Which of the following statement(s) is/are true concerning the surgical management of bleeding esophageal varices.
- A side-to-side portacaval shunt may be associated with the development of hepatofugal blood flow
- Selective shunts preserve prograde (hepatopedal) blood flow while decompressing esophageal varices or reducing portal pressure
- The presence of intractable ascites is a contraindication to the Warren shunt
- If the patient is considered a liver transplant patient, an interposition mesocaval shunt is a suitable alternative
a. A side-to-side portacaval shunt may be associated with the development of hepatofugal blood flow
b. Selective shunts preserve prograde (hepatopedal) blood flow while decompressing esophageal varices or reducing portal pressure
c. The presence of intractable ascites is a contraindication to the Warren shunt
d. If the patient is considered a liver transplant patient, an interposition mesocaval shunt is a suitable alternative
Although portosystemic shunts are the most effective therapy for preventing recurrent variceal hemorrhage, they are associated with the increased incidence of encephalopathy. A number of types of shunts have been described, primarily to avoid the consequences of complete diversion of portal blood flow or to simplify the operation. End-to-side portocaval shunts are hemodynamically unique in that all portal flow is diverted and the hepatic limb of the portal vein is ligated, thus preventing hepatofugal blood flow from the liver. With lateral side-to-side shunts, the hepatic limb of the portal vein remains patent. A greater compensatory increase in hepatic arterial flow occurs when the portal vein serves as an outflow track and the liver extracts oxygen and metabolites from the blood exiting through the patent limb of the portal vein (hepatofugal). The goal of selective shunts is to preserve prograde (hepatopedal) portal flow to the liver while selectively decompressing gastroesophageal varices (Warren shunt) or reducing portal pressures sufficiently to prevent variceal hemorrhage (small-diameter shunts). Most surgeons with a special interest in this field attempt to construct a selective shunt when the operation is elective, unless contraindications are present. The distal splenorenal shunt of Warren and the small-diameter interposition portocaval shunt of Sarfeh are the most common selective shunts used. The Warren shunt is an ascitogenic operation and therefore the presence of ascites that is difficult to control medically is a contraindication of this operation. An interposition mesocaval shunt is frequently preferred in emergent situations because the shunt is relatively safe to construct and promptly halts variceal hemorrhage. If future hepatic transplantation is contemplated, this shunt offers the advantages in that it does not involve dissection of the area of the hepatoduodenal ligament.
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