Distal splenorenal shunt (DSRS) for failed transjugular intrahepatic portocaval shunt (TIPS)

David R Elwood, James J Pomposelli, Elizabeth A Pomfret, W David Lewis, Roger L Jenkins
Lahey Clinic, Burlington, MA

Hypothesis: DSRS is a safe and effective treatment for Child’s class A and B cirrhotic patients with recurrent variceal hemorrhage after failed TIPS.
Design: Retrospective case review.
Setting: Hepatobiliary surgery and liver transplantation department in a tertiary referral medical center.
Patients: Between August 1, 1985 and May 1, 2005, 119 Child’s class A and B cirrhotic patients underwent DSRS for recurrent variceal hemorrhage. Of these, 17 had undergone TIPS prior to DSRS.
Main Outcome Measures: Morbidity, mortality, hospital length of stay, and subsequent liver transplant (LT) rate.
Results: The overall perioperative morbidity rate was 40.6%. 11.8% (n=13) patients developed encephalopathy and 6.4% (n=7) had recurrent variceal bleeding. Other complications included portal vein thrombosis, pancreatitis, pancreatic pseudocyst, pneumonia, and wound infection. The 30 day operative mortality was 6.5% (n=7). One year survival was 85.9%. Mean length of stay was 14.5 days. The incidence of DSRS for failed TIPS during the first decade of the study was 11%. This increased to 27% during the latter half of the study. Over the course of the study, 14 patients underwent LT a median of 3 yrs after DSRS without an increase in post LT morbidity or mortality.
Conclusions: Given the high failure rate of TIPS, DSRS is the preferred treatment for recurrent variceal hemorrhage in the well-compensated cirrhotic patient. In addition, DSRS does not cause increased morbidity or mortality in subsequent LT.

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