Rikkers L F, Rudman D, Galambos J T, Fulenwider J T, Millikan W J, Kutner M, Smith R B, Salam A A, Sones P J, Warren W D
Ann Surg. 1978 Sep;188(3):271-82. doi: 10.1097/00000658-197809000-00002.
In 1971 a prospective, randomized trial was initiated to determine efficacy of the distal splenorenal shunt in the management of cirrhotic patients who had previously bled from esophageal varices. When entry into the trial was terminated in 1976, 26 patients had received the distal splenorenal shunt (selective) and 29 had undergone a nonselective shunting procedure (18 interposition mesorenal, six interposition mesocaval, and five other nonselective shunts). Three operative deaths occurred in each group. Early postoperative angiography revealed preservation of hepatic portal perfusion in 14 of 16 selective patients (88%), but in only one of 20 nonselective patients (5%; p < .001). Quantitative measures of hepatic function (maximal rate of urea synthesis or MRUS and Child's score) were similar to preoperative values in the selective group but were significantly decreased in nonselective patients on the first postoperative evaluation (p < .001 for MRUS; p < .05 for Child's score). Eighty-seven per cent of selective and 81% of nonselective patients have now been followed for three to six years since surgery. Late postoperative evaluation of 29 survivors (12 selective, 17 nonselective) still shows an advantage to the selective group with respect to MRUS, Child's score, and incidence of hepatopetal portal blood flow, but differences are no longer statistically significant. However, if the seven patients with portal flow (five selective; two nonselective) are compared to the 20 with absent portal flow (seven selective; 13 nonselective), the former group has significantly higher values for MRUS (p < .05) and Child's score (p < .025). No patient with continuing portal perfusion has developed encephalopathy as compared to a 45% incidence of this complication in individuals without portal flow (p < .05). No significant differences between selective and nonselective groups have appeared with respect to total cumulative mortality (ten selective; 38%; eight nonselective, 28%), shunt occlusion (two selective, 10%; five nonselective, 18%), or recurrent variceal hemorrhage (one selective, 4%; two nonselective, 8%). Overall, significantly fewer selective patients have developed postoperative encephalopathy (three selective, 12%; 15 nonselective, 52%; p < .001). Therefore, we conclude that the distal splenorenal shunt, especially when its objective of maintaining hepatic portal perfusion is achieved, results in significantly less morbidity than nonselective shunting procedures.
1971年启动了一项前瞻性随机试验，以确定远端脾肾分流术对既往有食管静脉曲张出血的肝硬化患者的治疗效果。1976年试验结束时，26例患者接受了远端脾肾分流术（选择性），29例患者接受了非选择性分流手术（18例脾肾静脉搭桥、6例腔静脉搭桥和5例其他非选择性分流）。每组各有3例手术死亡。术后早期血管造影显示，16例选择性分流患者中有14例（88%）保留了肝门静脉灌注，而20例非选择性分流患者中只有1例（5%）保留了肝门静脉灌注（p<0.001）。肝功能的定量指标（尿素合成最大速率或MRUS以及Child评分）在选择性分流组中与术前值相似，但在术后首次评估时，非选择性分流患者的这些指标显著下降（MRUS，p<0.001；Child评分，p<0.05）。自手术以来，87%的选择性分流患者和81%的非选择性分流患者已随访3至6年。对29名幸存者（12例选择性分流、17例非选择性分流）的术后晚期评估显示，在MRUS、Child评分和肝向门静脉血流发生率方面，选择性分流组仍具有优势，但差异不再具有统计学意义。然而，如果将7例有门静脉血流的患者（5例选择性分流；2例非选择性分流）与20例无门静脉血流的患者（7例选择性分流；13例非选择性分流）进行比较，前者的MRUS值（p<0.05）和Child评分（p<0.025）显著更高。与无门静脉血流个体中45%的该并发症发生率相比，持续有门静脉灌注的患者未发生肝性脑病（p<0.05）。在总累积死亡率（10例选择性分流，38%；8例非选择性分流，28%）、分流闭塞（2例选择性分流，10%；5例非选择性分流，18%）或曲张静脉再出血（1例选择性分流，4%；2例非选择性分流，8%）方面，选择性分流组和非选择性分流组之间未出现显著差异。总体而言，选择性分流患者发生术后肝性脑病的明显较少（3例选择性分流，12%；15例非选择性分流，52%；p<0.001）。因此，我们得出结论，远端脾肾分流术，尤其是在实现维持肝门静脉灌注的目标时，其发病率明显低于非选择性分流手术。
