The distal splenorenal shunt

The surgical contributions to the therapy of lifethreatening hemorrhage from esophageal varices due to portal hypertension during the past twentyfive years clearly support a few virtually incontestable conclusions. Analysis of the data derived from both controlled and uncontrolled studies has identified that (1) successful portosystemic shunt of appropriate size will eliminate the threat of variceal hemorrhage ; (2) the risk of morbidity and mortality due to encephalopathy and liver failure is increased under these conditions [l-4]. This risk is of sufficient magnitude such that life expectancy for patients undergoing prophylactic portacaval shunt is not improved and may actually be reduced when compared to that of a comparable group of patients treated by medical means alone, even though the latter group is subject to the continuing risk of exsanguinating hemorrhage. In the light of this evidence, it is difficult to escape the conclusion that acute diversion of portal venous blood from the liver is fraught with hazard. This conclusion has been supported by extensive laboratory investigations [S] primarily in the dog, which have demonstrated biochemical and morphologic changes consistent with liver injury which frequently leads to the untimely death of the animal [6]. The inability to predict the magnitude of this risk for any individual patient within a cohort of cirrhotic patients requiring portacaval shunt therapy has suggested that individual differences in preoperative hemodynamic status may be a factor. C’ertainly it has been common clinical knowledge that s’everely restricted portal venous flow to the liver M manifested by patients with cavernous transformation of the portal vein or portal venous thrombosi,s is associated with a distinct survival rate whereas patients who suffer acute ligation of the portal vein rarely survive. Furthermore, in 1963, Warren and his colFrom the Department of Surgery, University of Miami and Affiliated Hospitals, Miami, Florida. This work was partially supported by USPHS Grant He 08411-05 and RR 261, University of Miami Clinical