Abstract
The distal splenorenal shunt (DSRS) was compared with the side-to-side portacaval shunt (PCS) in 93 prospectively matched patients with portal hypertension. After 38 months mean follow-up the two shunts had a different incidence of acute encephalopathy (22% in PCS group and 33% in DSRS group) and chronic encephalopathy (35% in PCS group and 17% in DSRS group), but the difference was not statistically significant. However, the only cases of severe and disabling chronic encephalopathy arose after PCS (p = 0.049). Actuarial curves of chronic encephalopathy showed that the maximum rate of encephalopathy (18%) in the DSRS group was reached 27 months after shunt surgery, whereas this value was reached and passed in PCS group only 4 months after shunt. Chronic encephalopathy occurred for a total duration of 20.1 months after PCS and only 11.1 months afer DSRS (p = 0.003) and occupied 46.3% of the follow-p of PCS patients, as contrasted to 18.7% of the follow-up of DSRS patients (p = 0.0001). DSRS is associated with a lower global incidence of chronic HE without severe forms and provides a better quality of life than does a nonselective shunt.
Full text
PDFSelected References
These references are in PubMed. This may not be the complete list of references from this article.
- Bismuth H., Houssin D., Grange D. Suppression of the shunt and esophageal transection. A new technique for the treatment of disabling postshunt encephalopathy. Am J Surg. 1983 Sep;146(3):392–396. doi: 10.1016/0002-9610(83)90425-7. [DOI] [PubMed] [Google Scholar]
- Britton R. C., Voorhees A. B., Jr, Price J. B., Jr Selective portal decompression. Surgery. 1970 Jan;67(1):104–113. [PubMed] [Google Scholar]
- Busuttil R. W. Selective and nonselective shunts for variceal bleeding. A prospective study of 103 patients. Am J Surg. 1984 Jul;148(1):27–35. doi: 10.1016/0002-9610(84)90285-x. [DOI] [PubMed] [Google Scholar]
- Cello J. P., Grendell J. H., Crass R. A., Weber T. E., Trunkey D. D. Endoscopic sclerotherapy versus portacaval shunt in patient with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up. N Engl J Med. 1987 Jan 1;316(1):11–15. doi: 10.1056/NEJM198701013160103. [DOI] [PubMed] [Google Scholar]
- Conn H. O., Leevy C. M., Vlahcevic Z. R., Rodgers J. B., Maddrey W. C., Seeff L., Levy L. L. Comparison of lactulose and neomycin in the treatment of chronic portal-systemic encephalopathy. A double blind controlled trial. Gastroenterology. 1977 Apr;72(4 Pt 1):573–583. [PubMed] [Google Scholar]
- 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]
- Conn H. O. Trailmaking and number-connection tests in the assessment of mental state in portal systemic encephalopathy. Am J Dig Dis. 1977 Jun;22(6):541–550. doi: 10.1007/BF01072510. [DOI] [PubMed] [Google Scholar]
- 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]
- Fékété F., Belghiti J., Grenier P., Lebrec D. L'encéphalopathie après anastomose spléno-rénale distale est-elle en rapport avec les modifications hémodynamiques splanchniques? Chirurgie. 1982 Jun;108(6):519–522. [PubMed] [Google Scholar]
- Hanna S. S., Smith R. S., 3rd, Henderson J. M., Millikan W. J., Jr, Warren W. D. Reversal of hepatic encephalopathy after occlusion of total portasystemic shunts. Am J Surg. 1981 Aug;142(2):285–289. doi: 10.1016/0002-9610(81)90294-4. [DOI] [PubMed] [Google Scholar]
- Harley H. A., Morgan T., Redeker A. G., Reynolds T. B., Villamil F., Weiner J. M., Yellin A. Results of a randomized trial of end-to-side portacaval shunt and distal splenorenal shunt in alcoholic liver disease and variceal bleeding. Gastroenterology. 1986 Oct;91(4):802–809. doi: 10.1016/0016-5085(86)90679-7. [DOI] [PubMed] [Google Scholar]
- Henderson J. M., Gong-Liang J., Galloway J., Millikan W. J., Jr, Sones P. J., Warren W. D. Portaprival collaterals following distal splenorenal shunt. Incidence, magnitude and associated portal perfusion changes. J Hepatol. 1985;1(6):649–661. doi: 10.1016/s0168-8278(85)80008-8. [DOI] [PubMed] [Google Scholar]
- Henderson J. M., Millikan W. J., Warren W. D. The distal splenorenal shunt: an update. World J Surg. 1984 Oct;8(5):722–732. doi: 10.1007/BF01655769. [DOI] [PubMed] [Google Scholar]
- Jackson F. C., Perrin E. B., Felix W. R., Smith A. G. A clinical investigation of the portacaval shunt. V. Survival analysis of the therapeutic operation. Ann Surg. 1971 Oct;174(4):672–701. doi: 10.1097/00000658-197110000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jackson F. C., Perrin E. B., Smith A. G., Dagradi A. E., Nadal H. M. A clinical investigation of the portacaval shunt. II. Survival analysis of the prophylactic operation. Am J Surg. 1968 Jan;115(1):22–42. doi: 10.1016/0002-9610(68)90127-x. [DOI] [PubMed] [Google Scholar]
- 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]
- Langer B., Taylor B. R., Mackenzie D. R., Gilas T., Stone R. M., Blendis L. Further report of a prospective randomized trial comparing distal splenorenal shunt with end-to-side portacaval shunt. An analysis of encephalopathy, survival, and quality of life. Gastroenterology. 1985 Feb;88(2):424–429. doi: 10.1016/0016-5085(85)90502-5. [DOI] [PubMed] [Google Scholar]
- 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]
- 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]
- Mutchnick M. G., Lerner E., Conn H. O. Portal-systemic encephalopathy and portacaval anastomosis: a prospective, controlled investigation. Gastroenterology. 1974 May;66(5):1005–1019. [PubMed] [Google Scholar]
- 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]
- Pappas S. C., Jones E. A. Methods for assessing hepatic encephalopathy. Semin Liver Dis. 1983 Nov;3(4):298–307. doi: 10.1055/s-2008-1040782. [DOI] [PubMed] [Google Scholar]
- Peto R., Pike M. C., Armitage P., Breslow N. E., Cox D. R., Howard S. V., Mantel N., McPherson K., Peto J., Smith P. G. Design and analysis of randomized clinical trials requiring prolonged observation of each patient. II. analysis and examples. Br J Cancer. 1977 Jan;35(1):1–39. doi: 10.1038/bjc.1977.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pezzuoli G., Spina G. P., Galeotti F., Opocher E. Faut-il encore pratiquer la dérivation sélective pour traiter l'hypertension portale? Chirurgie. 1982 Jun;108(6):513–518. [PubMed] [Google Scholar]
- Pezzuoli G., Spina G. P., Opocher E., Galeotti F., Zannini P. Portacaval shunt in the treatment of primary Budd-Chiari syndrome. Surgery. 1985 Aug;98(2):319–323. [PubMed] [Google Scholar]
- 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]
- Reiner D. S., Kaminski D. L. Comparative evaluation of selective and nonselective peripheral portosystemic shunts for treatment of variceal hemorrhage. Am J Surg. 1982 Dec;144(6):704–710. doi: 10.1016/0002-9610(82)90555-4. [DOI] [PubMed] [Google Scholar]
- Resnick R. H., Chalmers T. C., Ishihara A. M., Garceau A. J., Callow A. D., Schimmel E. M., O'Hara E. T. A controlled study of the prophylactic portacaval shunt. A final report. Ann Intern Med. 1969 Apr;70(4):675–688. doi: 10.7326/0003-4819-70-4-675. [DOI] [PubMed] [Google Scholar]
- 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]
- Rigau J., Terés J., Visa J., Bosch J., Conesa A., Grande L., Vilar J. A., García-Valdecasas J. C., Pera C. Long term follow-up of 100 patients with portal hypertension treated by a modified splenorenal shunt. Br J Surg. 1986 Sep;73(9):708–711. doi: 10.1002/bjs.1800730911. [DOI] [PubMed] [Google Scholar]
- Rikkers L. F., Cormier R. A., Vo N. M. Effects of altered portal hemodynamics after distal splenorenal shunts. Am J Surg. 1987 Jan;153(1):80–85. doi: 10.1016/0002-9610(87)90205-4. [DOI] [PubMed] [Google Scholar]
- Rikkers L. F. Portal hemodynamics, intestinal absorption, and postshunt encephalopathy. Surgery. 1983 Aug;94(2):126–133. [PubMed] [Google Scholar]
- 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]
- Vang J., Simert G., Hansson J. A., Thylen U., Bengmark T. S. Results of a modified distal spleno-renal shunt for portal hypertension. Ann Surg. 1977 Feb;185(2):224–228. doi: 10.1097/00000658-197702000-00016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Voorhees A. B., Jr, Price J. B. An update of portal systemic shunting and its complications. World J Surg. 1984 Oct;8(5):698–701. doi: 10.1007/BF01655765. [DOI] [PubMed] [Google Scholar]
- 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]
- Warren W. D., Millikan W. J., Jr, Henderson J. M., Abu-Elmagd K. M., Galloway J. R., Shires G. T., 3rd, Richards W. O., Salam A. A., Kutner M. H. Splenopancreatic disconnection. Improved selectivity of distal splenorenal shunt. Ann Surg. 1986 Oct;204(4):346–355. doi: 10.1097/00000658-198610000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 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]
- 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]
- 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]
- da Silva L. C., Strauss E., Gayotto L. C., Mies S., Macedo A. L., da Silva A. T., Silva E. F., Lacet C. M., Antonelli R. H., Fermanian J. A randomized trial for the study of the elective surgical treatment of portal hypertension in mansonic schistosomiasis. Ann Surg. 1986 Aug;204(2):148–153. doi: 10.1097/00000658-198608000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]