Long-Term Follow-Up After a Distal Splenorenal Shunt Procedure A Clinical and Hemodynamic Study Roger Mosimann, MD, Lausanne, Switzerland Claude Marquis, MD, Lausanne, Switzerland Francois Mosimann, MD, Lausanne, Switzerland Philippe Gertsch, MD, Lausanne, Switzerland Since its original description by Warren et al [I] in 1967, the distal splenorenal shunt has been per- formed with increasing frequency despite contro- versy about its efficacy. Over the last few years many reports have been published that provide evidence of excellent prevention of recurrent variceal bleeding and of postoperative encephalopathy, both at short-and long-term follow-up [2-71. Because the aim of the present study is to investigate retrospectively the long-term morbidity, mortality, and hemody- namic consequences of the operation, only those patients discharged before June 1979 are included. Material and Methods From 1969 to 1979, 28 patients were discharged after they underwent the distal splenorenal shunt procedure. One was lost to follow-up and another had a portacaval anastomosis for thrombosis of a Warren shunt zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA 36 days after the operation. Of the remaining 26 patients (19 men and 7 women) aged 37 to 70 years (mean 56.5 years), 10 died after discharge. The 16 surviving patients were interviewed and underwent clinical, hematologic, and biochemical examinations. Eight of them gave consent for late angio- graphic and endoscopic assessment (18 to 97 months postoperatively; mean 40.3 months). The patency of the shunt and the size of the portal vein were recorded. When esophageal varices were present, their volume and extent were assessed according to Paquet’s morphologic criteria [B]. Variceal pressure was measured endoscopically using the pressure gauge we described previously [9,10]. The causes of hypertension in 26 patients studied were alcohol ingestion in 15, postnecrotic cirrhosis in 5, biliary cirrhosis in 2, and cirrhosis of unknown cause in 4. The distal splenorenal anastomosis was end-to-end in 14 patients and end-to-side in 12. From the Department of Surgety B, Centre Hcspitalkr Universitaire Vaudois, Lausanne. Switzerland. Requests for reprints should be addressed to Roger Mosimann. MD, Service de Chirurgie B. 1011 Lausanne-Chuv, Switzerland. Results Clinical follow-up: Of the 26 patients, 10 died 3 to 87 months after surgery (mean 38.5 months). The causes of death in these 10 patients were liver failure with coma in 6, upper gastrointestinal bleeding in 2, brain hemorrhage in 1, and endocarditis and sepsis in 1. It is noteworthy that neither of the patients with fatal gastrointestinal hemorrhage suffered recurrent variceal bleeding; one had acute duodenal ulceration, the other hemorrhagic gastritis secondary to portal vein thrombosis. Both had a patent shunt at au- topsy. The surviving patients were 11 men and 5 women aged 37 to 66 years (mean 56 years) at the time of surgery. All but one had class A disease (Child’s classification). Eight of the patients had an end- to-end anastomosis. Survival from the time of surgery to June 1982 ranged from 40 to 156 months (mean 73.5 months). In this group, eight patients are pres- ently working full-time and two part-time, one has retired, and professional activity could not be as- sessed accurately in the other five patients. The clinical assessment of the surviving patients was as follows: recurrent variceal bleeding in one, enceph- alopathy in one, hepatoma in one, ascites in none, peptic ulcer disease in two, gallstones in two, and diabetes mellitus in three. The only patient who suffered a single episode of recurrent variceal bleeding 28 months postoperatively was managed conservatively. Only one patient showed signs of encephalopathy 2 months after operation, but they were minimal and transient. He is now well and has been followed for 80 months. Overall laboratory data (bilirubin and albumin values, serum glutamic and oxalacetic transaminase levels, prothrombin time, and white blood cell and Volume 145, zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA February 1953 253