Surgical treatment usually become a choice of treatment while endoscopic and medical treatment were inefficient especially in patients with previous recurrent variceal bleeding or severe hypersplenism, portal hypertensive gastropathy and biliopathy in portal hypertension (PH) especially in noncirrhotic or early stage of cirrhotic patients
Because of portal pressure drainage into the systemic circulation, Splenorenal shunt procedures result in a marked decrease in all severe PH complication. By preserving hepatopedal flow the Warren’s shunt also prevent encephalopathy
In this study, we present 116 patients (83 pediatrics and 33 adults) who underwent 127 surgical procedures because of complicated PH in between 2000 and 2024.
108 patients underwent selective splenorenal and 2 patients underwent Central portocaval shunt procedure. (38 patients underwent Distal Splenorenal (Waren), 69 patients underwent Proximal Splenorenal (PSRS) and one pediatric patient underwent Rex Shunt procedure. 2 adult patients underwent mesocaval shunt. 6 patients underwent Splenectomy (two of them with paraosophagogastric devascularization).Seven patients required early reoperation because of bleeding, chylothorax and early shunt thrombosis, and five of them are treated uneventfully.
Results: Three adult patients died (two of them with operative mortality). One pediatric patient died after liver transplantation. Overall survival is 99% and 90% for pediatric and adult patients respectively. In remaining patients there was no more than Grade 3 Clavien complication.
Six pediatric (7%) and one adult (3%) patients who had occluded shunts had variceal rebleeding required transfusion after operation.
Warren’s Shunt patency rate was 78% and 86% and PSRS patency rate was 80% and 75% respectively for pediatric and adult patients.
Despite medical treatment has up to 90% bleeding control in first bleeding; recurrent bleeding rate is up to 60% with high mortality rate. Closure of paraosophagogastric pathways between portal and caval systems by endoscopic ligation will further increase the pressure in the distal part of the varicose veins, may cause formation of fundal varices and progression of hypertensive gastropathy and biliopathy. Effective control of rebleeding and treatment of complications; is possible by draining the high pressure in the portal system into the low pressure caval system. Effective results of spleno renal shunt surgeries have been clearly demonstrated in large series and randomized controlled clinical trials with up to 35 years follow-up. Unfortunately, in clinical practice, selective shunt surgeries are not used as often as necessary, even in appropriate patients, In these circumstances, insist endoscopic interventions in recurrent bleeding episodes instead of surgical treatment may cause high rebleeding, severe pancytopenia, portal hypertensive gastropathy and biliopathy and even mortality especially in patients who have difficulties to access advanced medical centers.