Clinical

Distal splenorenal shunt favored for many cases of recurrent variceal bleeding

Last Updated: 2006-04-20 16:48:24 -0400 (Reuters Health)

NEW YORK (Reuters Health) - 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 B).

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in preventing further hemorrhage as well as encephalopathy and accelerated liver failure, at many centers it has now been replaced by the minimally invasive procedure TIPS.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. David 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.