Distal Splenorenal Shunt (DSRS): A Durable Bridge to Liver Transplantation

J. Pomposelli, A. Tongyoo, R. Jenkins, M. Akoad, W. Lewis, E. Pomfret.

Transplantation and Hepatobiliary Diseases, Lahey Clinic Medical Center, Burlington, MA.

Meeting: 2015 American Transplant Congress

Abstract number: C120

Keywords: Liver cirrhosis, Morbidity, Mortality, Surgical complications

Background: Variceal bleeding has a high rate of in-hospital mortality approaching 50%. Patients with well-compensated cirrhosis and recurrent variceal bleeding may benefit from long-term prophylaxis using DSRS rather than other approaches. The purpose of this study was to determine the outcome of cirrhotic patients after DSRS who failed medical therapy for variceal bleeding. Methods: 46 consecutive patients with cirrhosis who underwent DSRS between 9/1999 -10/2014 were studied. Patient demographics, diagnosis, preoperative MELD and Child's class, hospital LOS, complications, operative and long-term mortality, shunt patency and subsequent transplant were evaluated. Multivariate logistic regresssion analysis was performed to predict overall mortality rate. Results: 32 males (70%) and 14 females (30%) underwent DSRS after failing medical management for bleeding varicies. Alcohol (36.6%) and hepatitis C infection (29.3%) were the most common cause of cirrhosis and 70.7% of patients had Child's class A and 29.3% class B cirrhosis.

Age	MELD Score	Hospital LOS	Overall Morbidity	Operative (30 Day) Mortality	Overall Shunt Patency
54.2+/-10.6	9.8+/-5.7	9.1+/-5.7	41.5%	4.9%	97.6%

Hepatic encephalopathy and recurrent varicreal bleeding occurred in 7.3% and 2.4% of patients respectively. Multivariate logistic regression analysis determined that Child's class B or the preoperative presence of ascites were significant predictors of overall mortality postoperatively (p<0.05). Two patientss underwent subsequent liver transplant without difficulty. All patients were followed closely by the transplant service and had twice yearly imaging studies. One year survival was 90.1% and overall shunt patency was 97.6%. Conclusions: DSRS is a safe and effective treatment modality for recurrent variceal bleeding in well selected patients. DSRS has surperior patency rate over TIPS (>97% at 10 years) and serves an excellent bridge to liver transplnatation. DSRS should be considered for variceal prophylaxis in all well-compensated cirrhotic patients (Childs A), especially in those who fail standard medical therapy.

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