Emergency shunt. Role in the present management of variceal bleeding
L. F. Rikkers and G. Jin
Department of Surgery, University of Nebraska Medical Center, Omaha, USA.
OBJECTIVE: To evaluate the results of selective and nonselective emergency
portosystemic shunts in patients with acute variceal hemorrhage. DESIGN:
Retrospective review. SETTING: University medical center and Veterans
Affairs medical center. PATIENTS: Forty-two consecutive patients who
underwent emergency portosystemic shunts from 1978 through 1994. All
patients had chronic liver disease (29 [69%] had alcoholic cirrhosis) and
half had Child's class C disease. Sixteen patients were actively bleeding
at the time of surgery, and 26 had bled within 48 hours. Twenty-two
patients underwent a nonselective shunt and 20 underwent a distal
splenorenal shunt. The percentages of patients with Child's class C disease
and with active bleeding at the time of surgery were significantly higher
in the nonselective shunt group. MAIN OUTCOME MEASURES: Operative
mortality; early postoperative rebleeding, shunt patency, encephalopathy,
and ascites; and long-term survival. RESULTS: Operative mortality rates
were higher in patients with Child's class C disease (43% [9/21]) than in
patients with Child's class A or B disease (9% [2/21]) and were higher in
patients with active bleeding (all of whom underwent nonselective shunt)
(44% [7/16]) than in patients who underwent distal splenorenal shunt (10%
[2/20]). All shunts were patent after surgery, and no patient had
rebleeding during the early postoperative interval. Early postoperative
ascites and encephalopathy rates were similar after nonselective shunt and
distal splenorenal shunt. Long-term survival was superior in the lower-risk
distal splenorenal shunt group. CONCLUSIONS: Even though more effective
nonoperative treatments are now available, emergency portosystemic shunt
remains an important option for selected patients with acute variceal
hemorrhage. When bleeding can be temporarily controlled by nonoperative
means, distal splenorenal shunt is an effective and safe emergency
procedure. The mortality rate remains high for patients with Child's class
C disease undergoing protal decompression.
