Effect of Spontaneous Portosystemic Shunts on Hemorrhage from Esophagogastric Varices Jan-Sing Hsieh, M.D., Jaw-Yuan Wang, M.D., Che-Jen Huang, M.D., Fang-Ming Chen, M.D., Tsung-Jen Huang, M.D. Department of Surgery, Kaohsiung Medical University, No. 100, Shih Chuan 1st Road, 807 Kaohsiung, Taiwan Published Online: December 5, 2003 Abstract. The role of a massive spontaneous portosystemic shunt (MSPSS) in cirrhotic patients with portal hypertension remains unclear. The aim of this study was to investigate clinical outcomes and portal he- modynamic changes following ligation of the MSPSS during devascular- ization surgery. Portography and gastroendoscopy were performed before and after surgery for hemodynamic and follow-up studies. Three types of MSPSS were demonstrated portographically: 22 portoumbilical shunts, 18 splenorenal shunts, and 2 inferior mesenteric-caval shunts. A total of 40 MSPSS patients with esophagogastric variceal (EGV) bleeding underwent surgery: 26 had ligation of the MSPSS, and the remaining 14 served as the nonligation group. Neither the preoperative mean portal pressure (MPP) nor the postoperative MPP were significantly different between the ligation and nonligation groups (p > 0.1), and there was no significant difference regarding surgical mortality, recurrent varices, or cumulative survival rate for the two groups in the follow-up study. However, postoperative portog- raphy demonstrated persistent drainage of portal flow and decreased in- trahepatic portal perfusion in the nonligation patients. Clinical signs of hepatic encephalopathy subsided after ligation of the MSPSS in three pa- tients. Therefore ligation of the MSPSS, which may be responsible for the development of encephalopathy, is recommended during devascularization surgery for EGV in cirrhotic patients. Cirrhotic patients frequently develop a vast variety of portosys- temic collaterals as a consequence of long-standing portal hyper- tension [1, 2]. With the use of direct portography, previously un- known spontaneous portosystemic shunts have been increasingly recognized. Massive spontaneous portosystemic shunts (MSPSSs) are occasionally identified in a small group of patients. They are usually of large diameter and drain a significant amount of splanch- nic blood into the systemic circulation, bypassing the esophagogas- tric veins [1, 2]. The clinical importance of the shunts remains of great interest, as there is a discrepancy regarding the protective effect of MSPSSs from esophagogastric variceal (EGV) bleeding and the development of hepatic encephalopathy in cirrhotic pa- tients [1–8]. Many cirrhotic patients continue to maintain an el- evated portal pressure and suffer from variceal hemorrhage even in the presence of an MSPSS. We know of no literature concerning whether MSPSSs should be eradicated or preserved during EGV surgery. Thus we attempted to investigate the clinical outcomes and changes in the portal hemodynamics of cirrhotic patients fol- lowing ligation of the MSPSS during devascularization surgery to determine if an MSPSS affects the risk of variceal hemorrhage and encephalopathy. Patients and Methods Patients A total of 42 patients (35 men, 7 women) with a median age of 52 years (range 37–68 years) were included in this study during 1991– 1997. Liver cirrhosis was documented in all patients by histologic diagnosis, and they had had at least one previous or current episode of gastrointestinal bleeding. All of the patients were subjected to routine clinical, laboratory, endoscopic, and portographic exami- nations; and esophagogastric varices were well documented by en- doscopic examination in all of them. Altogether, 40 patients under- went surgery and were then divided into ligation and nonligation groups depending on whether the MSPSS was ligated or preserved during surgery. The clinical data for these patients are shown in Table 1. Percutaneous Transhepatic Portography Percutaneous transhepatic portography (PTP), previously de- scribed, was used to evaluate the number, size, and flow pattern of the shunts and EGV preoperatively in all patients [9]. The portal pressure was measured when the tip of the catheter was in the main portal trunk. The puncture site in the mid-axillary line was the ref- erence level. The presence of an MSPSS was considered when the contrast drained along the shunting channel, clearly delineating the inferior vena cava on a portogram (Fig. 1). Types of EGV and MSPSS All 42 patients with MSPSSs had EGV, as evidenced by preopera- tive endoscopy and portography. According to the endoscopic find- ings, 15 had esophageal varices, 16 had gastric varices, 9 had EGV, Correspondence to: Jaw-Yuan Wang, M.D., e-mail: cy614112@ms14. hinet.net WORLD Journal of SURGERY © 2003 by the Socie ´te ´ Internationale de Chirurgie World J. Surg. 28, 23–28, 2004 DOI: 10.1007/s00268-003-7068-7