Comparison of distal and proximal splenorenal shunts: a ten-year experience.

BACKGROUND

This study evaluated the effectiveness of distal (DSRS) versus the central or proximal (PSRS) splenorenal shunts in the elective treatment of bleeding varices.

METHODS

A series of 48 patients with portal hypertension and established variceal bleeding were randomized to undergo PSRS or DSRS. Preoperative evaluation included endoscopic examination, angiography, serum amino acid profile, liver chemistry studies, and neurologic evaluation. Any patient with significant ascites and hepatofugal flow underwent PSRS shunt procedures; the remainder were randomized prospectively.

RESULTS

Between 1979 and 1989, 29 patients underwent PSRS and 19 underwent DSRS. The mean length of follow-up was 48 months. The groups were equivalent with regard to age, gender, child's class, number of preoperative bleeds, and cause of disease. No difference was found in any of the factors measured. In particular there were no differences in the operative mortality rate (17% PSRS; 11% DSRS), 5-year survival rate (52% PSRS; 52% DSRS), rebleeding (34% PSRS; 32% DSRS), shunt occlusion (7% PSRS; 11% DSRS), development of individual episodes of postoperative encephalopathy (28% PSRS; 26% DSRS), chronic postoperative encephalopathy (17% PSRS; 11% DSRS), or mean branched-chain/aromatic amino acid ratios (PSRS = 0.88 +/- 0.05; DSRS = 0.66 +/- 0.05).

CONCLUSIONS

The results do not support the contention that DSRS is associated with either greater survival or less encephalopathy than PSRS.