Surgical outcomes of distal splenorenal shunt or liver transplantation in treatment of schistosomal refractory variceal bleeding. Wael Mohialddin Ahmed Doush1. the distal splenorenal shunt (dsrs) is a surgical procedure during which the vein from the spleen (called the splenic vein) is detached from the portal vein and. the distal splenorenal shunt (dsrs) procedure provides good long-term control of bleeding in many people with portal hypertension. dsrs controls bleeding in.
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BoxKhartoumSudan. Schistosomiasis is one of the most prevalent neglected tropical diseases, remains a serious public health problem in many developing countries in the tropics and subtropics and its pathogenesis depends on the parasite-host interaction. Periportal fibrosis of schistosomiasis complicated by portal hypertension results from increased intrahepatic vascular resistance and blood flow through the portal venous system.
This leads to portosystemic collateral variceal veins formation which dilates until they finally rupture and bleed due to progressive rising in the portal venous pressure. The clinical impact of esophagogastric varices is critical due to the rebleeding rate of esophageal varices remains high within two years after cessation of acute bleeding from medium or large varices.
In the present review, we will discuss hepatosplenic schistosomiasis and oesophagogastric varices pathophysiology and review the current surgical outcomes of distal splenorenal shunt or liver transplantation in schistosomal refractory variceal bleeding.
The variceal rebleeding risk is highest within the first 6 weeks with a peak in the first 5 days[ 1 ].
In Sudan, a country endemic with schistosomiasis, with prevalence rates increased to Portal hypertension due to schistosomal periportal fibrosis caused acute variceal bleeding in the majority of cases while liver cirrhosis is less common[ 4 ].
Ten to twenty percent of patients were not controlled with endoscopic and pharmacological therapy, known as refractory variceal bleeding which needs more aggressive therapies to deal with it[ 78 ]. Although surgical procedures were less frequently performed with endoscopic therapy and transjugular intrahepatic portosystemic shunt TIPS development, it controls variceal rebleeding effectively. Furthermore, it indicated in patients with well-preserved liver function, treating hypersplenism and rarely inducing hepatic encephalopathy[ ehunt ].
Sometimes called Bilharziasis or snail fever referred to Theodor Bilharz, a German surgeon working at Cairo Medical School who discovered the fluke in within the mesenteric veins of an Splenorenao boy at autopsy [Figure 1].
Then described terminal spine mature ova and lateral spine immature ova, produced by the female worms[ 1112 ].
Furthermore, McDonagh[ 13 ] has introduced antimony as an anti-bilharzial agent[ 14 ]. The World Health Organization includes schistosomiasis shung a neglected tropical disease. The disease is believed to affect approximately million individuals in many countries and kills more thanpeople per year, with most cases occurring in Africa, the Eastern Mediterranean and the Americas [Figure 2]. Furthermore, the disease is considered a risk for million people living in endemic rural areas of tropical countries and associated with poor socioeconomic status[ 1215 ].
The movement of people from endemic zones with unplanned djstal establishment and irrigation projects led to newer endemic foci appearance. Thus, there is a need for an effective schistosomal control program dostal of health and hygiene education, reduction of water contamination through sanitary and safe water supply facilities, snail control measures and mass chemotherapy to eliminate the threat from several endemic countries[ 12 ].
In the sgunt areas, children, women, fishermen, and farmers in irrigation channels are often infected with schistosomes and the pathogenic changes in schistosomiasis depend on interplay between host and parasite factors[ 1216 ].
A Simplified Technique of Performing Splenorenal Shunt (Omar’s Technique)
The life cycle characterized by the adult worms live in terminal venules of the bowel S. Inside the human body, schistosomula, enter the vasculature of the host, then migrate to the lungs and remain there for several days before travelling to the liver. They feed on red blood cells which maturate and mate in liver vessels to form adult worms, living in the venous system where the females lay their eggs[ 19 – 21 ]. Most of the eggs carried upstream via the portal veins to the liver and trapped in the pre-sinusoidal portal venules[ 21 ].
Some eggs retained in the bowel or bladder wall while others passed into the lumen of intestine or bladder with feces or urine through their lytic secretions or carried proteases [Figure 3].
In advanced hepatosplenic schistosomiasis, the direct effect of ova deposition in the portal tributaries that it cause granuloma formation defined as inflammation surrounding eggs and limits adjacent tissues damage from its secreted antigens which replaced overtime weeks post-infection with periportal fibrosis[ 17 ]. At this stage, patients complain of abdominal pain, anorexia and diarrhea. Subsequently, hepatosplenomegaly and portal hypertension complicated by esophageal variceal bleeding, ascites and hepatic coma indicate the end stage of liver disease[ 202223 ].
Theodor Bilharz, a German surgeon who discovered the Schistosomal blood fluke in Diagnostic procedures include the demonstration of ova in stool which occurs after 45 days of infection sometimes has low sensitivity and if negative the rectal biopsy has a beneficial role in diagnosis and healing control[ 2425 ]. Patients with schistosomiasis have prolongation of the bleeding profile including prothrombin time, partial thromboplastin time, thrombin time and hypofibrinogenemia which are well-established findings[ 29 ].
Furthermore, these laboratory data are independently correlated with the presence of large esophageal varices or combined in the Child-Pugh score.
The ultrasonography of the liver giving data on the liver size, echotexture, margins and degree of ascites[ 30 ]. Also, it assesses the underlying periportal fibrosis severity by measuring the portal tract thickness in which reflects the hemodynamic changes and provides a good estimate clinical status of patients with periportal fibrosis which graded from I-III as follow: Sometimes it discovers the distention of portal and splenic veins exceeding 12 or 10 mm width respectively[ 25 ].
Furthermore, color doppler ultrasound showed hepatic left lobe hypertrophy and right lobe atrophy which was commonly seen in the hepatosplenic schistosomiasis[ 33 ]. The oesophagogastroduodenoscopy OGD can demonstrate esophagogastric varices [Figure 4]. In patients with schistosomiasis alone the liver cirrhosis is rare but if co-infected with hepatitis B or C virus, progression to cirrhosis is brisk and this is common in endemic regions like Egypt and the Middle East[ 202534 – 38 ].
Also, it helped in regression of periportal fibrosis. Praziquantel therapy considered ineffective once the late fibrotic stage in the liver and oesophageal variceal bleeding were developed need to be treated by endoscopic therapy or selective shunt procedures[ 4243 ]. Portosystemic collateral veins developed to decompress the portal venous system that manifested clinically by esophageal varices when increasing of the hepatic venous pressure gradient more than 10 mmHg[ 48 – 50 ].
Furthermore, the risk of variceal bleeding increases by other factors like physical exercise, increased intra-abdominal pressure and nonsteroidal anti-inflammatory drugs which alter variceal wall[ 51 – 53 ].
A number of studies for noninvasive oesophageal varices prediction revealed splenomegaly is the most clinical sign[ 5455 ]. As ultrasonography is the preferred initial test which can diagnose the presence of portocollateral vessels[ 30 ]. Computed tomography scan and magnetic resonance imaging MRI diagnosed oesophageal varices by a good visualization of the portal venous system.
Distal Splenorenal Shunt | Cleveland Clinic
By Angio-MRI the risk of variceal bleeding in patients can be evaluated through azygos blood flow measurement. Newly diagnosed patients must undergo screening OGD which considered as a gold standard test for detection of changes that indicate a high risk of bleeding include cherry-red spots, varices on varices, large varices and erosion on varices [Figure 6] [ 59 ]. Primary prevention of variceal bleeding first episode needs the follow-up of variceal size by the following point[ 6162 ]:.
If no esophageal varices discovered, screening endoscopy must undergo every three years. If small esophageal varices detected screening endoscopy must be repeated every two years.
Poorly compliance patients or contraindications to beta-blocker drugs need endoscopic band ligation to be considered. Propanolol reduced portal pressure and blood flow within it through the decreased cardiac output beta one receptor blockage and arteriolar splanchnic vasoconstriction beta two receptor blockage [ 63 ]. Furthermore, it prevents rising of portal pressure during physical exercise and postprandial period and its reducing bacterial translocation rate[ 64 – 66 ].
Some authors have revealed that praziquantel decrease or reverse sonographically periportal fibrosis by parasitic load reduction aimed to primary prophylaxis against a first variceal bleeding in the significant number of schistosomal cases[ 67 – 69 ]. The association of variceal bleeding with recurrence and death considered as a medical emergency need to be treated in the intensive care unit for hypovolemia correction and complications prevention starting by plasma expander with preference to crystalloid trough at least two gauge peripheral catheters with the regular check of vital signs.
Blood samples for baseline laboratory tests can be done upon initial presentation complete blood count; renal function test; liver function test; international normalized ratio. While coagulopathy can be corrected by fresh frozen plasma and vitamin K[ 616274 – 77 ]. Airway must be secured immediately especially in encephalopathic patients, due to increased risk of bronchial aspiration of blood or gastric contents during hematemesis and endoscopic procedures.
Twenty-five percent to fifty percent of patients with variceal bleeding have infections like spontaneous bacterial peritonitis, urinary tract infections and pneumonia. Hence, oral norfloxacin mg twice daily for 7 days was recommended to improve survival and usage of lactulose is mandatory for encephalopathy prevention[ 61627980 ].
Before diagnostic endoscopy intravenous vasoactive therapy must start urgently with 2 mg every 4 h for the first 48 h and maintained for 5 days using 1 mg of terlipressin every 4 h to prevent rebleeding or somatostatin mg bolus dose followed by mg infused hourly as the second choice for 5 days.
Both drugs reduce the hepatic venous pressure gradient, variceal pressure and azygos blood flow[ 82 – 87 ]. Also, terlipressin improves the renal function of hepatorenal syndrome patients by reducing renal vasoconstriction and should not be used in patients with cardiovascular disease[ 88 – 92 ]. Furthermore, another study was showed the use of terlipressin improves outcomes following acute variceal bleeding[ 93 ].
Within 12 h of hospital admission OGD performed to identify the source of bleeding and allowing hemostatic treatment done on an empty stomach through nasogastric tube lavage or i. Either endoscopic sclerotherapy or endoscopic band ligation can be practiced and the recommendation for endoscopic band ligation as first-line treatment achieved by elastic bands maximally per session every weeks until the variceal obliteration or small varices ligation become impossible.
Complications are fewer than in endoscopic sclerotherapy such as moderate post-ligation ulcer bleeding[ 6194 ]. Several sclerosant agents like ethanol, ethanolamine, polidocanol, sodium morrhuate and tetradecyl sulfate have the similar effect which can be injected paravariceal or intravariceal with mL per session every weeks until variceal obliteration has been achieved.
The frequent complications include dysphagia, retrosternal pain, bleeding ulcers, shujt perforation and stricture[ 94 ].
With this procedure lung, spleen or brain embolization is the most serious complication[ 6297 ]. Failing of vasoactive drug and endoscopic treatment combination, need initially balloon tamponade followed by repeat endoscopic therapy.
If bleeding persists TIPS or surgical shunt creation must be performed as a rescue therapy and second-line treatment[ 6194 ]. A creation of a TIPS percutaneously reduces portal pressure and thus prevents variceal bleeding. It complicated by thrombosis, stenosis and encephalopathy through portal flow diversion from the liver. Furthermore, liver transplantation considered dixtal Child-Pugh class C patients[ 616299 ].
According to the Baveno V consensus, refractory variceal bleeding was defined as a single episode of clinically significant rebleeding from portal hypertensive sources recurrent melena, hematemesis resulting in hospital admission, multiple blood transfusion and drop in hemoglobin up to three grams below normal level. Rebleeding within first 5 days was regarded as treatment failure, while rebleeding up to 6 weeks splenoreal as secondary prophylaxis failure[ ].
There are several factors that associated with variceal rebleeding like red color signs on varices, variceal size, liver disease deterioration, portal pressure, bacterial infection and portal vein thrombosis[ – ]. The rebleeding time frame calcified into very early rebleeding that occur within 5 days of acute bleedingearly rebleeding within 6 weeks of acute bleeding and delayed splenorenap. Therefore, the prevention of variceal rebleeding can start on the sixth day of acute bleeding[ ].
The leading cause of death is recurrent variceal bleeding associated with a preserved liver function. Although the end-stage liver failure was rarely seen in schistosomal patients, the deterioration of hepatic reserve has been expected following massive variceal bleeding with developed ascites and the splenic size regression.
Also, propranolol significantly reduced variceal rebleeding, improved survival and reduces variceal pressure and wall tension in schistosomal portal hypertension.
Endoscopic band ligation is preferable to endoscopic sclerotherapy by reducing recurrent variceal bleeding risk and variceal stricture incidence in poor intolerance or beta-blocker therapy contraindications[ – ]. Furthermore, other authors have revealed that the combination of beta-blockers and endoscopic band ligation is superior to banding ligation alone in prevention of variceal recurrence and refractory bleeding[ – ]. If both beta-blocker drugs and endoscopic band ligation failed to prevent recurrent variceal bleeding then the options shutn distal splenorenal shunt or TIPS considered as bridge procedures for liver transplantation[ 6162 ].
The surgical treatment has been considered the best alternative for patients with schistosomal recurrent variceal bleeding due to well-preserved liver function and upper digestive tract bleeding is the dangerous disease complication[ – ]. Currently, Van Buuren et al. At the University of Miami InWarren and colleagues[ ] were established distal splenorenal shunt DSRS aimed to decompress selectively the venous collaterals around the stomach and lower esophagus thereby prevents recurrent variceal bleeding and maintains portal blood flow which dostal the risk of accelerated liver failure and postoperative encephalopathy [Figure 7] [ – ].
The improved surgical techniques in splenopancreatic disconnection and omental division significantly reduced dista, encephalopathy risk and spkenorenal good results in patients with schistosomal portal hypertension[- ]. Splenorrenal variceal bleeding to pharmacologic and endoscopic therapy with shuunt liver function unlikely to undergo transplantation within five years. splenorenap
Portal hypertensive patients with well-preserved liver function and patent splenic vein complicated by refractory bleeding, because of extra-hepatic portal vein thrombosis[splenorenl. Patients live in some geographic locations who cannot return back for multiple visits of endoscopy or TIPS[ ]. Splenofenal who considered for the DSRS needs perioperative evaluation including the following points:.
Upper gastrointestinal endoscopy to confirm high-risk gastroesophageal varices as a source of refractory bleeding. Identify the cause of portal hypertension with variceal bleeding in which hepatosplenic schistosomiasis is the major cause in African countries like Sudan.
Imaging of hepatic vascular anatomy required before surgical intervention in which using of doppler ultrasound, CT or magnetic resonance MR vascular imaging help in the portal or splenic venous thrombosis identification. In addition, a combination of venous and arterial angiographic study gives information on superior mesenteric, fistal and splenic veins patency, flow direction, hepatic venous pressure gradient and left renal vein anatomy.