Relationship and interaction between serum sodium concentration and portal hemodynamics in patients with cirrhosis.

BACKGROUND AND AIM: To examine the relationship between hyponatremia and portal hemodynamics and their effect on the prognosis of cirrhosis. METHODS: Portal hemodynamic parameters measured by Doppler ultrasound and serum sodium concentrations were examined in 153 cirrhosis patients (mean age 62.2 ± 12.0 years; median observation period, 34.1 m). RESULTS: Study participants included 16 patients with hyponatremia (Na < 135 mEq/L), who showed a significantly greater frequency of possessing a splenorenal shunt (SRS; P = 0.0068), and 137 patients without hyponatremia. Serum sodium concentrations were significantly lower in patients with SRS than in those without (P = 0.0193). An increased prothrombin time-international normalized ratio was a significant predictive factor for developing hyponatremia a year later (8/96; Hazard ratio 14.415; P = 0.028). The cumulative survival rate was significantly lower in patients with hyponatremia (46.7% at 1 and 3 years) than in those without (91.8% at 1 year, 76.8% at 3 years; P < 0.001). The cumulative survival rate was significantly lower in patients who had developed hyponatremia after 1 year (100% at 1 year, 62.5% at 3 years) than those who had not (100% at 1 year, 89.0% at 3 years; P < 0.001). The cumulative survival rate was significantly worse in patients with both hyponatremia and SRS (20% at 1 year). CONCLUSIONS: There was a close linkage between the serum sodium concentration and portal hemodynamic abnormality, presence of SRS, and their interaction may negatively influence the prognoses in cirrhosis.

Long-term efficacy of distal splenorenal shunt with splenopancreatic and gastric disconnection for esophagogastric varices in patients with idiopathic portal hypertension.

Idiopathic portal hypertension (IPH) requires invasive measures to prevent rupture and bleeding of esophagogastric varices. However, the long-term results of shunt surgery for IPH have not been reported. In particular, the pros and cons of surgery that preserves the spleen and its long-term hematologic effects have not been described. The records of 15 patients who underwent distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for IPH between 1983 and 1998 was reviewed retrospectively. One patient died within 3 years of surgery, for a 3-year survival rate of 93%; the 10-year survival rate was 64%. Three patients (18%) suffered rebleeding from esophagogastric varices. The white blood cell and platelet counts were higher 3-5 years and 7-13 years postoperatively compared with preoperative values. Four of five patients who underwent postoperative computed tomography had a smaller spleen postoperatively. DSRS with SPGD provides long-term hemostasis for esophagogastric variceal bleeding in IPH and alleviates hypersplenism. DSRS with SPGD is an effective treatment for patients with IPH in whom long-term survival is expected.

Diminished morbidity and mortality in portal hypertension surgery: relocation in the therapeutic armamentarium.

Although several effective therapeutic options are available for bleeding from portal hypertension, surgery has a well-defined role in the management of patients with good liver function who are electively operated. The aim of this investigation was to evaluate the operative mortality and morbidity of portal blood flow-preserving procedures in a highly select patient population. The records of 148 patients operated on between 1996 and 2000 using one of two techniques (selective shunts or a Sugiura-Futagawa operation [complete portoazygos disconnection]) were analyzed with particular attention to operative mortality, postoperative rebleeding, and encephalopathy. Survival was calculated according to the Kaplan-Meier method. Sixty-one patients had distal splenorenal shunts placed, and 87 patients had a devascularization procedure. Operative mortality for the group as a whole was 1.2%. In the group with selective shunts, the rebleeding rate was 4.9%, the encephalopathy rate was 9.8%, and the shunt obstruction rate was 1.6%. Survival at 24 months was 94% and at 48 months was 92%. In those undergoing devascularization, the encephalopathy rate was 5% and the rebleeding rate was 14%. Survival at 24 months was 90% and at 48 months was 86%. Portal blood flow-preserving procedures have very low morbidity and mortality rates at specialized centers. In addition, a low rebleeding rate is associated with a good quality of life. Low-risk patients with bleeding portal hypertension should be considered for surgical treatment.

Selective shunts for portal hypertension: current role of a 21-year experience.

The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child-Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function.

[Clinical application of spleno-renal shunt].

The results of splenorenal shunt (SRS) in 405 patients were compared with those of simple splenectomy (SS) in 376 cirrhotic patients in the treatment of portal hypertension. The recurrent bleeding rate was 10.12% in SRS group and 21.2% in SS group, respectively (P < 0.001). The mortality of rebleeding was 2.96% in SRS group and 10.6% in SS group, respectively (P < 0.01). Death from hepatic failure developed at 16.5% of SRS patients and at 9.8% of SS patients, respectively (P < 0.01). The rate of postoperative variceal bleeding and mortality in prophylactic SRS group were 4.9% and 6.2%, and 15.1% and 26.4% in prophylactic SS group, respectively (P < 0.01). The authors are in favor of prophylactic SRS and modified side-to-side SRS for its simplicity and good results.

Long-term evaluation of distal splenorenal shunt with splenopancreatic and gastric disconnection.

BACKGROUND: This study was aimed at evaluating advantages of distal splenorenal shunt (DSRS) with splenopancreatic and gastric disconnection (DSRS-SPGD) over DSRS with splenopancreatic disconnection (DSRS-SPD) and standard DSRS (S-DSRS). METHODS: DSRS-SPGD, DSRS-SPD, and S-DSRS were performed on 62, 7, and 55 patients, respectively, from 1970 to 1992. Comparison was performed in the following aspects: (1) long-term results in ratio of rebleeding, survival rate, and quality of life and (2) portal hemodynamics evaluated by preoperative and postoperative angiography. Portal blood flow was assessed by the ratio of the diameter of portal vein (PV) to superior mesenteric vein (SMV), and shunt selectivity was evaluated by selectivity grade. RESULTS: Incidence of rebleeding was significantly lower in patients who underwent DSRS-SPGD than in those who underwent S-DSRS (p < 0.05). Grade 0 and I performance status was better in patients who underwent DSRS-SPGD. Accumulated survival ratio for 5 and 7 years was 78.3% and 70.5% in patients who underwent DSRS-SPGD, 59.7% and 44.1% in patients who underwent S-DSRS, and 75% and 75% in patients who underwent DSRS-SPD. Hemodynamic evaluation showed significantly lower PV/SMV ratio and degree of change in PV/SMV ratio of patients who underwent S-DSRS and DSRS-SPD. Many patients who underwent S-DSRS and DSRS-SPD exhibited loss of shunt selectivity at grades II and III. In contrast, patients who underwent DSRS-SPGD maintained satisfactory PV/SMV ratio and selectivity grade. CONCLUSIONS: DSRS-SPGD clearly showed advantages in decrease of rebleeding and improvement of quality of life resulting from maintenance of shunt selectivity and portal blood flow.

Surgery for bleeding esophageal varices.

A total of 72 patients were operated for bleeding esophageal varices over five years. Cause of portal hypertension was cirrhosis in 33, Schistosomal fibrosis in 23 and a combination of the two diseases in 3 cases. Biopsy was not available in 13 patients. Fifty-eight patients were child grade A and B, while 14 patients were grade C. Overall, there were 16 hospital deaths (22.2%) and 28 patients had complications (38.8%). Specifically, Hassab's operation was done in 40 patients with 12.5% mortality and 11.7% incidence of rebleeding. Hassab's operation plus esophageal transection in 13 patients was associated with 46.1% mortality and no incidence of rebleeding. Warren's splenorenal shunt, done in 11 patients, was accompanied by 1 (9%) death and no incidence of rebleeding. Mortality rate increased significantly when esophageal transection was added to Hassab's operation. It is concluded that for low risk patients being operated electively, Warren's shunt is an acceptable alternative to Hassab's operation which is better suited to emergency situations. Esophageal transection should not be added to Hassab's operation because this increases the mortality.

Distal splenorenal shunting for bleeding gastric varices.

In patients with bleeding gastric varices from causes other than splenic vein thrombosis, endoscopic sclerotherapy and ablative surgery have yielded poor results. Over a 3-year period starting in June 1989, a total of 30 distal splenorenal shunts were performed prospectively on 19 paediatric and 11 adult patients with bleeding gastric varices and good liver function. The mean (s.d.) age was 17(12) (range 6-50) years; there were 20 male and ten female patients of whom six had cirrhosis, four non-cirrhotic portal fibrosis and 20 portal vein thrombosis. Two patients died and two more had shunt thrombosis; all four were considered failures of treatment. Hypersplenism was present in 15 patients but reverted to normal in 13. In 26 patients the gastric varices disappeared. Concomitant oesophageal varices were present in 22 patients and showed marked regression, with no rebleeding over a mean (s.d.) follow-up of 21(10) (range 7-39) months. A distal splenorenal shunt was effective in controlling gastric variceal haemorrhage in 26 of 30 patients in whom liver function was well preserved.

Selective shunts in selected older cirrhotic patients with variceal hemorrhage.

Whereas portal systemic shunts pose significant problems in many patients, they have long been thought to have particular risks when undertaken in older cirrhotic patients, with devastating encephalopathy reportedly common in older patients undergoing nonselective shunt surgery. With advances in anesthesia management and perioperative monitoring and the advent of selective shunting, we postulated that both the operative and long-term outcomes might be improved. In this context, we reviewed our recent experience with selective shunts [distal splenorenal (DSRS) and small-diameter interposition portacaval grafts (IPCG)] in patients over the age of 60 years with variceal bleeding. Nineteen consecutive cirrhotic patients over 60 years of age undergoing elective or urgent selective shunt surgery for variceal hemorrhage since 1986 were identified. Sixteen patients underwent DSRS, and 3 underwent IPCG. The etiologies of the cirrhosis were multiple, with 12 of 19 classified as Child's B or C disease. There were no operative deaths, and all but one patient returned home following the surgery. No patient has had recurrent bleeding or required further surgery for portal hypertension-related problems. Three of 19 developed encephalopathy, and 4 of 19 died of liver failure within 1 year of surgery. Of the 14 patients still alive and well (mean postoperative survival: 44 months, range: 4 to 74 months), all remain free of encephalopathy and live independently. Based on this experience, it would appear that one can anticipate satisfactory short- and long-term outcomes after selective shunt surgery in selected patients with variceal bleeding over the age of 60 years. These patients with portal hypertension should not, therefore, be rejected for shunt surgery based on age alone.

Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. A meta-analysis of 4 randomized clinical trials.

Meta-analysis was used to evaluate 4 clinical trials comparing distal spleno-renal shunt (DSRS) with endoscopic sclerotherapy (EVS) in the prevention of variceal rebleeding: the interval between bleeding and therapy ranges from < 14 days to > 100 days. A questionnaire was sent to each author of the published trials concerning methods, definitions and results of the trials in order to obtain more detailed and up-to-date information. The selected end-points for the meta-analysis were: rebleeding, mortality and chronic encephalopathy. Analysis of the results in the questionnaires was made using the method proposed by Collins. The pooled relative risk (i.e. the combined Odds ratio of each trial as an estimate of overall efficacy) of rebleeding was statistically reduced by DSRS (0.16; 95% confidence interval 0.10-0.27). Despite this, the overall risk of death following DSRS was only marginally decreased (0.78; 95% confidence interval 0.47-1.29); the lack of homogeneity in the results does not permit any significant conclusions on this end-point. However, in non-alcoholic patients, the decrease in risk of death was greater, and this without heterogeneity, following DSRS than EVS (0.59; 95% confidence interval 0.23-1.50). The overall risk of chronic encephalopathy was slightly increased after DSRS (1.86; 95% confidence interval 0.90-3.86). In conclusion, DSRS significantly reduced the risk of rebleeding compared to EVS without increasing the risk of chronic hepatic encephalopathy. However, DSRS did not significantly affect the overall death risk. Only in non-alcoholic disease did it seem to show an advantage over EVS.

Selective shunt in the management of variceal bleeding in the era of liver transplantation.

This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach.

Long-term results after modified distal splenorenal shunt with expanded PTFE interposition.

Forty consecutive patients with esophagogastric varices underwent a modified distal splenorenal shunt with expanded polytetrafluoroethylene (PTFE) interposition and were followed up for 12 to 66 months (mean 44.7). The operations were urgent in 9, elective in 14, and prophylactic in 17 patients. There were 24 males and 16 females. Age ranged from 32 to 76 years with an average of 53.8. The causes of portal hypertension were liver cirrhosis in 32, chronic hepatitis in 4, idiopathic portal hypertension in 3, and primary biliary cirrhosis in 1. Twenty-six patients were in Child's class A, 6 in class B, and 8 in class C. The operative death rate within 1 month was 2.5% and the overall in-hospital mortality rate was 5%. The shunt patency rate was 97.2% at early and 100% at late examinations. Only one patient (2.5%) had upper gastrointestinal bleeding. Hepatic encephalopathy was seen in 8 (20.5%) of 39 surviving patients. Six patients died of liver failure and another six died from various causes during the follow-up period. Twenty-six patients (65%) are alive at present. The 1-, 3-, and 5-year cumulative survival rates were 87.4%, 73.3% and 48.8%, respectively. The current modified shunt can be carried out more safely and easily and yield a similar result to that with the original Warren shunt. In order to avoid hepatic encephalopathy and liver failure, however, it is not wise to persist in this procedure.

[Distal splenorenal shunt without deconnection in the prevention of recurrent digestive hemorrhage in the cirrhotic patient]. / La dérivation spléno-rénale distale sans déconnexion dans la prévention des récidives d'hémorragie digestive chez le cirrhothique.

The emergent treatment of gastrointestinal hemorrhage caused by the rupture of esophageal varices in cirrhotic patients is based on sclerotherapy. The prevention of frequent recurrence may be an indication of portocaval shunting. Over an 8-year period, 72 patients were operated with a distal splenorenal shunt without deconnection aimed at preventing gastrointestinal rebleeding. This was non-emergent surgery. The Child-Pugh grade was 41 A and 31 B. All patients had an angiography, which demonstrated the lack of arterioportal reflux. Operative mortality was 2.7%. Actuarial survival at 5 years was of 67%, respectively 71% for grade A and 60% for grade B. Patency of the shunt was estimated to be 90%. Persistence of hepatopetal flow on control arteriography has been established in 65% of cases. Rebleeding was observed in 10% of cases, and episodes of encephalopathy in 10% as well out of 60 studied cases, 29 presented with a chronic increase in ammoniemia (48%). Two risk factors of mortality have been demonstrated: age higher than 60 years, and relapse of ethylic intoxication, which has been observed in 40% of cases. Later hepatic transplantation has been performed in one case, without success. These results are similar to those obtained with Warren's procedure. Further development of hepatic transplantation may limit its indications.

The modified distal splenorenal shunt in the elective treatment of variceal hemorrhage.

We report on our experience with a modified version of the distal splenorenal shunt (DSRS) initially described by Warren. Since 1976 more than 150 shunts have been done in the department. The first part of this study shows the long-term results of a series of 100 consecutive patients treated electively. The estimated survival at 80 months was around 30%. On the other hand, the median survival rate (68 months) and the five-year survival (52%) of Child's A patients differed significantly from those of Child's B patients (8 months and 15%, respectively). These results suggested that the modified DSRS was an effective and relatively safe procedure for the elective treatment of variceal bleeding and warranted a prospective and randomized trial to compare DSRS and endoscopic sclerotherapy (ES). In the second part of the study, in which ES was compared with DSRS, both modalities showed a similar survival rate, although patients in the DSRS group had a higher incidence of encephalopathy and patients in the ES group were more prone to rebleed. It was concluded that ES was a good alternative to DSRS for the elective treatment of esophageal variceal bleeding. If orthotopic liver transplant is considered the only definitive mode of treatment for the elective management of portal hypertension, the DSRS should be reserved for patients in whom ES has not been totally effective, or varices are located predominantly in the fundus of the stomach.

[The fate of Warren's splenorenal shunt in the era of sclerotherapy]. / Devenir du shunt splénorénal distal selon Warren à l'ére de la sclérothérapie.

From 1969 to 1990, 52 patients underwent splenorenal shunt after one or more esophageal variceal hemorrhages. Sixty days' mortality was 15.4% (8 deaths). 3 patients were lost to follow-up soon after hospital discharge. The remaining 41 patients could be followed for 5.5 years on average: 26 died, 3 were lost to follow-up late after discharge and 12 are presently alive. Only 4 of the followed-up patients suffered recurrent bleeding due to a thrombosed shunt. Temporary mental disturbances were noted in 4 cases but no incapacitating encephalopathy was recorded. In the last 10 years, performance of the Warren shunt has decreased strikingly as a result of the increasing popularity of endoscopic sclerotherapy. Surgical and anesthetic techniques have, however, improved too, resulting in a lower morbidity and mortality rate. Recurrent bleeding and neurological sequelae being rare, we conclude that distal splenorenal shunt remains a valuable alternative to long-term sclerotherapy in selected cases.

[Distal splenorenal anastomosis in the treatment of digestive hemorrhage in portal hypertension]. / L'anastomose spléno-rénale distale dans le traitement des hémorragies digestives de l'hypertension portale.

One hundred and ten distal splenorenal anastomoses (DSRA) were performed between 1976 and 1988 for gastrointestinal haemorrhages secondary to portal hypertension. Thirty five patients underwent DSRA (Warren's operation) followed by a mesenteric disconnection procedure. Eleven patients (10%) died (nine Child B and two Child A), including two after an emergency shunt. The mortality was influenced by age (p less than 0.01) and by the number of previous episodes of ictero-ascitic decompensation (p less than 0.02). A single anastomotic thrombosis was observed; the high flow rate of the anastomoses (mean: 1200 +/- 650 ml/min) explains the high patency rate (more than 90%). Eleven patients developed partial or total thrombosis of the portal trunk less than 6 weeks after the operation. The quality of hepatic perfusion was not significantly influenced by the mesenterico-splenic disconnection and this was omitted in 75 patients. The mesenterico-splenic collateral venous circulation was more developed in the absence of disconnection (p less than 0.05). The long-term actuarial survival was 83% at one year, 53% at five years, 47% at eight years and 28% at ten years. Survival was not influenced by the disconnection. Warren's operation is more difficult to perform than a porto-caval or mesenterico-caval shunt. DSRA appears to have three advantages: 1) a high flow rate as it is arterialised by the splenic artery, 2) hepatopetal portal perfusion maintained for several days, weeks or months, possibly reducing the risk of encephalopathy, 3) the absence of dissection of the hepatic pedicle preserves the possibilities of liver transplantation.

[Clinical results of selective distal splenorenal and latero-lateral portacaval anastomoses. Comparative prospective study of 93 patients]. / Résultats cliniques des anastomoses spléno-rénale distale sélective et porto-cave latéro-latérale. Etude prospective comparée de 93 patients.

The distal splenorenal shunt (DSRS) was compared with the side-t-side portacaval shunt (PCS) in 93 prospectively matched cirrhotic patients with portal hypertension. After a mean follow-up of 38 months, no differences were observed in operative mortality, long term survival and variceal rebleeding between the two groups. There was no significant difference in terms of acute encephalopathy (22% in PCS group and 33% in DSRS group) and chronic encephalopathy (35% in PCS and 17% in DSRS). However, the only cases of severe and disabling chronic encephalopathy (CE) arose after PCS (p = 0.049). Actuarial curves of CE showed that the maximum rate of this complication (18%) in the DSRS group was reached 27 months after shunt surgery, whereas this value was reached and passed in PCS group only 4 months after shunt. CE occurred for a total duration of 20.1 months after PCS and only 11.1 months after DSRS (p = 0.003) and occupied 46.3% of the follow-up of PCS patients in contrast to 18.7% of the follow-up of DSRS patients (p = 0.001). DSRS is associated with a lower global incidence of CE without severe forms and provides a better quality of life than does a nonselective shunt.

Splenorenal arterial shunt in the treatment of renovascular hypertension. Approach by a lumbar-retroperitoneal incision.

In a period of 16 years, 29 consecutive patients were operated on for a splenorenal arterial shunt through a lumbotomy incision and a retroperitoneal approach. There were 18 males and 11 females with a medium age of 42 years. All cases had uncontrollable and severe hypertension for an average medium time of 48 months, 11 patients had variable degrees of renal insufficiency. The diagnosis was made utilizing standard methods including in all cases angiography of the abdominal aorta, celiac axis and renal arteries. One patient died after the operation due to intestinal infarction, the remaining have been followed for a medium time of 50 months. All patients improved or cured their renal insufficiency. The hypertension was cured in 23, improved in 4 and failed in 1, this latter patient was successfully autotransplanted. A precise exposition of the surgical technique is presented with comments about their advantages and indications. A review of the literature in surgical experience with the technique of splenorenal arterial anastomosis has been done.

Anastomose espleno-renal distal seletiva versus esclerose esdoscópica para controle das varizes esofagianas em pacientes portadores de esquistossomose / Distal splenorenal shunt versus endoscopic sclerotherapy for management of variceral bleeding in schistosomiasis

Foi realizado um estudo prospectivo comparando a anastomose espleno-renal distal seletiva (AERDS) com a escleroterapia endoscopica das varizes esofagianas, em 60 pacientes, tendo sido alocado metade dos pacientes em cada grupo. Todos os pacientes eram esquistossomoticos hepatesplenicos. O seguimento dos pacientes foi de quatro anos. A recidiva hemorragica no grupo esclerosado foi de 33,3% contra 6,6%, no grupo AERDS. Entretanto, apenas metade do grupo esclerosado (16,6%) necessitou mudar a terapia, isto e, realizar a cirurgia, para controlar a recidiva hemorragica. Quanto a mortalidade, no grupo da esclerose, nao observamos nenhum obito. No grupo AERDS ocorreram dois obitos no P.O. imediato. A encefalopatia nao foi observada no grupo esclerosado. Um paciente apresentou os sintomas dois anos apos a cirurgia. Os pacientes portadores de esplenomegalia volumosa, frequentemente associada ao hiperesplenismo, nao se benefician neste particular com a escleroterapia. A escleroterapia necessita de uma selecao dos pacientes com melhor nivel socio-cultural, pois a terapia incompleta com o abandono ou irregularidade do programa, levara fatalmente ao insucesso