Impact Of Spontaneous Splenorenal Shunt On Long-term Survival Of Patients With Liver Cirrhosis

Background and aims Liver cirrhosis is a potentially life-threatening global health problem.Liver cirrhosis is the 14 th most common cause of death among adults in the world and the fourth most common cause of death in Europe,with 103 million people dying of liver cirrhosis every year.Portal hypertension is the most common complication of liver cirrhosis.Its pathophysiological mechanism is still unclear.It was initially considered to be the result of destruction of normal liver tissue structure and dysfunction.Now some studies have manifested that the increase of portal blood flow caused by visceral vasodilation also plays an important role.With the increase of portal vein pressure,various portal systemic collateral circulations can be formed in patients with liver cirrhosis.Spontaneous splenorenal shunt(SSRS)is one of the most common types of spontaneous portosystemic shunt.Abdominal enhanced computed tomography or magnetic resonance imaging is commonly used clinical methods to diagnose SSRS.SSRS may reduce portal pressure and increase the risk of hepatic encephalopathy.However,the impact of SSRS on the long-term survival of patients with liver cirrhosis remains unclear.Based on our clinical observations,we hypothesized that SSRS may worsen liver function and increase the risk of death by reducing hepatic perfusion.MethodsIn a prospective database,we continuously collected the data of patients with non-malignant liver cirrhosis who were diagnosed in our department and underwent abdominal enhanced CT or MRI examination and upper gastrointestinal endoscopy.All patients who admitted to our hospital from December 2014 to August 2019 were screened.According to the presence of SSRS in abdominal enhanced CT or MRI,patients were divided into two groups: with SSRS and without SSRS.The maximum diameters of portal vein system vessels and SSRS were measured.Liver to abdominal area ratio(LAAR)score was calculated.The patients were followed up,and the last follow-up date was August 31,2019.Kaplan-Meier curves were used to show the survival probability and compared by log-rank test.Univariate and multivariate Cox regression analyses were performed to explore the predictors for death.ResultsThe prevalence of SSRS was 30.3%.Median maximum diameters of left portal vein,right portal vein,main portal vein,superior mesenteric vein,splenic vein,and SSRS were 12.80 mm,10.50 mm,16.45 mm,12.30 mm,13.10 mm,and 13.50 mm,respectively.Patients with SSRS had significantly thinner median maximum diameters of right portal vein(9 mm vs.11.20 mm,P = 0.001)and main portal vein(15.30 mm vs.16.80 mm,P = 0.017)than those without SSRS.The prevalence of portal vein system thrombus was 32.8%.Patients with SSRS had a higher prevalence of portal vein system thrombus than those without SSRS(35.1% vs.31.8%,P = 0.715),but this difference did not reach statistical significance.Patients with SSRS had a higher prevalence of hepatic encephalopathy(10.8% vs.7.1%,P = 0.487),a lower prevalence of gastrointestinal bleeding(67.6% vs.78.8%,P = 0.184),and a higher prevalence of ascites than those without SSRS(62.2% vs.58.8%,P = 0.731)than those without SSRS,but there were no significant difference between them.Median LAAR score was 29.60(range: 13.64-42.27).Patients with SSRS had a significant lower median LAAR score(25.39 vs.31.58,P < 0.001)than those without SSRS.Median Child-Pugh score was 6(range: 5-12).Patients with SSRS had a significantly higher median Child-Pugh score than thosewithout SSRS(7 vs.6,P = 0.046).Median MELD score was 10.20(range: 6.43-27.50).Patients with SSRS had a significantly higher median MELD score than those without SSRS(12.17 vs.9.79,P = 0.006).A median follow-up duration is 10.05 months.Patients with SSRS had a significantly higher mortality rate than those without SSRS(18.9% vs.4.7%,P = 0.012).Kaplan-Meier curve analysis also found a significantly lower cumulative survival rate in overall patients with SSRS(P = 0.014).Cox regression analysis demonstrated that SSRS was a statistically significant risk factor associated with increased mortality of patients with liver cirrhosis(hazard ratio = 4.161,95% confidence interval: 1.215-14.255,P = 0.023).ConclusionsSSRS is common in patients with liver cirrhosis.The influence of the diameter of right portal vein and main portal vein on liver cirrhosis in patients with SSRS cannot be ignored,and the diameter of portal vein in patients with SSRS is thinner.There is a close relationship between SSRS and deterioration of liver function.Patients with SSRS have worse liver function.SSRS have smaller liver volume and lower cumulative survival rates.SSRS is a significant risk factor for increasing mortality in patients with liver cirrhosis.