ABSTRACT
The objective of this work was to evaluate specifically the surgical experience, portal haemodynamics, clinical outcome and survival in Egyptian schistosomal portal hypertensive bleeders after the small diameter partial portacaval shunts [SDPPCS]. This prospective study included fifty-six patients out of two hundred and fifty-four patients with schistosomal hepatic fibrosis, portal hypertension, and splenomegaly and complicated by bleeding oesophageal varices. All patients belonged to class A or B of Pugh modification of Child-Turcotte classification of cirrhosis. All patients were studied preoperatively with endoscopy and color duplex. All patients showed a preoperative haemodynamics pattern with hepatopedal flow. The fifty-six patients were prepared for elective small diameter partial portacaval shunt, SDPPCS, using the 8 mm, non-compressible polytetrafluoroethylene [PTFE] graft, Gore-Tex, W. L. Gore and Associates, Inc., Elkton, Md.].Postoperative duplex study was repeated one month, six months, and one year after operation. The portal flow cephalad and caudal to shunt site were measured, shunt patency was directly visualized, and flow in IVC cephalic to shunt in the intrahepatic portion was measured. Postoperative endoscopic evaluation, every three months during the first year, then every six months afterwards, to assess the downgrading of varices. One-three years of follow-up were the time allowed before reporting the final results. The episodes of variceal bleeding, ascites and encephalopathy were recorded for all patients. Twenty-one cases [37.5%] belonged to child s class A, and thirty-five cases [62.5%] were class B. SDPPCS was abandoned in 5/56 [8.9%]. Causes of operative failure in graft replacement were: adhesions due to previous cholecystectomy in 1/56 [1.8%], very thin walled PV in 1/56 [1.8%], very small PV < 10 mm in 3/56 [5.35%], extensive collaterals around the PV in 2/56 [3.58%], and medially displaced PV with inability to dissect a sufficient segment in 1/56 [1.8%]. Complications: were in the form of PV thrombosis in 1/56 [1.8%], IVC thrombosis in 1/56 [1.8%], shunt thrombosis in 2/56 [3.58%], and transected CBD in 1/56 [1.8%]. SDPPCS permitted sufficient volume of prograde flow of portal blood to the liver leading to maintenance of liver functions and low incidence of encephalopathy. SDPPCS resulted in progressive diminution of the size and grade of esophageal and gastric varices, as well as, disappearance of risk signs, thus guarding against rebleeding. There was statistically significant difference in downgrading of esophageal and gastric varices and improvement of gastropathy. SDPPCS resulted in improvement in hematological abnormalities with significant increase of blood elements, especially for thrombocytopenia. SDPPCS resulted in significant decrease in splenic size and splenic congestion. There was no operative mortality. Survival after SDPPCS was 91.07%. Shunt was patent in 49/51 patients [96%]. Three patients [5.357%] complained of mild encephalopathy after SDPPCS. Small diameter partial portacaval shunt [SDPPCS], using 8 mm PTFE graft, is feasible technically and is effective in controlling bleeding esophageal bleeding with preservation of a prograde hepatic portal flow, that preclude encephalopathy, in Egyptian schistosomal portal hypertensive bleeders. It could be considered as an alternative to difficult cases meant for DSRS, or shunt procedures in splenectomized patients