Esophageal varices

Distal Splenorenal Shunt for Esophageal Varices

The distal splenorenal shunt was designed to decompress esophageal varices while maintaining portal perfusion pressure. Dissatisfaction with the standard portacaval shunt, primarily because of subsequent hepatic failure, led to investigation of the use of the distal splenorenal shunt in patients with bleeding esophageal varices. Although the distal splenorenal shunt has a sound physiologic basis, the technical problems can be formidable. For this reason, the procedure has been recommended for use only in the ideal situation. In five previous randomized studies, the operative mortality rates for elective distal splenorenal shunt averaged 13 percent. In the urgent setting, the Mayo Clinic has reported a 38 percent mortality rate; 76 percent of the patients had total splenorenal shunts and 24 percent had distal splenorenal shunts.

Mitchell and Ignatius report that since 1976, the distal splenorenal shunt has been their procedure of choice for patients requiring decompressive shunt surgery in either an emergency or elective situation, if a patent splenic vein exists. This technique decompresses esophageal varices while preserving hepatic flow.

The authors' describe the results in 43 patients who underwent this procedure during a ten-year period. The patients ranged in age from 18 to 84 years. Six patients were categorized with Child's Class A disease, 18 patients with Child's Class B disease and 19 with Child's Class C disease. Surgery was performed as an emergency (within 24 hours of admission) in 16 patients (37 percent), as urgent (24 to 72 hours) in 19 patients (42 percent) and as elective in eight patients (19 percent). Nineteen (44 percent) of the 43 patients were actively bleeding immediately prior to surgery. The operative mortality rate was 5 percent (two of 43 patients); 34(79 percent) of the patients were long-term survivors.

The authors note that technical dexterity and the use of fine suture technique are essential. Rapid execution of the procedure minimizes the amount of blood loss. In the authors' series, the average blood loss was 440 mL and the average operative time was two and one-half hours.

The authors conclude that the distal splenorenal shunt can be performed for emergency and elective therapy of bleeding esophageal varices. The procedure is associated with a low incidence of complications and provides the patient with an excellent long-term quality of life. (American Journal of Surgery, September 1988, vol. 156, p. 169.)

COPYRIGHT 1989 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group