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Chapter 89 - Portal shunting procedures
- from Section 19 - Vascular Surgery
- Edited by Michael F. Lubin, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Neil H. Winawer, Emory University, Atlanta
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- Book:
- Medical Management of the Surgical Patient
- Published online:
- 05 September 2013
- Print publication:
- 15 August 2013, pp 629-632
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- Chapter
- Export citation
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Summary
Decompressive portosystemic shunts play a significant role in the treatment of patients with portal hypertension and gastroesophageal varices. The main indication for portal shunting procedures is the prevention of recurrent variceal bleeding in patients with cirrhosis and portal hypertension after failure of endoscopic interventions (banding, sclerotherapy). Portal shunting procedures are not indicated for prophylaxis against variceal bleeding in patients who have not yet bled. In these patients, medical management (non-selective beta-blockers) and endoscopic therapies are utilized. The ideal candidates for shunt procedures are Child–Turcotte–Pugh (Child's) class A or B patients who have favorable venous anatomy. The procedures themselves can be divided into two main categories: total shunts and selective distal splenorenal (Warren) shunt.
With total shunts, the entire portal venous blood flow is shunted away from the liver into the systemic venous circulation. This includes end-to-side and side-to-side portacaval shunts, central splenorenal shunts, Marion–Clatworthy mesocaval shunts, interposition mesocaval shunts, and radiologically placed transjugular intrahepatic portosystemic shunts (TIPS). The small graft portacaval interposition shunt is a modification designed to achieve partial rather than total diversion of portal venous flow. If patients who require total shunts are potential candidates for liver transplantation, mesocaval rather than portacaval shunts should be chosen to preclude dissection in the liver hilum, which would complicate subsequent liver transplantation.
81 - Portal shunting procedures
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- By Tarek A. Salam, Emory University, School of Medicine, Atlanta, GA, Atef A. Salam, Emory University, School of Medicine, Atlanta, GA
- Edited by Michael F. Lubin, Emory University, Atlanta, Robert B. Smith, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Nathan O. Spell, Emory University, Atlanta, H. Kenneth Walker, Emory University, Atlanta
-
- Book:
- Medical Management of the Surgical Patient
- Published online:
- 12 January 2010
- Print publication:
- 10 August 2006, pp 629-632
-
- Chapter
- Export citation
-
Summary
Decompressive portosystemic shunts play a significant role in the treatment of patients with portal hypertension and gastroesophageal varices. The main indication for portal shunting procedures is the prevention of recurrent variceal bleeding in patients with cirrhosis and portal hypertension after failure of endoscopic sclerotherapy. Portal shunting procedures are not indicated for prophylaxis against variceal bleeding in patients who have not yet bled. The ideal candidates for shunt procedures are patients at Child's class A or B risk levels who have favorable venous anatomy. The procedures themselves can be divided into two main categories:
Total shunts
With total shunts, the entire portal venous blood flow is shunted into the systemic venous circulation. This includes end-to-side and side-to-side portacaval shunts, central splenorenal shunts, Marion–Clatworthy mesocaval shunts, interposition mesocaval shunts, and the recently introduced transjugular intrahepatic portosystemic shunt (TIPS). The small graft portacaval interposition shunt is a modification designed to achieve partial rather than total diversion of portal venous flow.
Selective distal splenorenal (Warren) shunt
With the selective distal splenorenal shunt, the gastroesophageal varices are selectively decompressed by way of the upper stomach through the short gastric veins and the disconnected splenic vein into the left renal vein, while enough pressure is maintained in the portal and superior mesenteric veins to drive blood through the diseased liver. The spleen is not removed in this procedure.
Because it is associated with a lower incidence of encephalopathy and hepatic insufficiency, the distal splenorenal shunt is used in most patients.