ABSTRACT
We believe that splenectomy is contraindicated in patients with portal hypertension and secondary hypersplenism. The greatest threat to life in this group of patients is variceal bleeding, and the primary consideration in the management of these patients should be to control this bleeding. Concomitant improvement in the hematologic indices of hypersplenism is achieved by DSRS.
Subject(s)
Hypersplenism/etiology , Hypertension, Portal/complications , Splenectomy , Thrombocytopenia/etiology , Hematocrit , Hemorrhage/therapy , Humans , Hypersplenism/blood , Hypersplenism/surgery , Hypertension, Portal/blood , Hypertension, Portal/surgery , Leukopenia/etiology , Platelet Count , Retrospective Studies , Splenomegaly/etiology , Splenorenal Shunt, Surgical , Thrombocytopenia/blood , Thrombocytopenia/therapy , Varicose Veins/therapyABSTRACT
Stenosis of a distal splenorenal shunt may lead to inadequate variceal decompression with the risk of rebleeding. We report this complication in three patients at five, 16 and 17 months after DSRS, with successful management by balloon dilation. One patient had rebled from varices and the other two showed roentgenologic evidence of inadequate variceal decompression. All of the shunts were patent but showed a mean pressure gradient of 15 millimeters of mercury which was reduced to a mean of 7 millimeters of mercury by dilation. Angiography at 15 months showed no restenosis and sustained reduction of the pressure gradient in one patient. The other two patients await long term follow-up observation. Rebleeding or reappearance of varices are indications for repeat angiography after DSRS to determine the cause. The risk of dilating a venous anastomosis must be weighed against the risk of rebleeding; the results of this report demonstrate that this can be done with a satisfactory outcome.
Subject(s)
Portasystemic Shunt, Surgical/adverse effects , Splenorenal Shunt, Surgical/adverse effects , Aged , Constriction, Pathologic , Dilatation , Esophageal and Gastric Varices/surgery , Female , Gastrointestinal Hemorrhage/etiology , Gastrointestinal Hemorrhage/surgery , Humans , Liver Circulation , Male , Middle Aged , Postoperative Complications/therapy , Radiography , Renal Circulation , Spleen/blood supply , Splenic Artery/diagnostic imaging , Splenic Vein/diagnostic imaging , Time FactorsABSTRACT
Twenty consecutive patients classified as Child's A and B with variceal bleeding from schistosomal hepatic fibrosis were electively managed by the distal splenorenal shunt. Patients were assessed clinically by angiography and were observed for up to 16 months. The over-all survival rate was 85 per cent with an operative mortality rate of 10 per cent. All of the patients had patent shunts as confirmed angiographically and all maintained hepatic perfusion; there was also a 40 per cent immediate reduction in the size of the spleen postoperatively as measured on the angiograms. None of the patients had encephalopathy and only two patients had postoperative ascites.