar]
  28. Smith-Laing G., Scott J., Long R. G., Dick R., Sherlock S. Role of percutaneous transhepatic obliteration of varices in the management of hemorrhage from gastroesophageal varices. Gastroenterology. 1981 May;80(5 Pt 1):1031–1036. [PubMed] [Google Scholar]
  29. Smith R. B., 3rd, Warren W. D., Salam A. A., Millikan W. J., Ansley J. D., Galambos J. T., Kutner M., Bain R. P. Dacron interposition shunts for portal hypertension. An analysis of morbidity correlates. Ann Surg. 1980 Jul;192(1):9–17. doi: 10.1097/00000658-198007000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. TYGSTRUP N. THE GALACTOSE ELIMINATION CAPACITY IN CONTROL SUBJECTS AND IN PATIENTS WITH CIRRHOSIS OF THE LIVER. Acta Med Scand. 1964 Mar;175:281–289. doi: 10.1111/j.0954-6820.1964.tb00576.x. [DOI] [PubMed] [Google Scholar]
  31. 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]
  32. Thomford N. R., Sirinek K. R., Martin E. W., Jr A series of 20 successful Warren shunts. Arch Surg. 1975 May;110(5):584–587. doi: 10.1001/archsurg.1975.01360110130021. [DOI] [PubMed] [Google Scholar]
  33. Turcotte J. G., Lambert M. J., 3rd Variceal hemorrhage, hepatic cirrhosis, and portacaval shunts. Surgery. 1973 Jun;73(6):810–817. [PubMed] [Google Scholar]
  34. Tylén U., Simert G., Vang J. Hemodynamic changes after distal splenorenal shunt studied by sequential angiography. Radiology. 1976 Dec;121(3 Pt 1):585–589. doi: 10.1148/121.3.585. [DOI] [PubMed] [Google Scholar]
  35. Voorhees A. B., Jr, Price J. B., Jr, Britton R. C. Portasystemic shunting procedures for portal hypertension. Twenty-six year experience in adults with cirrhosis of the liver. Am J Surg. 1970 May;119(5):501–505. doi: 10.1016/0002-9610(70)90162-5. [DOI] [PubMed] [Google Scholar]
  36. WANTZ G. E., PAYNE M. A. Experience with portacaval shunt for portal hypertension. N Engl J Med. 1961 Oct 12;265:721–728. doi: 10.1056/NEJM196110122651502. [DOI] [PubMed] [Google Scholar]
  37. Warren W. D., Zeppa R., Fomon J. J. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967 Sep;166(3):437–455. doi: 10.1097/00000658-196709000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Widrich W. C., Robbins A. H., Johnson W. C., Nabseth D. C. Long-term follow-up of distal splenorenal shunts: evaluation by arteriography, shuntography, transhepatic portal venography, and cinefluorography. Radiology. 1980 Feb;134(2):341–345. doi: 10.1148/radiology.134.2.7352211. [DOI] [PubMed] [Google Scholar]
  39. 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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