Devascularization procedure and DSRS: a controlled randomized trial on selected haemodynamic portal flow pattern in schistosomal portal hypertension with variceal bleeding.

OBJECTIVES

The use of duplex studies for the portal tree has revolutionized the concepts of haemodynamic pathophysiology in the case of portal hypertensive bleeders. The identification of possible haemodynamic patterns in schistosomal bleeders, and the effects of devascularization procedure and distal lienorenal shunts on a selected haemodynamic pattern, are the aim of this work.

PATIENTS AND METHODS

Patients (219) with schistosomal hepatic fibrosis and history of bleeding oesophageal varices were studied. The patency, diameter, velocity and flow volume/min in the portal and splenic veins were followed by coloured Duplex. Two matched groups (30 patients each) with the most commonly found haemodynamic pattern (splenic vein flow exceeding portal vein flow) were operated upon. Devascularization procedure was done for the first group (A) and distal splenorenal shunt for the second group (B).

RESULTS

Coloured duplex assessment of portal circulation in schistosomal patients identified four haemodynamic patterns. Pattern I (approximately 59%); splenic vein flow exceeds the portal vein flow. Pattern II (approximately 28%); portal vein flow exceeds splenic vein flow. In both patterns, the portal flow was hepatopedal. Patterns III and IV (8% and 5%, respectively) were associated with hepatofugal flow. Splenic vein flow exceeds portal vein flow in pattern III and the reverse in pattern IV. Distal lienorenal shunts done for patients with haemodynamic pattern I was followed by a rebleeding rate of 3.3% while devascularization done for patients with the same pattern was followed by a rebleeding rate of 26.6%. Mild encephalopathy was detected in 10% of patients with distal lienorenal shunts and responded to dietary regulations.

CONCLUSIONS

DSRS proved to be ideal for schistosomal patients with hepatopedal flow and splenic vein flow exceeding portal vein flow; since in addition to eliminating the high splenic flow out of portal circulation, it decreased the pressure in the gastroesophageal region. Other patterns with their frequencies and the suggested surgical procedures were also presented.