Abstract
Despite the best conservative measures available for the control of major variceal hemorrhage, some patients either continue to bleed, or rebleed early, and require emergency surgery. One hundred patients with cirrhosis and uncontrolled bleeding were treated with emergency portasystemic shunts between 1968 and 1983. Fifty eight patients had end-to-side portacaval shunts and 42 had Dacron interposition mesocaval shunts. Both groups were comparable with respect to age, sex and prevalence of alcoholism. There was an increased severity of liver disease as assessed by Child's class in the mesocaval group of patients. Overall in-hospital mortality was 31% with no significant difference demonstrated between the mesocaval group (28%) and the portacaval group (33%), nor between alcoholic cirrhotics (34%) and non-alcoholic cirrhotics (21%). Mortality rates based on severity of liver disease were: Child's A (1/6) 17%, Child's B (9/48) 19%, and Child’s C (21/46) 46%. There was a statistically significant difference between Child's A & B and Child's C (p < 0.01). Four patients were lost to follow-up. No significant differences were found in 5 year survival by life table analysis comparing portacaval (39%) vs. mesocaval (28%) groups or alcoholic cirrhotics (36%) vs. non-alcoholic cirrhotics (29%). Encephalopathy in survivors was absent in 46%, mild in 28% and severe in 26% of patients. There was no significant difference in encephalopathy rates following portacaval or mesocaval shunting. Neither operation was clearly superior and choice of operation can be made on the basis of technical and anatomical factors and surgeon experience. Emergency shunting remains a useful option for patients with variceal bleeding refractory to other more conservative therapy, and is associated with acceptable early mortality and long term survival rates.
Highlights
The treatment of variceal hemorrhage remains a difficult and challenging problem
Between 1968 and 1983, 100 patients with biopsy proven cirrhosis and variceal bleeding underwent emergency portasystemic shunting. These were patients who continued to bleed despite medical management including attempted correction of coagulopathy, IV Pitressin, balloon tamponade and injection sclerotherapy; or had early recurrent uncontrolled bleeding
Injection sclerotherapy has been used as long term primary elective therapy for variceal bleeding with shunt procedures reserved for failures
Summary
The treatment of variceal hemorrhage remains a difficult and challenging problem. Most patients stop bleeding either spontaneously or with non-operative management including Pitressin, balloon tamponade and injection sclerotherapy. Either continue to bleed, or rebleed after initial control and may require emergency surgical intervention to stop the bleeding. Portasystemic shunting remains the standard surgical management in this situationa’2’3, there is less agreement as to which shunt is best. The mesocaval shunt has been preferred by some4’5’6’7’8 because it is felt to leave a lower encephalopathy rate; and discouraged by others9’1’1a because of its higher thrombosis rate. This report documents our experience with mesocaval and portacaval shunting for refractory
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