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Table 1. 
Underlying Etiologies of Portal Hypertension in 111 Patients With Child-Pugh Class A and Class B Cirrhosis Undergoing Distal Splenorenal Shunt
Underlying Etiologies of Portal Hypertension in 111 Patients With Child-Pugh Class A and Class B Cirrhosis Undergoing Distal Splenorenal Shunt
Table 2. 
Perioperative Morbidity and Complications Occurring at More Than 30 Days After DSRS Surgery*
Perioperative Morbidity and Complications Occurring at More Than 30 Days After DSRS Surgery*
1.
Warren  WDZeppa  RFomon  JJ Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg 1967;166437- 455
PubMedArticle
2.
Spellberg  MA The treatment of ascites and esophageal varices. Am J Gastroenterol 1969;51208- 226
PubMed
3.
Hermann  REHenderson  JMVogt  DP  et al.  Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation: lessons and prospects. Ann Surg 1995;221459- 466
PubMedArticle
4.
Colapinto  RFStronell  RDGildiner  M  et al.  Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience. AJR Am J Roentgenol 1983;140709- 714
PubMedArticle
5.
Rossle  MSiegerstetter  VHuber  M  et al.  The first decade of the transjugular intrahepatic portosystemic shunt: state of the art. Liver 1998;1873- 89
PubMedArticle
6.
Ter Borg  PCHollemans  MVan Buuren  HR  et al.  Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3-9 years. Radiology 2004;231537- 545
PubMedArticle
7.
Silva  RFArroyo  PC  JrDuca  WJ  et al.  Complications following transjugular intrahepatic portosystemic shunt: a retrospective analysis. Transplant Proc 2004;36926- 928
PubMedArticle
8.
Helton  WSMaves  RWicks  K  et al.  Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison. Arch Surg 2001;13617- 20
PubMedArticle
9.
Clavien  PASelzner  MTuttle-Newhall  JE  et al.  Liver transplantation complicated by misplaced TIPS in the portal vein. Ann Surg 1998;227440- 445
PubMedArticle
10.
Mazziotti  AMorelli  MCGrazi  GL  et al.  Beware of TIPS in liver transplant candidates. Hepatogastroenterology 1996;431606- 1610
PubMed
11.
Comar  KMSanyal  AJ Portal hypertensive bleeding. Gastroenterol Clin North Am 2003;321079- 1105
PubMedArticle
12.
Ryan  BMStockbrugger  RWRyan  JM A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology 2004;1261175- 1189Article
13.
Knechtle  SJ Portal hypertension: from Eck's fistula to TIPS. Ann Surg 2003;238S49- S55
PubMedArticle
14.
Henderson  JMNagle  ACurtas  S  et al.  Surgical shunts and TIPS for variceal decompression in the 1990s. Surgery 2000;128540- 547
PubMedArticle
15.
Nagasue  NKohno  HOgoawa  Y  et al.  Appraisal of distal splenorenal shunt in the treatment of esophageal varices: an analysis of prophylactic, emergency, and elective shunts. World J Surg 1989;1392- 99
PubMedArticle
16.
Orozco  HMercado  MAGarcia  JG  et al.  Selective shunts for portal hypertension: current role of a 21-year experience. Liver Transpl Surg 1997;3475- 480
PubMedArticle
17.
Khaitiyar  JSLuthra  SKPrasad  N  et al.  Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt: a comparative study. Hepatogastroenterology 2000;47492- 497
PubMed
18.
Orozco  HMercado  MA The evolution of portal hypertension surgery: lessons from 1000 operation and 50 years' experience. Arch Surg 2000;1351389- 1393
PubMedArticle
19.
Rossle  MHaag  KOchs  A The transjugular intrahepatic portosystemic stent-shunt procedure for variceal hemorrhage. N Engl J Med 1994;330165- 171
PubMedArticle
20.
Sanyal  AJFreeman  AShiffman  ML  et al.  Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective, controlled study. Hepatology 1994;2046- 55
PubMed
21.
Somberg  KARiegler  JLLeBerge  JM  et al.  Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: incidence and risk factors. Am J Gastroenterol 1995;90549- 555
PubMed
22.
Freedman  AMSanyal  AJTisnado  J  et al.  Complications of transjugular intrahepatic portosystemic shunt (TIPS): a comprehensive review. Radiographics 1993;131185- 1210
PubMedArticle
23.
LaBerge  JMRing  EJGordon  Rl  et al.  Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. Radiology 1993;187413
PubMed
24.
Knechtle  SJAlessandro  AMArmbrust  MJ  et al.  Surgical portosystemic shunts for treatment of portal hypertensive bleeding: outcome and effect on liver function. Surgery 1999;126708- 713
PubMedArticle
25.
Sanyal  AJFreedman  AMLuketic  VA  et al.  The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997;112889- 898
PubMedArticle
26.
Casado  MBosch  JGarcia-Pagan  JC  et al.  Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998;1141296- 1303
PubMedArticle
27.
LaBerge  JMFerrell  LDRing  EJ  et al.  Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 1993;4779- 786
PubMedArticle
28.
Selim  NFendley  MJBoyer  TD  et al.  Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis. Ann Surg 1998;227600- 603
PubMedArticle
29.
Zacks  SLSandler  RSBiddle  AK  et al.  Decision-analysis of transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt for portal hypertension. Hepatology 1999;291399- 1405
PubMedArticle
30.
Wong  LLLorenzo  CLimm  WM  et al.  Splenorenal shunt: an ideal procedure in the Pacific. Arch Surg 2002;1371125- 1129
PubMedArticle
31.
Millis  JMMartin  PGomes  A  et al.  Transjugular intrahepatic portosystemic shunts: impact on liver transplantation. Liver Transpl Surg 1995;1229- 233
PubMedArticle
32.
Hutchins  RRPatch  DTibballs  J  et al.  Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: a new method for portal anastomosis—a surgical salvage procedure. Liver Transpl 2000;6237- 238
PubMedArticle
33.
Dell’Era  AGrande  LBarros-Schelotto  P  et al.  Impact of prior portosystemic shunt procedures on outcome of liver transplantation. Surgery 2005;137620- 625
PubMedArticle
34.
Jenkins  RLGedaly  RPomposelli  JJ  et al.  Distal splenorenal shunt: role, indications, and utility in the era of liver transplantation. Arch Surg 1999;134416- 420
PubMedArticle
Paper
April 1, 2006

Distal Splenorenal ShuntPreferred Treatment for Recurrent Variceal Hemorrhage in the Patient With Well-Compensated Cirrhosis

Author Affiliations

Author Affiliations: Division of Hepatobiliary Surgery and Liver Transplantation, Lahey Clinic Medical Center, Burlington, Mass.

Arch Surg. 2006;141(4):385-388. doi:10.1001/archsurg.141.4.385
Abstract

Hypothesis  Distal splenorenal shunt (DSRS) is a safe and effective treatment for patients with Child-Pugh class A and B cirrhosis with recurrent variceal hemorrhage after failed transjugular intrahepatic portosystemic shunt.

Design  Retrospective case review.

Setting  Hepatobiliary surgery and liver transplantation department in a tertiary referral medical center.

Patients  Between August 1, 1985, and May 1, 2005, 119 patients with Child-Pugh class A and B cirrhosis underwent DSRS for recurrent variceal hemorrhage. Of these, 17 (14.3%) had thrombosed or failing transjugular intrahepatic portosystemic shunt prior to DSRS.

Intervention  Distal splenorenal shunt for recurrent variceal hemorrhage after failure of conservative management.

Main Outcome Measures  Morbidity, mortality, and subsequent liver transplantation rate.

Results  The overall perioperative morbidity rate was 31.5%. Thirteen patients (11.7%) developed encephalopathy and 6 (5.4%) had recurrent variceal hemorrhage. Other complications included portal vein thrombosis, pancreatitis, pancreatic pseudocyst, pneumonia, and wound infection. The 30-day operative mortality rate was 6.4% (n = 7). The 1-year survival rate was 85.9%. The incidence of DSRS for failed transjugular intrahepatic portosystemic shunt during the first 12 years of the study (1985-1997) was 11.1% (9/81). This proportion increased to 26.7% (8/30) during the second half of the study (1997-2005). During the 20-year period, 15 patients (13.5%) underwent liver transplantation a mean of 5.1 years after DSRS without an increase in morbidity or mortality after transplantation.

Conclusions  Distal splenorenal shunt may be the preferred treatment for recurrent variceal hemorrhage in the patient with well-compensated cirrhosis. In addition, DSRS does not cause increased morbidity or mortality in subsequent liver transplantation.

The distal splenorenal shunt (DSRS) was first described in 1967 by Warren and colleagues1 as a long-term surgical treatment for portal hypertension and variceal hemorrhage (VH). Management of VH at that time was limited to medical interventions, Sengstaken-Blakemore tube compression, endoscopic variceal sclerosis, and nonselective surgical shunts, such as the end-to-side portocaval shunt.2 As a selective shunt, the DSRS was an improvement over nonselective shunting procedures because it preferentially decompresses the venous collaterals around the stomach and lower esophagus, thereby preventing further hemorrhage.3 The DSRS also maintains portal blood flow to the liver and diminishes the risks of postoperative encephalopathy and accelerated hepatic failure.

In 1983, the transjugular intrahepatic portosystemic shunt (TIPS), also a nonselective shunt, was introduced.4 It was initially offered as an alternative to the surgical portocaval shunt as an emergency intervention for VH. Gradually, the indications for TIPS broadened to include recurrent variceal bleeding in stable patients with compensated liver disease.5 In many institutions, TIPS has largely replaced DSRS as the long-term treatment option for VH in patients with Child-Pugh class A and B cirrhosis.

The TIPS procedure, however, is not an equal replacement for the DSRS. It is associated with a high rate of encephalopathy, stenosis, and occlusion.68 Lifetime surveillance and frequent interventions are required to maintain shunt patency. The incidences of complications such as procedure-related bleeding, ascites, and encephalopathy are significant. Malpositioned TIPS stents can interfere with, or preclude altogether, surgical portosystemic shunting and future liver transplantation.9,10

We have reviewed the DSRS experience of a single group of hepatobiliary and liver transplantation surgeons. We compare the results of DSRS in patients with Child-Pugh class A and early class B cirrhosis with published standards with TIPS. Results of patients with failed TIPS subsequently treated with DSRS are discussed.

METHODS

Between August 1, 1985, and May 1, 2005, 119 patients underwent DSRS by the hepatobiliary and liver transplantation team at the Lahey Clinic Medical Center in Burlington, Mass. Patients were offered the DSRS procedure for recurrent gastric or esophageal variceal bleeding after failing endoscopic management or TIPS. Institutional review board approval was obtained for a retrospective medical record review of this cohort of patients. Medical records were examined for patient demographics, cause of underlying liver disease, documented variceal type, Child-Pugh class, history of TIPS, complications, 30-day mortality, and 1-year survival. Complete medical record data were available for 111 patients. Child-Pugh classification and variceal location were identified for 104 patients. One patient was lost to follow-up within 1 month of surgery. Descriptive analyses of the data were performed using a commercially available statistical package.

RESULTS

Eighty-one men (68.1%) and 38 women (31.9%) underwent DSRS at a mean age of 50.0 years (range, 20-80 years). In 44 cases (39.6%), cirrhosis and portal hypertension were due to alcohol abuse, and 19 cases (17.1%) were due to chronic hepatitis C infection. All underlying etiologies of portal hypertension in patients undergoing DSRS are listed in Table 1. Seventy-three (70.2%) had Child-Pugh class A disease and 31 (29.8%) had class B disease. Sixty-two patients (59.6%) had esophageal varices, 10 patients (9.6%) had varices isolated to the stomach, and 32 patients (30.8%) had both esophageal and gastric varices.

The overall perioperative morbidity rate was 31.5% (35/111). Most of these complications were minor and easily treated postoperatively. One patient developed recurrent variceal bleeding; 3 patients accumulated significant ascites. Thrombosis of the portal vein, identified by duplex ultrasonography, occurred in 6 patients.

Seven patients (6.4%) died during the perioperative period. Causes of death included acute respiratory distress syndrome and multiorgan system dysfunction (n = 2), acute liver decompensation and renal failure (n = 1), cardiac dysrhythmia (n = 1), myocardial infarction (n = 1), coagulopathy with uncontrolled hemorrhage from varices (n = 1), and retroperitoneal bleeding (n = 1).

The mean follow-up time after surgery was 5.3 years. Thirteen patients (11.7%) developed hepatic encephalopathy, and 6 patients (5.4%) had episodes of recurrent variceal bleeding. The survival rate for all patients followed up for at least 1 year was 85.9% (79/92). Causes of perioperative morbidity and complications occurring more than 30 days after surgery are demonstrated in Table 2.

Seventeen patients (15.3%) underwent DSRS because of failed TIPS. During the first 12 years of the study, 11.1% (9/81) of the patients receiving a DSRS had had a prior TIPS procedure. This proportion increased to 26.7% (8/30) during the last 8 years of the study (P = .09). This occurred despite the overall incidence of DSRS diminishing from 6.75 cases per year during the early period to 3.75 cases annually in subsequent years. Stent procedure dates were available only for the last 8 of these 17 patients. The DSRS procedure was performed a mean of 22 months (range, 0-76 months) after TIPS. Three of these patients had undergone TIPS revisions. One TIPS was revised 7 times. In 5 patients, attempts to salvage TIPS stents by percutaneous recannulation were unsuccessful.

During the course of the study, fifteen patients (13.5%) who had received a DSRS underwent liver transplantation after a mean interval of 5.1 years. Fourteen of these patients received cadaveric grafts; 1 received a graft from a live adult donor. Perioperative mortality for this group was 0%.

COMMENT

In the short-term management of VH secondary to portal hypertension, there are well-established algorithms to guide treatment.11 The use of β-blockers, octreotide, and nitrates along with endoscopic intervention with banding or sclerotherapy are typically effective at controlling bleeding. Unless a long-term therapy is pursued, the risk of recurrent bleeding is approximately 30% to 50%, and patients face significant risk of mortality with each episode. Choosing the best long-term management of VH depends on the underlying etiology of the portal hypertension, the degree of liver decompensation, variceal location, and factors specific to the patient. Roughly 20% of acute bleeds, for example, arise from gastric varices that respond poorly to endoscopic measures.12 For the patients with end-stage cirrhosis, definitive treatment for VH is liver transplantation.13 In patients with Child-Pugh class A and early class B liver disease, the 2 principal options are DSRS and TIPS.11

Each of these shunting procedures has been shown to satisfactorily prevent recurrent VH.14 The reported incidence of recurrent bleeding is 3.8% to 14% following DSRS1418 and 15% to 30% after TIPS.1921 During the 20-year period covered in this review, 6 (5.4%) of our patients are known to have developed recurrent VH. All of the recurrences occurred outside of the postoperative period.

The DSRS and TIPS interventions are both associated with significant potential for complications. The reported perioperative mortality rates for DSRS are 0% to 14%.1418 In our cohort, the perioperative morbidity and mortality rates were 31.5% and 6.4%, respectively. The complications ranged from pneumonia and cardiac arrhythmias to problems specific to treating patients with liver failure, such as hepatic decompensation, renal failure, and portal vein thrombosis. The early morbidity and mortality rates for all patients undergoing TIPS are 49% and 7% to 45%, respectively.14,19,22,23 For patients with Child-Pugh class A and B cirrhosis, these rates are somewhat lower (morbidity, 9%-25%; mortality, 20%-26%).8,14,17 The TIPS complications include portal vein thrombosis, hemoperitoneum, hemolytic anemia, biliary-venous fistula, and vegetative shunt infections. Fifteen percent to 30% of patients develop TIPS-related encephalopathy.1921 Thirteen (11.7%) of our patients developed significant portosystemic encephalopathy; the reported rate after DSRS is 5% to 19%1418,24

A more critical issue when considering the patient with well-compensated cirrhosis is the durability of TIPS. The procedure has a 75% incidence of shunt dysfunction or thrombosis at 6 months to 1 year detectable by duplex ultrasonography.25,26 By 2 years, nearly all patients with TIPS have functional stenosis or thrombosis due to pseudointimal hyperplasia.27 To avoid TIPS loss, patients must undergo frequent surveillance with duplex ultrasonography or venography and then face percutaneous dilatations or stent redeployments.8

When a TIPS ultimately fails or cannot be revised further in a patient with well-compensated liver disease, DSRS has been used as a salvage procedure.28 In our experience, a total of 15.3% of the patients referred for DSRS had already undergone TIPS or attempted TIPS, and several of these have been revised repeatedly. The percentage of patients who were post-TIPS increased between the former and latter parts of this study, from 11.1% to 26.7% (P = .09). While not statistically significant, we suspect that this trend reflects the increased use of TIPS during the past 10 years and subsequent increase in TIPS-associated complications.5 It is of little surprise then that DSRS has been shown in cost analysis to be less expensive than TIPS.8,29 The DSRS is also better suited for noncompliant patients and for those who have limited access to specialized medical centers capable of dealing with TIPS failures.30

Last, the possibility that a patient may be a future candidate for liver transplantation must be considered. Migration or malplacement of TIPS into the suprahepatic vena cava and right atrium or into the portal vein is reported to occur in up to 8% of patients.7 The presence of metal wall stents in these locations can make hepatectomy technically treacherous and may disqualify the patient from consideration for transplantation.31,32 From a surgical standpoint, DSRS does not compromise future transplantation because it avoids dissection around the porta hepatis.33 In our cohort of patients, we are aware of 6 cases of portal vein thrombosis after DSRS. Three of these patients later underwent transplantation despite the portal thrombosis without any technical difficulties. Although these numbers are small, we have already demonstrated that previous DSRS does not negatively impact subsequent transplantation.34

The DSRS may be considered first-line therapy for recurrent VH in patients with Child-Pugh class A and early class B cirrhosis who have failed endoscopic sclerotherapy or banding and who are unlikely to undergo transplantation within 5 years. When performed at a center with technical expertise, the short-term rates of rebleeding, encephalopathy, and other complications are acceptable and superior to TIPS. The durability of DSRS makes it a much better option in appropriately selected patients, and it avoids the burden of TIPS surveillance and revision. The DSRS adds little to the difficulty or morbidity of future liver transplantation.

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Article Information

Correspondence: David R. Elwood, MD, Division of Hepatobiliary Surgery and Liver Transplantation, Lahey Clinic Medical Center, 41 Mall Rd, Burlington, MA 01805 (david_r_elwood@lahey.org).

Accepted for Publication: December 2, 2005.

Previous Presentation: This paper was presented at The 86th Annual Meeting of the New England Surgical Society; October 1, 2005; Bretton Woods, NH; and is published after peer review and revision. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript.

References
1.
Warren  WDZeppa  RFomon  JJ Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg 1967;166437- 455
PubMedArticle
2.
Spellberg  MA The treatment of ascites and esophageal varices. Am J Gastroenterol 1969;51208- 226
PubMed
3.
Hermann  REHenderson  JMVogt  DP  et al.  Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation: lessons and prospects. Ann Surg 1995;221459- 466
PubMedArticle
4.
Colapinto  RFStronell  RDGildiner  M  et al.  Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience. AJR Am J Roentgenol 1983;140709- 714
PubMedArticle
5.
Rossle  MSiegerstetter  VHuber  M  et al.  The first decade of the transjugular intrahepatic portosystemic shunt: state of the art. Liver 1998;1873- 89
PubMedArticle
6.
Ter Borg  PCHollemans  MVan Buuren  HR  et al.  Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3-9 years. Radiology 2004;231537- 545
PubMedArticle
7.
Silva  RFArroyo  PC  JrDuca  WJ  et al.  Complications following transjugular intrahepatic portosystemic shunt: a retrospective analysis. Transplant Proc 2004;36926- 928
PubMedArticle
8.
Helton  WSMaves  RWicks  K  et al.  Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison. Arch Surg 2001;13617- 20
PubMedArticle
9.
Clavien  PASelzner  MTuttle-Newhall  JE  et al.  Liver transplantation complicated by misplaced TIPS in the portal vein. Ann Surg 1998;227440- 445
PubMedArticle
10.
Mazziotti  AMorelli  MCGrazi  GL  et al.  Beware of TIPS in liver transplant candidates. Hepatogastroenterology 1996;431606- 1610
PubMed
11.
Comar  KMSanyal  AJ Portal hypertensive bleeding. Gastroenterol Clin North Am 2003;321079- 1105
PubMedArticle
12.
Ryan  BMStockbrugger  RWRyan  JM A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology 2004;1261175- 1189Article
13.
Knechtle  SJ Portal hypertension: from Eck's fistula to TIPS. Ann Surg 2003;238S49- S55
PubMedArticle
14.
Henderson  JMNagle  ACurtas  S  et al.  Surgical shunts and TIPS for variceal decompression in the 1990s. Surgery 2000;128540- 547
PubMedArticle
15.
Nagasue  NKohno  HOgoawa  Y  et al.  Appraisal of distal splenorenal shunt in the treatment of esophageal varices: an analysis of prophylactic, emergency, and elective shunts. World J Surg 1989;1392- 99
PubMedArticle
16.
Orozco  HMercado  MAGarcia  JG  et al.  Selective shunts for portal hypertension: current role of a 21-year experience. Liver Transpl Surg 1997;3475- 480
PubMedArticle
17.
Khaitiyar  JSLuthra  SKPrasad  N  et al.  Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt: a comparative study. Hepatogastroenterology 2000;47492- 497
PubMed
18.
Orozco  HMercado  MA The evolution of portal hypertension surgery: lessons from 1000 operation and 50 years' experience. Arch Surg 2000;1351389- 1393
PubMedArticle
19.
Rossle  MHaag  KOchs  A The transjugular intrahepatic portosystemic stent-shunt procedure for variceal hemorrhage. N Engl J Med 1994;330165- 171
PubMedArticle
20.
Sanyal  AJFreeman  AShiffman  ML  et al.  Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective, controlled study. Hepatology 1994;2046- 55
PubMed
21.
Somberg  KARiegler  JLLeBerge  JM  et al.  Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: incidence and risk factors. Am J Gastroenterol 1995;90549- 555
PubMed
22.
Freedman  AMSanyal  AJTisnado  J  et al.  Complications of transjugular intrahepatic portosystemic shunt (TIPS): a comprehensive review. Radiographics 1993;131185- 1210
PubMedArticle
23.
LaBerge  JMRing  EJGordon  Rl  et al.  Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. Radiology 1993;187413
PubMed
24.
Knechtle  SJAlessandro  AMArmbrust  MJ  et al.  Surgical portosystemic shunts for treatment of portal hypertensive bleeding: outcome and effect on liver function. Surgery 1999;126708- 713
PubMedArticle
25.
Sanyal  AJFreedman  AMLuketic  VA  et al.  The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997;112889- 898
PubMedArticle
26.
Casado  MBosch  JGarcia-Pagan  JC  et al.  Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998;1141296- 1303
PubMedArticle
27.
LaBerge  JMFerrell  LDRing  EJ  et al.  Histopathologic study of stenotic and occluded transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 1993;4779- 786
PubMedArticle
28.
Selim  NFendley  MJBoyer  TD  et al.  Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis. Ann Surg 1998;227600- 603
PubMedArticle
29.
Zacks  SLSandler  RSBiddle  AK  et al.  Decision-analysis of transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt for portal hypertension. Hepatology 1999;291399- 1405
PubMedArticle
30.
Wong  LLLorenzo  CLimm  WM  et al.  Splenorenal shunt: an ideal procedure in the Pacific. Arch Surg 2002;1371125- 1129
PubMedArticle
31.
Millis  JMMartin  PGomes  A  et al.  Transjugular intrahepatic portosystemic shunts: impact on liver transplantation. Liver Transpl Surg 1995;1229- 233
PubMedArticle
32.
Hutchins  RRPatch  DTibballs  J  et al.  Liver transplantation complicated by embedded transjugular intrahepatic portosystemic shunt: a new method for portal anastomosis—a surgical salvage procedure. Liver Transpl 2000;6237- 238
PubMedArticle
33.
Dell’Era  AGrande  LBarros-Schelotto  P  et al.  Impact of prior portosystemic shunt procedures on outcome of liver transplantation. Surgery 2005;137620- 625
PubMedArticle
34.
Jenkins  RLGedaly  RPomposelli  JJ  et al.  Distal splenorenal shunt: role, indications, and utility in the era of liver transplantation. Arch Surg 1999;134416- 420
PubMedArticle

Benedict Cosimi, MD, Boston, Mass: I feel a bit of a déjà vu here. When I was a surgical resident, portosystemic shunting was the only thing available for bleeding varices and that's all we did. It was for these patients that Bob Linton championed the splenorenal shunt, admittedly a proximal rather than distal shunt. Then along came the TIPS procedure and nobody continued to do these portosystemic shunts. I would venture to say that many residents now don't even know how to do most of the portosystemic shunts. Now you are advocating that we go back. What has changed? Did TIPS just not prove to be what we thought it was?

Dr Elwood: Thank you for your question. TIPS has not proven to be what we thought it was. The hepatobiliary and liver transplant surgeons, as well as gastroenterologists, who follow patients with cirrhosis over the long-term are growing frustrated with TIPS chronic management for variceal bleeding. These patients are committed to frequent surveillance ultrasounds and often require stent manipulations. It is very disheartening to have patients with early disease come into clinic with encephalopathy post-TIPS that will not resolve until they are transplanted. It is even worse to discover on referral to a transplant center a venous complication, such as the one I showed earlier, that prevents or complicates transplantation. We hope that hepatobiliary surgeons who are experienced with this procedure will start teaching the younger generation so we can go back to using something that is more durable.

Nabil Atweh, MD, Bridgeport, Conn: I wonder if over the 20 years you have noticed any increase in the rate of failures of surgically performing the distal splenorenal shunt. The reason I am saying that is that there has been an increase in the use of sclerosing agents, which seems to spread all the way to underneath the pancreas and cause sclerosing fibrosis to form that makes the procedure more difficult. These are the techniques that the gastroenterologists have used more aggressively recently. Did you notice a drop in the rate of success in achieving a distal splenorenal shunt?

Dr Elwood: At one point while examining our data, I did break down the group's experience into early and late time periods. The complication and mortality rates were similar, despite the fact that more patients had undergone previous TIPS and other interventions during the latter period.

Dr Atweh: Were there any other procedures performed different than the distal splenorenal shunt for variceal bleeding?

Dr Elwood: I included in this series only the distal splenorenal shunts. Our group does have experience with other surgical shunt options, including portocaval shunts, side-to-side splenorenal shunt, mesocaval shunt, and 1 mesogonadal shunt.

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