Distal splenorenal shunt - Role, indications, and utility in the eva of liver transplantation

Hypothesis: The distal splenorenal shunt (DSRS) continues to play an import ant role in the management of recurrent variceal bleeding with minimal nega tive impact on subsequent orthotopic liver transplantation (OLT). Design Case-control study. Setting: Hepatobiliary surgery and liver transplantation unit in a tertiary referral medical center. Patients: From August 1, 1985, through October 31, 1997, a single team of s urgeons performed 81 DSRS procedures for recurrent variceal hemorrhage. Ele ven patients undergoing OLT subsequent to DSRS were compared with a group o f 274 patients undergoing OLT without any previous shunt during the same pe riod. Main Outcome Measures: Operative time, use of blood products, length of hos pital stay, perioperative complications, and survival rates. Results: Operative (30-day)mortality for DSRS was 6% (n = 5). From follow-u p information available for 74 patients, the 1- and 5-year survival rates w ere 86.4% (n = 64) and 74.3% (n = 55), respectively. Recurrent variceal ble eding and hepatic encephalopathy occurred in 5 (6.8%) and 11 patients (14.9 %), respectively, after DSRS. In 9 patients, DSRS was used as salvage for f ailed transjugular intrahepatic portosystemic shunt. Conclusions: Distal splenorenal shunt is a safe, durable, and effective tre atment for controlling recurrent variceal hemorrhage in patients with accep table operative risk and good liver function. It does not compromise future liver transplantation and can considerably delay the time until transplant ation is required. Given the early occlusion rate and need for constant sur veillance, transjugular intrahepatic portosystemic shunting should be reser ved for patients with Child C classification cirrhosis with chronic hemorrh age or intractable ascites or as an emergency procedure for patients with u ncontrollable bleeding using endoscopic therapy.