W. Dean Warren, MD, FACS, Father of Selective Shunts for Variceal Hemorrhage: Lessons Learned.

Dr Dean Warren was born in 1924 and died prematurely from cancer in 1989. He was a man of uncommon intelligence, wit, collegiality, integrity, honesty, and a true leader in American surgery. In 1966, he and his colleagues (Drs Zeppa and Fomon) presented a new concept for surgical shunts to control variceal hemorrhage while maintaining portal perfusion or hepatopetal blood flow. He termed this new shunt the distal splenorenal shunt (DSRS), which was the first selective shunt invented. The DSRS selective shunt was a brilliant improvement over the total shunt concept proposed by Nicolai Eck and was practiced worldwide during the 1980s. In a space of 2 decades, Dr Warren's pioneering work would show that the selective DSRS was superior to total shunts for treatment of portal hypertension, but that endoscopic sclerotherapy was a better first-line treatment for variceal hemorrhage than his own creation. His absolute adherence to the principles he espoused in his presidential address to the Society for Surgery of the Alimentary Tract in 1973 were employed in his research and treatment of patients. This paper details Dr Warren's extraordinary research accomplishments and sets a lesson for us that well-designed clinical trials including randomization are essential in the advancement of the care of surgical patients.

Balloon-occluded retrograde transvenous obliteration of gastric varices: conception, evolution, and history.

The idea of transvenous obliteration of varices that complicate portal hypertension dates back to the 1970s. The clinical use of this minimally invasive procedure was probably lost with the advent of transjugular intrahepatic portosystemic shunt shortly afterward. The concept of retrograde obliteration of a gastrorenal shunt through the left renal vein originated from Olson et al at Indiana University. However, the Japanese (Kanagawa et al and subsequent authors) defined, developed, and technically perfected the clinical implementation of balloon-occluded retrograde transvenous obliteration. The evolution of balloon-occluded retrograde transvenous obliteration has come full circle, now gaining popularity in the United States, especially in patients who are not candidates for transjugular intrahepatic portosystemic shunt.

Bleeding oesophageal varices.

BACKGROUND: The Danish contribution to evaluation and treatment of bleeding oesophageal varices. METHODS: Danish papers dealing with portal hypertension and oesophageal varices have been reviewed and set in relation to international publications. RESULTS: The Danish papers have mainly contributed with controlled clinical trials concerning both primary and secondary prophylaxis. Furthermore, they have dealt with pathophysiologic, clinical and experimental studies concerning portal haemodynamics and the evolution and treatment of variceal bleeding. CONCLUSION: The Danish studies have been well designed and are frequently cited. Further prospective randomized studies in the new treatment modalities are encouraged.

Big shunts for small patients with portal hypertension: a bit of history.

This is a brief resume of my personal experiences that led to the development of two portosystemic shunt procedures designed to be used in small patients with bleeding varices and portal hypertension. Both enable one to decompress the congested protal venous system in the preschool-aged group when about two thirds of such patients begin to suffer their first life threatening bleeding episodes.