Distal splenorenal shunt--premise, perspective, practice

Despite progress in our understanding and management of patients with portal hypertension, the long-term control of variceal bleeding remains a significant challenge. With further clarification of the underlying pathophysiology and technological advances that have facilitated progress in both diagnosis and treatment, the goal of safe, selective management of patients presenting with variceal hemorrhage is closer to realization. While a variety of non-operative therapies have been advocated, shunt surgery remains the most reliable and durable method of controlling the portal hypertension and the bleeding. More than 20 years ago, Warren and Zeppa introduced the concept of selective shunting to prevent recurrent variceal hemorrhage. The distal splenorenal shunt (DSRS) was advocated as an approach that could selectively decompress the esophageal and gastric varices (resulting in effective bleeding control) while maintaining prograde portal flow (presumably leading to a lower incidence of post-shunt encephalopathy and hepatic failure). While the hemodynamic basis for the DSRS remains valid, its selectivity is neither uniform nor durable and this shunt is neither applicable nor effective in all patients bleeding from varices. It remains, however, appropriate and safe therapy in selected cirrhotic patients with variceal hemorrhage. With careful pretreatment assessment (in the context of the advances that have occurred in both operative and anesthetic management), the DSRS retains an important role in the management of patients with variceal bleeding.