This paper is only available as a PDF. To read, Please Download here.
Abstract
Hepatic dysfunction after portacaval shunting (PCS) has been attributed to loss of
portal perfusion to the liver. Proponents of selective systemic shunting state that
reduced encephalopathy and hepatic dysfunction with this procedure result from the
maintenance of portal perfusion to the liver through the hypertensive mesenteric venous
circulation. We questioned the importance of maintaining the diminished portal flow
to the cirrhotic liver because hepatofugal flow is known to develop in many of these
patients. We sought to further define mechanisms that may contribute to the maintenance
of critical flow to the liver in compensated hepatic cirrhosis. We demonstrated a
primary relationship between mesenteric venous hypertension (MVH) and increased hepatic
arterial blood flow after diversion of portal blood flow. Fifteen dogs had vena caval
stenosis above an end-to-side PCS to establish MVH and deprive the liver of portal
blood flow. Another 15 dogs had end-to-side PCS alone. A half hour after shunting,
hepatic arterial blood flow had increased significantly in all dogs. Hemodynamic parameters
remained stable throughout. Six weeks later, mesenteric pressure increased 98% ± 3%
with intracaval stenosis (from 9.6 ± 0.1 to 19.0 ± 0.3 cm H2O). Mesenteric pressure was unchanged with PCS alone (9.0 ± 0.1 cm H2O). Increased hepatic arterial flow was significantly elevated in all dogs above pre-shunt
values by 6 weeks postshunt. With MVH, however, further augmentation in hepatic arterial
flow was noted in the chronic state (1.5 ± 0.1 vs 0.9 ±0.1 ml/min/gm, p < 0.05). There
was significant correlation between MVH and increased hepatic arterial flow in the
chronic state (r = 0.79, p = 0.05). Hepatic arterial flow 6 weeks after PCS with MVH
was associated with lower blood ammonia and improved hepatocellular function compared
with animals with PCS alone. These results support the hypothesis that MVH is important
in maintaining blood supply—beyond providing driving force for sustained portal flow
to the liver. This is an important consideration in the medical and surgical management
of portal hypertension, a condition in which profound reduction in portal pressure
may negatively affect compensatory hepatic arterial blood flow.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Effect of sustained mesenteric venous hypertension on hepatic arterial flow after portacaval shunting [Abstract].Gastroenterology. 1988; 94 (Pt 2): 559
- Portal vein and hepatic artery interactions: studies in the isolated, perfused liver.Gastroenterology. 1962; 43: 547-556
- The vascularity of the liver II. The influence of the portal blood-flow upon the flow in the hepatic artery.Q J Exp Physiol. 1911; 4: 93-110
- Liver and biliary disease.in: 2nd ed. WB Saunders, Philadelphia1985: 3-44
- Hepatic blood flow after canine portasystemic shunting.Ann Surg. 1982; 196: 153-161
- Acute and chronic splanchnic blood flow responses to portacaval shunt in the normal dog.Gastroenterology. 1980; 78: 1432-1433
- Effect of portal venous blood flow diversion on portal pressure.J Clin Invest. 1980; 65: 1388-1397
- Pathoanatomic considerations.in: Schiff ER Schiff AE Liver and biliary disease. 6th ed. JB Lippincott, Philadelphia1985: 22-31
- Splanchnic arterial blood flow in rats with portacaval shunts.Am J Physiol. 1984; 246: G331-G334
- Liver hemodynamics and portacaval shunt.Surg Gynecol Obstet. 1980; 150: 587-592
- Blood flow relationship between hepatic artery and portal vein.Science. 1965; 150: 1030-1031
- Changes in splanchnic blood flow in portal hypertensive rats.Eur J Clin Invest. 1982; 12: 327-333
- Hemodynamic variables and prognosis following portacaval shunts.Surg Gynecol Obstet. 1974; 178: 359-369
- Spontaneous reversal of portal venous blood flow in cirrhosis.Surg Gynecol Obstet. 1968; 126: 315-323
- Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. 1967; 166: 437-455
- A randomized controlled trial of the distal splenorenal shunt.Ann Surg. 1978; 188: 271-282
- Restoration of portal venous perfusion and reversal of encephalopathy by balloon occlusion of portal systemic shunt.Gastroenterology. 1984; 87: 208-212
- The animal with an Eck fistula.Physiol Reviews. 1961; 41: 607-621
- Distal splenorenal shunt.in: Schwartz SI Current modalities in surgery (#10). Innovative Publishing Co, Marlton, New Jersey1985: 1-16
- Clinical implications of portal hemodynamics after small-diameter portacaval H graft.Surgery. 1984; 96: 223-229
- A systemic appraisal of portacaval H-graft diameters clinical and hemodynamic perspectives.Ann Surg. 1986; 204: 356-363
- Influence of stomal size of portacaval shunts on peripheral blood ammonia levels.Ann Surg. 1963; 158: 172-181
- Enhanced survival in patients with variceal bleeding after elective portal decompression.Am J Surg. 1983; 145: 596-598
- Hepatic nerves: a review of their functions and effects.Can J Physiol Pharmacol. 1980; 58: 105-123
- Sympathetic influences on gastrointestinal function.in: The enteric nervous system. Churchill Livingstone, New York1987: 219-223
- Physiology of the intestinal circulation.in: Raven Press, New York1984: 49-59
- The adrenergic innervation of the gastrointestinal tract.Ergeb Physiol. 1974; 69: 1-51
- Adenosine as putative regulator of hepatic arterial flow.Am J Physiol. 1985; : H331-H338
- The relationship between prostacyclin activity and pressure in the portal vein.Hepatology. 1982; 2: 236-242
- Liver blood flow. I. Intrinsic and nervous control of liver blood flow.Gastroenterology. 1981; 81: 159-173
- Role of humoral factors in the intestinal hyperemia associated with chronic portal hypertension.Am J Physiol. 1984; 247: G486-G493
- The origins, pathways and terminations of neurons with VIP-like activity in the guinea-pig small intestine.Neuroscience. 1983; 8: 665-676
- Ammonia absorption from canine colon after portacaval shunt.Br J Surg. 1977; 64: 851-856
- Portal hemodynamics. Intestinal absorption and post-shunt encephalopathy.Surgery. 1983; 94: 126-133
- Cirrhosis.in: Schiff ER Schiff EA Disease of the liver. 6th ed. JB Lippincott, Philadelphia1985: 797-806
- Hepatic artery flow improvement after portacaval shunt: a single hemodynamic clinical correlate.Ann Surg. 1976; 184: 289-302
- Loss of hepatic portal perfusion after selective shunts [Editorial].Am J Surg. 1981; 141: 581
- Matched control study of distal splenorenal and portacaval shunts in the treatment of bleeding esophageal varices.Am J Surg. 1979; 138: 62-67
- Quantitative estimation of metabolic and hemodynamic hepatic function: the effect of shunt surgery.Surg Gastroenterol. 1982; 1: 77-85
- Effect of portasystemic shunt operations on hepatic portal perfusion.Am J Surg. 1981; 141: 169-174
- The metabolic basis of portasystemic encephalopathy and the effect of selective vs. nonselective shunts.Ann Surg. 1974; 180: 573-579
- Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation.Ann Surg. 1984; 200: 711-717
- Measurement of porta-systemic shunting in the rat using gamma-labeled microspheres.Am J Physiol. 1981; 240: G371-G375
- Local control of hepatic arterial and portal venous flow in the dog.Am J Physiol. 1966; 211: 712-720
- Hemodynamic studies in long- and short-term portal hypertensive rats: the relation to systemic glucagon levels.Hepatology. 1986; 6: 414-418
- Liver blood flow. II. Effect of drugs and hormones on liver blood flow.Gastroenterology. 1981; 81: 356-375
- Lack of effect of indomethacin on systemic and splanchnic hemodynamics in portal hypertensive rats.Clin Sci. 1985; 68: 605-607
- Sympathetic nervous control of intramural blood flow in the feline and human intestines.Gastroenterology. 1977; 72: 41-48
- Local colloid trapping in the liver in the inferior vena cava syndrome.J Nucl Med. 1981; 22: 344-346
- Hemodynamic changes in patients with venous obstruction.Hepatology. 1983; 3: 550-553
- Cardiac output and intracardiac pressure in patients with arteriovenous fistulas.J Clin Invest. 1953; 32: 543-547
- Increased blood flow through the portal system in cirrhotic rats.Gastroenterology. 1984; 87: 1120-1126
- Disease of the liver and biliary system.in: 7th ed. Blackwell Scientific, Oxford1985: 133-181
- 2nd ed. Portal hypertension. Current problems in surgery. 25. Year Book Medical Publishers, Chicago1988: 151-223
- Hemodynamic changes following distal splenorenal shunt.Infect Surg. 1987; 12: 676-681
- Effects of insulin, glucagon, and insulin/glucagon infusion on liver morphology and cell division after complete portacaval shunts in dogs.Lancet. 1976; 2: 821-825
- Splenopancreatic disconnection: improved selectivity of distal splenorenal shunt.Ann Surg. 1987; 204: 346-355
- Effects of portasystemic shunting on visceral and portal blood flow in the dog.Gastroenterology. 1982; 83: 1170-1176
- Hemodynamic differences between alcoholic and non-alcoholic cirrhotics following distal splenorenal shunt. Effect on survival?.Ann Surg. 1983; 198: 325
- The Eck fistula in animals and humans.in: 2nd ed. Current problems in surgery. 20. Year Book Medical Publishers, Chicago1983: 688-754
- Effect of selective blockade of B2-adrenergic receptors on portal and systemic hemodynamics in a portal hypertensive rat model.Gastroenterology. 1985; 88: 896-900
- Comparison of three adrenoreceptor blocking agents in patients with cirrhosis and portal hypertension.Gut. 1984; 25: 73-76
- Propanolol increases arterial ammonia in liver cirrhosis.Lancet. 1982; 2: 951-952
- Portal and systemic effects of selective infusion of vasopressin into the superior mesenteric artery in cirrhotic patients.Gastroenterology. 1975; 69: 6-12
- Precipitation of hepatic encephalopathy by propanolol in cirrhosis.Br Med J. 1983; 287: 585
- Propanolol for prophylaxis of bleeding in cirrhotic patients with large varices: a multicenter, randomized clinical trial.Hepatology. 1988; 8: 1-5
- Treatment of acute variceal bleeding.Clin Gastroenterol. 1985; 14: 185
- Prophylactic endoscopic sclerotherapy of esophageal varices: a prospective controlled study.Lancet. 1985; 2: 773-775
- Distal splenorenal shunt vs. endoscopic sclerotherapy for long-term management of variceal bleeding. Preliminary report of a prospective, randomized trial.Ann Surg. 1986; 203: 454-462
Article info
Publication history
Accepted:
January 18,
1989
Footnotes
☆This investigation was supported in part by the Alvin Baldwin, Jr., Chair in Surgery.
Identification
Copyright
© 1989 Published by Elsevier Inc.
