Controversy still surrounds the place of portalsystemic shunting in the
therapy of
bleeding esophageal varices. Recently, a selective shunt, the distal
splenorenal shunt, has achieved some degree of popularity and, apparently, is associated with less
chronic encephalopathy. Because of this, a trial was initiated at the Massachusetts General Hospital and continued at the University of Cincinnati Medical Center, prospectively randomizing central and distal
splenorenal shunts in consecutive elective cases of patients with established variceal
bleeding. Preoperative evaluation included endoscopic examination at the time of
hemorrhage, angiography and upper gastrointestinal series, emphasis on mental function including EEG,
amino acids, neurologic examination, as well as standard liver chemistries. Nineteen patients underwent central
splenorenal shunts and 23 distal
splenorenal shunt. There was one operative death from
hemorrhagic pancreatitis in a Child's Class A patient with distal
splenorenal shunt. Four late deaths, from
gunshot wound, auto accident, overwhelming
pneumonitis similar to postsplenectomy syndrome, and metastatic
carcinoma (2.5 years after operation), have been recorded in the distal
splenorenal shunt group, and none in the central
splenorenal shunt group. On follow-up angiographic examination, six shunts have clotted, with three patients requiring reoperation, generally mesocaval shunt. There has been no
chronic encephalopathy, three individual episodes of
encephalopathy, two in the central
splenorenal shunt group and one in the distal
splenorenal shunt group, two associated with gastrointestinal
bleeding and one with intercurrent
infection and overdiuresis. Follow-up liver chemistries and
amino acids which may be useful as an
indicator of hepatic function suggest that although the distal shunt group had a better
amino acid pattern before operation,
branched-chain amino acids tend to become lower in the distal group while remaining the same in the central group.
Aromatic amino acids increase post shunt, equally in the two groups. The results do not support the contention that distal
splenorenal shunt is associated either with greater survival or freedom from
encephalopathy than central
splenorenal shunt, a small side-to-side shunt.
Ascites seems better controlled by the central
splenorenal shunt.