Warren W D, Millikan W J, Henderson J M, Abu-Elmagd K M, Galloway J R, Shires G T, Richards W O, Salam A A, Kutner M H
Ann Surg. 1986 Oct;204(4):346-55. doi: 10.1097/00000658-198610000-00002.
Distal splenorenal shunt (DSRS) improves survival from variceal bleeding in nonalcoholic cirrhotics but not in alcoholic subjects. The metabolic response after DSRS is also different in alcoholic and nonalcoholic cirrhotics. Portal perfusion, quality of blood perfusing the liver, cardiac output, and liver blood flow do not change in nonalcoholics. In alcoholics, portal perfusion is frequently lost (60%), quality of blood perfusing the liver decreases, and cardiac output and liver blood flow increase. It is proposed that portal flow is lost in alcoholics via pancreatic and colonic collaterals after surgery. Elimination of this sump by adding complete dissection of the splenic vein and division of the splenocolic ligament to DSRS (splenopancreatic disconnection, SPD) could preserve portal perfusion, decrease shunt loss of hepatotrophic factor, and improve survival in alcoholic cirrhotics. This report compares data 1 year after surgery in two groups of cirrhotics: group I (8 nonalcoholic; 16 alcoholic) had DSRS without SPD; group II (17 nonalcoholic; 11 alcoholic) received DSRS + SPD.
Portal perfusion grade, cardiac output (CO), liver blood flow (f), hepatic function (GEC), and hepatic volume (vol) were measured before and 1 year after surgery. Shunt loss of hepatotrophic factor was estimated by insulin response (change in plasma concentration over 10 minutes: AUC) after arginine stimulation.
Groups I and II were similar before surgery. Metabolically, nonalcoholics remained stable after both DSRS and DSRS + SPD. After standard DSRS, alcoholics lost portal perfusion (75%, p less than 0.05), CO, and f increased (p less than 0.05), and quality of blood perfusing the liver was decreased (GEC/f: p less than 0.05). DSRS + SPD preserved portal perfusion better (p less than 0.05) in alcoholic cirrhotics than did DSRS alone. After DSRS + SPD, the metabolic response in alcoholics resembled that of nonalcoholics. CO, f, and GEC/f remained stable. These data show: DSRS + SPD preserves postoperative portal perfusion in alcoholic cirrhotics better than DSRS alone. Metabolic response to DSRS + SPD is similar in alcoholic and nonalcoholic cirrhotics. Because portal perfusion and metabolic integrity are preserved after DSRS + SPD, its use in alcoholic cirrhotics should improve survival.
远端脾肾分流术（DSRS）可提高非酒精性肝硬化患者因静脉曲张出血的生存率，但对酒精性肝硬化患者无效。DSRS术后酒精性和非酒精性肝硬化患者的代谢反应也有所不同。非酒精性肝硬化患者的门静脉灌注、肝脏灌注血液质量、心输出量和肝血流量均无变化。酒精性肝硬化患者门静脉灌注常丧失（60%），肝脏灌注血液质量下降，心输出量和肝血流量增加。有人提出，酒精性肝硬化患者术后门静脉血流通过胰腺和结肠侧支循环丧失。通过在DSRS基础上增加脾静脉完全解剖和脾结肠韧带离断（脾胰断流术，SPD）来消除这个“贮血池”，可保留门静脉灌注，减少肝营养因子的分流损失，并提高酒精性肝硬化患者的生存率。本报告比较了两组肝硬化患者术后1年的数据：第一组（8例非酒精性；16例酒精性）行DSRS但未行SPD；第二组（17例非酒精性；11例酒精性）接受DSRS + SPD。
在手术前及术后1年测量门静脉灌注分级、心输出量（CO）、肝血流量（f）、肝功能（GEC）和肝脏体积（vol）。通过精氨酸刺激后胰岛素反应（10分钟内血浆浓度变化：AUC）评估肝营养因子的分流损失。
第一组和第二组术前情况相似。代谢方面，非酒精性肝硬化患者在DSRS和DSRS + SPD术后均保持稳定。标准DSRS术后，酒精性肝硬化患者门静脉灌注丧失（75%，p < 0.05），CO和f增加（p < 0.05），肝脏灌注血液质量下降（GEC/f：p < 0.05）。DSRS + SPD在酒精性肝硬化患者中比单独DSRS能更好地保留门静脉灌注（p < 0.05）。DSRS + SPD术后，酒精性肝硬化患者的代谢反应与非酒精性肝硬化患者相似。CO、f和GEC/f保持稳定。这些数据表明：DSRS + SPD比单独DSRS能更好地保留酒精性肝硬化患者术后的门静脉灌注。酒精性和非酒精性肝硬化患者对DSRS + SPD的代谢反应相似。由于DSRS + SPD术后门静脉灌注和代谢完整性得以保留，其用于酒精性肝硬化患者应能提高生存率。
