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Role, Indications, and Utility in the Era of Liver Transplantation

Roger L. Jenkins, MD; Roberto Gedaly, MD; James J. Pomposelli, MD, PhD; Elizabeth A. Pomfret, MD, PhD; Fredric Gordon, MD; W. David Lewis, MD

Arch Surg. 1999;134:416-420.

Hypothesis  The distal splenorenal shunt (DSRS) continues to play an important role in the management of recurrent variceal bleeding with minimal negative 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 surgeons performed 81 DSRS procedures for recurrent variceal hemorrhage. Eleven patients undergoing OLT subsequent to DSRS were compared with a group of 274 patients undergoing OLT without any previous shunt during the same period.

Main Outcome Measures  Operative time, use of blood products, length of hospital stay, perioperative complications, and survival rates.

Results  Operative (30-day) mortality for DSRS was 6% (n=5). From follow-up information available for 74 patients, the 1- and 5-year survival rates were 86.4% (n=64) and 74.3% (n=55), respectively. Recurrent variceal bleeding 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 failed transjugular intrahepatic portosystemic shunt.

Conclusions  Distal splenorenal shunt is a safe, durable, and effective treatment for controlling recurrent variceal hemorrhage in patients with acceptable operative risk and good liver function. It does not compromise future liver transplantation and can considerably delay the time until transplantation is required. Given the early occlusion rate and need for constant surveillance, transjugular intrahepatic portosystemic shunting should be reserved for patients with Child C classification cirrhosis with chronic hemorrhage or intractable ascites or as an emergency procedure for patients with uncontrollable bleeding using endoscopic therapy.

From the Division of Hepatobiliary and Transplantation Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

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