Distal Splenorenal Shunt Favored for Many Cases of Recurrent Variceal Bleeding

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Distal Splenorenal Shunt Favored for Many Cases of Recurrent Variceal

Bleeding

NEW YORK (Reuters Health) Apr 20 - Findings from a new study suggest that

the distal splenorenal shunt (DSRS) is the preferred treatment for recurrent

variceal bleeding, provided that the patient has well-compensated cirrhosis

(Child-Pugh class A and .

Unlike portocaval shunts, the DSRS is a selective shunt; it preferentially

drains the varices around the stomach and esophagus, while maintaining blood

flow to the liver. Although DSRS is effective in preventing further

hemorrhage as well as encephalopathy and accelerated liver failure, at many

centers it has now been replaced by the minimally invasive procedure TIPS.

However, TIPS, which stands for transjugular intrahepatic portosystemic

shunt, is a nonselective shunt and not a comparable replacement for DSRS,

lead author Dr. R. Elwood and colleagues, from the Lahey Clinic

Medical Center in Burlington, Massachusetts, emphasize.

In the present study, reported in the Archives of Surgery for April, the

researchers describe their experience with 119 patients who underwent DSRS

between August 1, 1985 and May 1, 2005. All of the patients had Child-Pugh

class A or B cirrhosis and 17 were treated after TIPS failed.

Nearly one third of patients experienced perioperative complications, the

report indicates. Encephalopathy occurred in 13 patients (11.7%) and

recurrent variceal hemorrhage was noted in 6 (5.4%). By contrast, with TIPS,

early complication rates are typically lower and rates of encephalopathy and

recurrent bleeding are higher.

Other complications seen in the study group included portal vein thrombosis,

pancreatitis, pancreatic pseudocyst, pneumonia, and wound infection. Fifteen

patients underwent liver transplantation with a mean interval of 5.1 years

following DSRS. Moreover, this history of DSRS did not complicate

transplantation.

DSRS was associated with a 30-day operative mortality rate of 6.4% and

1-year survival of 85.9%. By contrast, an early mortality rate of 20% to 26%

has been reported with TIPS.

The proportion of DSRS operations performed for failed TIPS increased from

11.1% during the first 12 years of the study to 26.7% during the last 9

years.

" When performed at a center with technical expertise, the short-term rates

of rebleeding, encephalopathy, and other complications (with DSRS) are

acceptable and superior to TIPS, " the authors state. " The durability of DSRS

makes it a much better option in appropriately selected patients, and it

avoids the burden of TIPS surveillance and revision. "

Arch Surg 2006;141:385-388.

http://www.medscape.com/viewarticle/530419

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