Acta Chirurgica Belgica

ISSN: 0001-5458 (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tacb20

An analysis on the use of Warren’s distal

splenorenal shunt surgery for the treatment of
portal hypertension at the University Hospitals
Leuven

Karel M. Van Praet, Laurens J. Ceulemans, Diethard Monbaliu, Raymond

Aerts, Ina Jochmans & Jacques Pirenne

To cite this article: Karel M. Van Praet, Laurens J. Ceulemans, Diethard Monbaliu, Raymond
Aerts, Ina Jochmans & Jacques Pirenne (2020): An analysis on the use of Warren’s distal
splenorenal shunt surgery for the treatment of portal hypertension at the University Hospitals
Leuven, Acta Chirurgica Belgica, DOI: 10.1080/00015458.2020.1726099

To link to this article: https://doi.org/10.1080/00015458.2020.1726099

Accepted author version posted online: 05

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Published online: 13 Feb 2020.

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ACTA CHIRURGICA BELGICA
https://doi.org/10.1080/00015458.2020.1726099

ORIGINAL PAPER

An analysis on the use of Warren’s distal splenorenal shunt surgery for

the treatment of portal hypertension at the University Hospitals Leuven
Karel M. Van Praeta,b,c, Laurens J. Ceulemansa,d,e, Diethard Monbaliua, Raymond Aertsa,f, Ina Jochmansa
and Jacques Pirennea
a
Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium; bDepartment of
Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; cDZHK (German Center for Cardiovascular
Research), Berlin, Germany; dLung Transplantation Unit, University Hospitals Leuven, Leuven, Belgium; eDepartment of Thoracic
Surgery, University Hospitals Leuven, Leuven, Belgium; fDepartment of Abdominal Surgery, University Hospitals Leuven, KU
Leuven, Leuven, Belgium

ABSTRACT ARTICLE HISTORY

Introduction: Extrahepatic portal vein thrombosis (PVT) is the most common cause of portal Received 13 January 2020
hypertension (PH), particularly in children. PH-related manifestations include refractory vari- Accepted 2 February 2020
ceal bleeding, splenomegaly and ascites. Albeit more rarely performed, the distal splenorenal
KEYWORDS
shunt (Warren’s shunt) has proven to be effective in selectively decompressing the collateral
Distal splenorenal shunt;
circulation. The aim of our study was to describe our experience with the distal splenorenal Warren’s shunt; outcome;
shunt and to determine the long-term effect on PH-related side-effects. portal hypertension; portal
Methods: Distal splenorenal shunt operations performed at our institution between 2000 vein thrombosis
and 2014 were reviewed for: age, male/female ratio, children/adults ratio, body mass index,
indications, grade of PVT (Yerdel classification), maximal shunt-flow velocity, shunt patency
and thrombosis, re-intervention for variceal bleeding and survival. Complications of PH
(esophageal variceal bleeding and ascites) were compared pre- versus post-operatively (last
follow-up). Paired student t-test and fisher’s exact were applied for pre- versus post-operative
comparison. Results are reported as median [range].
Results: Fourteen patients with PVT and refractory complications of PH underwent distal
splenorenal shunt surgery. Age was 15 years [4.5–66]. Male/female ratio was 7/7. PVT -grade
was 2 [1–4]. Follow-up was 3 [0.5–14]. All shunts were patent (100%) with no shunt throm-
bosis (0%) at last follow-up. There was no re-intervention for variceal bleeding (0%) and sur-
vival at last follow-up was 100%. Occurrence of esophageal variceal bleeding was higher
pre-operatively (57%) than postoperatively (0%) (p ¼ .0032) and also the incidence of ascites
was higher pre-operatively (79%) than postoperatively (0%) (p < .0001).
Conclusions: Based on our experience, the distal splenorenal shunt can be considered a
valuable surgical technique for PVT-induced PH, with excellent post-operative prevention of
complications of PH.

Abbreviations: BMI: Body Mass Index; DSRS: Distal Splenorenal Shunt; eGFR: estimated
Glomerular Filtration Rate; ERCP: Endoscopic Retrograde Cholangio Pancreatography; MRCP:
Magnetic Resonance Cholangio Pancreatography; PH: Portal Hypertension; PSE:
Portosystemic Encephalopathy; PV: Portal Vein; PVT: Portal Vein Thrombosis; SBP:
Spontaneous Bacterial Peritonitis; SMV: Superior Mesenteric Vein; TIPS: Transjugular
Intrahepatic Portosystemic Shunt

Introduction
Over the last few years, the etiology of extrahe-
patic portal vein thrombosis (PVT) has been better
defined and large case series have improved our
understanding of the natural history of this condi-
tion [1]. These advantages allow a reappraisal to
be made of the approach to treatment of patients
with PVT, possibly tailored to the individual patient
according to the duration, etiology and extension
of the disease [1]. The focus of this manuscript will
be on portal hypertension (PH) in the light of PVT
due to both inherited and acquired factors.
PVT is known to be an important cause of PH,
particularly in children [2]. PH is an almost
unavoidable complication of PVT, and it accounts
for life-threatening complications such as massive
bleeding from gastroesophageal varices, spleno-
megaly, intractable ascites, spontaneous bacterial
peritonitis (SBP), portal hypertensive biliopathy,
portosystemic encephalopathy (PSE) and

CONTACT Karel M. Van Praet vanpraet@dhzb.de Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin (Deutsches
Herzzentrum Berlin), Augustenburger Platz 1, Berlin, 13353, Germany
ß 2020 The Royal Belgian Society for Surgery
2 K. M. VAN PRAET ET AL.
hepatorenal syndrome [3]. However, an evidence-
based approach to the management of PH in chil-
dren does exist [4].
For the patient with recurrent complications of
PH but adequate hepatic function, controversy
exists in regard to the best method of prophylaxis
against future bleeding. The use of portosystemic
shunt surgery to decompress PH has declined dur-
ing the past decade in favor of alternative thera-
pies [5]. Currently, the number of transjugular
intrahepatic portosystemic shunt (TIPS) and endo-
scopic procedures, sclerotherapy and pharmaco-
logical therapy by far exceed that ever achieved
with surgical shunts [6]. But if these primary thera-
pies fail, distal splenorenal shunt (DSRS or Warren’s
shunt) surgery has been regarded by many as the
most effective therapy to control recurrent compli-
cations of PH. However, low operative risk and a
well-preserved liver function are mandatory [7].
The aim of our study was to describe our
experience with DSRS and to determine the long-
term effect on PH-related side-effects.
Patients and methods
Patient population and study design
Fourteen consecutive patients who underwent
DSRS for PH due to PVT between 2000 and 2014
were retrospectively reviewed using data prospect-
ively collected in an ad hoc database.
Figure 1. Classification of portal vein thrombosis by Yerdel et al. Adapted from Lai Q et al. [9].
Demographics
Data collected included age, children/adults ratio,
male/female ratio, BMI and PVT etiology.
Classification of PVT
PVT usually arises within the liver and extends to
the portal vein (PV). In some cases, the thrombosis
further extends to mesenteric branches resulting
in a splanchnic venous thrombosis. Anatomically,
PVT can be classified into four grades according to
Yerdel’s classification as shown in Figure 1: (i) min-
imally or partially thrombosed PV, in which the
thrombus is mild or, at the most, confined to
<50% of the vessel lumen with or without minimal
extension into the superior mesenteric vein (SMV);
(ii) >50% occlusion of the PV, including total
occlusions, with or without minimal extension into
the SMV; (iii) complete thrombosis of both PV and
proximal SMV, with distal SMV fully open; (iv) com-
plete thrombosis of the PV and proximal as well as
distal SMV. PVT was graded according to (pre)-
operative (radiographic) findings according to this
classification model. Figure 2 shows a preoperative
computed tomography scan of one of our patients
with grade 4 PVT [8].
Operative technique
DSRS was performed by the methods previously
published by Dean Warren et al. [10]. All patients
 ACTA CHIRURGICA BELGICA 3

Figure 2. (A) An image of a computed tomography scan of pre-operative portal vein thrombosis grade 4. The arrows in the
left scan show the extent of the thrombus. (B) A postoperative image of a computed tomography scan of the DSRS. The arrows
in the right scan indicate the shunt.

Figure 3. Schematic illustration of Warren’s shunt. The shunt is fashioned by bringing the splenic vein down without tension
or kinking to the anterior/superior surface of the left renal vein. Pathways of collateral development after DSRS can be seen.
Adapted from Henderson et al. [11].

Outcome
had the designated operative procedure, with
selective transsplenic variceal decompression and Shunt-related data collected included maximal
maintenance of portal perfusion of the liver. The shunt-flow velocity, shunt patency and
procedure is illustrated in Figure 3. thrombosis.
4 K. M. VAN PRAET ET AL.

Maximal shunt-flow velocity was defined as Table 1. Demographics, distal splenorenal

maximal velocity (Vmax) in centimeters per shunt-related endpoints, follow-up and survival
at last follow-up.
second of blood flow through the DSRS at last
Age (years) 15 [4.5–66]
follow-up on Doppler-ultrasound investigation; Children/adults 9/5
Male/female 7/7
Shunt patency was defined as whether the DSRS BMI (kg/m2) 20 [14–29]
was patent on last-follow-up ultrasound evalu- Grade of PVT (Yerdel) 2 [1–4]
Follow-up (years) 3 [0.5–14]
ation; Thrombosis of shunt was defined as shunt Shunt patency (%) 100%
re-thrombosis on last follow-up ultrasound Shunt thrombosis (%) 0%
Maximal shunt flow velocity (cm/s) 46 [16–40]
evaluation. Re-intervention for variceal bleeding (%) 0%
Survival at last follow-up (%) 100%
Post-operative re-intervention for variceal
bleeding was defined as postoperative
bleeding requiring an endoscopic re-intervention Statistics
and was designated as being from esophageal
Paired student t-test and fisher’s exact test were
varices.
applied for pre- versus post-operative comparison.
Clinical assessment focused on complications of
Results are reported as median [range].
PH. The following PH-related data were collected
and compared pre- versus post-operatively.
Esophageal variceal bleeding. This was desig- Results
nated as bleeding from varices supported by Demographics
clinical investigation and endoscopic findings;
Splenomegaly was defined as the ratio of cranio- As summarized in Table 1, median age at the day
caudal spleen-size, as found on computed tom- of surgery was 15 years [4.5–66]. Children/adults
ography scan, over stature in centimeters length; ratio, male/female ratio and BMI. The children/
Hypersplenism was defined as defects in all three adults ratio was 9/5 in our study population,
blood cell lineages, namely red blood cell, whereas the male/female ratio was 7/7. BMI at the
(hemoglobin), leukocyte and thrombocyte count; day of surgery was 20 [14–29]. PVT etiology was
Ascites was defined as presence of ascites con- found to be idiopathic (n ¼ 7), congenital (n ¼ 2),
firmed on ultrasound prior to DSRS surgery and hemochromatosis (n ¼ 1), protein-C deficiency
postoperatively at last follow-up; SBP was defined (n ¼ 1), liver sarcoidosis (n ¼ 2) and post-liver trans-
as occurrence of this condition pre- versus post- plant (n ¼ 1).
operatively. It was assessed by mention in the
pre -and postoperative patient records; Portal Classification of PVT
hypertensive biliopathy was defined as occurrence
All patients had perioperatively confirmed splanch-
of jaundice and measurement of total bilirubin,
nic thrombosis with the grade of PVT being
alkaline phosphatase, AST and ALT blood levels
2 [1–4].
[12,13]; PSE was defined as encephalopathy,
according to the West Haven classification model
of encephalopathy, due to portosystemic shunts Operative technique
as this might be seen in patients with PVT and As shown in Figure 2, the DSRS can be seen on a
PH. Therefore, we analyzed whether this patho- postoperative computed tomography scan.
logic manifestation was reported in the patient’s
clinical records; Hepatorenal syndrome was
defined as a decrease in renal function due to Outcome
splanchnic vasodilation and its adverse effects on Results for shunt-related outcomes are shown in
renal function as commonly seen with PVT and Table 1.
PH. This was assessed by measurement of cre- Shunt patency, shunt thrombosis and maximal
atinine and estimated glomerular filtration rate shunt flow velocity. Postoperative ultrasound evalu-
(eGFR). Last follow-up was defined as the interval ation proved that all DSRS were patent (100%)
between the day of operation and the day of without any re-thrombosis (0%) at the day of
the last consultation at our hospital. Survival at last follow-up. Postoperative maximal shunt flow
last follow-up was defined as whether the patient velocity was 46 cm/s [16–40].
was still alive on the day of last consultation at Table 2 shows the results of pre- versus post-
our hospital. operatively comparison of complications of PH.
 ACTA CHIRURGICA BELGICA 5

Table 2. Comparison of complications associated with portal hypertension pre-versus post-operatively.

Endpoints Pre-operative Post-operative p Value Paired t-test or Fisher’s exact
Esophageal variceal bleeding (%) 57% 7% .0032 Fisher
Ratio spleen-CC length/ stature 0.109 [0.086–0.181] 0.089 [0.071–0.127] .0204 t-test
Hypersplenism
Hemoglobine (g/dL) 9.15 [6.8–13] 14 [10.5–16.9] <.0001 t-test
Thrombocytes (109/L) 65.5 [30–159] 135 [61–267] .0003 t-test
Leukocytes (109/L) 2.725 [0.9–6] 6.9 [2.36–9.79] <.0001 t-test
Ascites (%) 79% 0% <.0001 Fisher
Spontaneous bacterial peritonitis 43% 0% <.0001 Fisher
Portal hypertensive biliopathy
Jaundice (%) 14% 0% .4815 Fisher
Total bilirubine (mg/dL) 1.205 [0.52–1.77] 0.655 [0.32–1.2] .0056 t-test
Alkaline phosphatase (IU/L) 419.5 [57–1111] 80 [39–363] .0027 t-test
AST (IU/L) 35 [20–161] 22 [10–45] .0110 t-test
ALT (IU/L) 26 [15–368] 15.5 [7–32] .0442 t-test
Hepatorenal syndrome 29% 0% .0978 Fisher
Creatinine level (mg/dL) 0.93 [0.35–1.54] 0.665 [0.35–0.95] .0035 t-test
Portosystemic encephalopathy 14% 0% .4815 Fisher

Esophageal variceal bleeding. The prevalence of
preoperative esophageal variceal bleeding was
57%, whereas the postoperative prevalence was
found to be 7% (p ¼ .0032).
Postoperative re-intervention for varciceal bleed-
ing. None of our patients needed postoperative
endoscopic intervention for variceal re-bleeding
(0%) (Table 1).
Splenomegaly. The preoperative spleen CC
length/stature ratio was 0.109 [0.086–0.181],
whereas the postoperative spleen CC length/stat-
ure ratio measured to be 0.089 [0.071–0.127]
(p ¼ .0204).
Hypersplenism. Preoperative hemoglobin,
thrombocyte and leukocyte count were 9.15 g/dL
[6, 8–13], 65.5  109/L [30–159] and 2.725  109/L
[0.9–6], respectively. Postoperatively they were
14 g/dL [5–16] (p < .0001), 135  109/L [61–267]
(p ¼ .0003), and 6.9  109/L [2.36–9.79] (p < .0001),
respectively.
Ascites. Prevalence of ascites in the preoperative
setting was 79%, postoperative it was 0%
(p < .0001).
SBP. Preoperative SBP was diagnosed in six
patients (43%), whereas postoperatively no
patients were found with SBP (0%) (p < .0001).
Portal hypertensive biliopathy. Jaundice was
found in 14% of our patients preoperatively,
whereas none of the patients presented with jaun-
dice during later consultations (0%) (p ¼ .4815).
Preoperatively, total bilirubin, alkaline phosphat-
ase, AST and ALT measured 1.205 mg/dL
[0.52–1.77], 419.5 IU/L [57–1111], 35 IU/L [20–161],
26 IU/L [15–368], respectively. Postoperatively they
were 0.655 mg/dL [0.32–1.2] (p ¼ .0056), 80 IU/L
[39–363] (p ¼ .0027), 22 IU/L [10–45] (p ¼ .0110),
15.5 IU/L [7–32] (p ¼ .0442), respectively.
PSE. West Haven grade 1 PSE was reported in
two patients preoperatively (14%), whereas none
of our patients reported symptoms of this patho-
logical condition postoperatively (0%) (p ¼ .4815).
Hepatorenal syndrome. Hepatorenal syndrome
was present in four patients (29%) preoperatively,
whereas no patients had postoperative hepatore-
nal syndrome (0%) (p ¼ .0978). Creatinine level was
0.93 mg/dL [0.35–1.54] pre-operatively, whereas
post-operatively it was found to be 0.665 mg/dL
[0.35–0.95] (p ¼ .0035). EGFR was 69.5 mL/min/
1.73 m2 [56–84] pre-operatively. Post-operatively it
was >90 mL/min/1.73 m2 [72–90].
Last follow-up. Last follow-up was
3 years [0.5–14].
Survival at last follow-up. At the day of last con-
sultation, all patients were alive (100%).
Discussion
Our current findings reemphasize the value of por-
tosystemic shunt surgery in the overall treatment
repertoire for patients with complications of PH
due to PVT as it is associated with excellent out-
comes, little morbidity and no mortality at the day
of last follow-up. The selective DSRS was first
described by Warren et al. [10]. This procedure has
found to be effective in selectively decompressing
gastroesophageal varices while preserving portal
perfusion of the liver [7]. As a consequence of por-
tal vein obstruction, systemic and splanchnic
hemodynamics undergo specific and important
modifications [14,15]. Numerous procedures
besides shunting have been advocated over the
years, but none has proven to be as reliable or
to be comparable with respect to morbidity and
mortality [12]. The DSRS procedure has also been
6 K. M. VAN PRAET ET AL.
performed successfully in infants for years [4,12].
Traditionally, PH in children has been associated
with a high incidence of PVT as seen in the present
series. This study was designed to evaluate the
relative efficacy of DSRS in preventing re-occur-
rence of complications of PH. Therefore, our end-
points of clinical importance were esophageal
variceal re-bleeding, reduction of splenomegaly
and hypersplenism and re-occurrence of ascites
and SBP. We also looked at reduction of portal
hypertensive biliopathy and the incidence of PSE
pre- versus post-operatively. Creation of a DSRS
provides a low-pressure, high-flow shunt in the left
upper quadrant of the abdomen that controls
bleeding from esophageal varices refractory to
medical or endoscopic treatment [16]. Our merely
7% esophageal variceal re-bleeding rate after DSRS
is similar to that reported by others [17]. The pri-
mary cause for re-bleeding is shunt thrombosis,
which allegedly occurs in 3–14% of patients [17].
Experience with DSRS in our hospital showed a
shunt thrombosis rate of 0% at last follow-up.
However, variceal re-bleeding after DSRS may also
occur with a patent shunt but inadequate variceal
decompression [17]. Variceal decompression by
DSRS requires an adequate outflow through the
short gastric veins, the splenic vein and shunt, and
the left renal vein to the inferior vena cava [17].
Development of an adequate outflow for complete
esophageal decompression may take 4–6 weeks in
some patients, making this the highest risk-time
for re-bleeding [17]. Furthermore, a non-occluding
untraceable thrombus can occur in up to 20% of
patients after DSRS due to subsequent thickening
and narrowing of the portal vein, transgastric
veins, pancreatic veins or splenic vein [17]. We
report a median postoperative maximal shunt flow
velocity at last follow-up of 46 cm/s as proof of
adequate outflow. Furthermore, splenomegaly,
hypersplenism and, consequently, pancytopenia
are commonly present in chronic PVT [12].
Decrease in spleen size as splenic effect of DSRS is
related to the improvement of venous stasis as the
shunt diminishes splenic volume overload [12]. In
the present series, evolution in splenomegaly was
presented as the ratio of cranio-caudal spleen-size/
stature as we tried to correct for differences in
age within our series. Our results show us that
spleen size decreases significantly after DSRS.
Consequently, hypersplenism and its associated
defects in all three blood cell lineages effectively
improved. Ascites as a common complication of
PH is mostly transient. It is often associated with
renal failure and SBP in older patients [12].
Preoperatively confirmed ascites was complicated
by SBP in six of our patients. Postoperatively, the
incidence of SBP was 0. Although SBP is generally
known as a complication of ascites due to cirrho-
sis, the literature reports few cases of non-cirrhotic
conditions with ascites complicated by SBP. In
addition, albeit poorly documented in the litera-
ture, previously data report a 10% incidence of
ascites in the first month after DSRS [11]. In our
experience, this marker of advanced PH has an
occurrence of 0% late after operation. Moreover,
ascites and the adverse hemodynamic changes as
seen with PVT reduce renal function [15,12].
Consequently, four patients from our series pre-
sented with clinical symptoms and biochemic find-
ings consistent with hepatorenal syndrome. This
was reported in the patients’ clinical records. We
assume that the cascade of splanchnic vasodila-
tion, impaired barrier function of the gut, bacterial
translocation and its resulting inflammatory status
with compensatory activation of the renin-angio-
tensin-activating system and renal vasoconstriction
in combination with ascites can affect patients
with non-cirrhotic PH due to PVT as well. Although
slowly progressive, abnormalities of the extrahe-
patic biliary tree have been reported in more than
80% of patients with chronic PVT; biliary changes
like indentations of para-choledochal collaterals on
the bile duct, localized ischemic strictures or dilata-
tions and chronic cholestasis or cholangitis are the
principal reasons [12]. In general, diagnosis of por-
tal hypertensive biliopathy is best made with
endoscopic retrograde cholangio pancreatography
(ERCP) or magnetic resonance cholangio pancrea-
tography (MRCP) examination [12,13]. Because
both diagnostic tools were not used preopera-
tively, we looked at specific clinical and biochem-
ical markers configuring the so-called portal
hypertensive biliopathy, as depicted in Table 2.
From these results, we can conclude that DSRS
leads to a significant improvement of markers of
biliary function postoperatively. In the patient with
chronic PVT, PSE is relatively uncommon and tran-
sient [12,13]. A well-known significant advantage
of DSRS includes a low incidence of encephalop-
athy postoperatively [18]. Application of a DSRS
results in preservation of portal perfusion of the
liver and retention of liver function [11,19]. Hence
our consideration for DSRS as a valuable procedure
to treat preoperatively confirmed PSE. Previous
studies focused on nitrogen metabolism, measur-
ing ammonia tolerance, urea synthesis rates and

amino acid metabolism [11]. These data showed
improvement of preoperative levels of function in
patients after DSRS. The parallel clinical improve-
ment of encephalopathy in the group with better
nitrogen metabolism and DSRS was interpreted as
providing a metabolic basis for their improvement
in encephalopathy [11]. Our present series experi-
ence an excellent survival at last follow-up. This is
consistent with findings defined by others [10],
although we must admit that our median follow-
up of 3 years is shorter than reported by other
long-term studies.
Conclusion
Based on our experience, distal splenorenal shunt-
ing continues to be an effective and safe proced-
ure for controlling esophageal variceal bleeding
and other clinically important complications of PH.
Our results prove that DSRS is well suited for treat-
ment of these complications considering the pau-
city of life-sustaining alternatives in these seriously
ill patients. It serves as an excellent salvage
procedure for children and adults with good
liver function and acceptable operative risk.
Furthermore, at our center, DSRS is a durable tech-
nique, with a good patency and no mortality at
last follow-up.
Disclosure statement
No potential conflict of interest was reported by
the author(s).
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