Portasystemic shunts in the management of massive hemorrhage from esophageal varices due to cirrhosis of the liver

Abstract

Twenty-four years ago the first successful application of portacaval shunts for variceal hemorrhage was described by Blakemore and Lord [1] and Whipple [Z]. Since then a torrent of reports has been published, mostly favorable, describing indications, technics and results of a variety of shunts. In spite of this, critical studies by Cohn and Blaisdell [3] and Nachlas [4] have raised serious doubts about the efficacy of these procedures in the prolongation of life or improvement of the well-being of survivors. Surgical mortality rates have been of sufficient magnitude in many series to give pause to the internist and may influence his decision in the direction of a conservative, nonoperative approach. The careful studies by Chalmers and his associates [5] currently raise serious doubts regarding the use of portacaval shunts for the prophylaxis of hemorrhage from esophageal varices in cirrhotic patients, Randomized studies by them [5] and by Lindenmuth [6] appear most convincing and show no benefit in terms of longevity. The decreased likelihood of postshunt hemorrhage is nullified by the increased incidence of disabling encephalopathic episodes. Chalmers et al [5] have also critically analyzed the role of portacaval shunts in the treatment of massive hemorrhage from esophageal varices due to cirrhosis of the liver and have appealed strongly for a randomized study to assess the possible value of surgical measures over a nonoperative regimen. To date no such study has been reported. Other than longevity there are important factors which may disenchant the objective observer on advising a portacaval shunt for his patient. Postshunt encephalopathic episodes have been estimated as occurring in 25 per cent of patients, with serious disability in perhaps half of these [ 71. Low