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Should Portosystemic Shunt Be Reconsidered in the Treatment of Intractable Ascites in Cirrhosis?

Should Portosystemic Shunt Be Reconsidered in the Treatment of Intractable Ascites in Cirrhosis? Abstract • Fifty-seven cirrhotic patients with intractable ascites had a portosystemic shunt. In 35 patients, a peritoneovenous shunt had previously failed. Forty-six patients were in Pugh's class B and 11 were in class C. There were three operative deaths (5.3%). Fifty-three (98.2%) of the 54 survivors were cleared of ascites. In one patient, ascites persisted because of postshunt heart failure that resulted in a marked increase of caval pressure. Twenty-seven patients (50%) had late encephalopathy, which was severe and disabling in 12 (22%). One- and three-year survival rates were 72% and 36%, respectively. These results suggest that although portosystemic shunts are remarkably effective in dealing with ascites, the high rate of postoperative encephalopathy is a strong argument against their routine use in the management of intractable ascites in cirrhosis. (Arch Surg 1988;123:987-991) References 1. Prokesch RC, Rimland D: Infectious complications of the peritoneo-venous shunt . Am J Gastroenterol 1983;78:235-240. 2. Fulenwider JT, Smith RB III, Redd CS, et al: Peritoneovenous shunts: Lessons learned from an eight-year experience with 70 patients . Arch Surg 1984;119:1133-1137.Crossref 3. Harmon DC, Demirjian Z, Ellman L, et al: Disseminated intravascular coagulation with the peritoneovenous shunt . Ann Intern Med 1979;90:774-776.Crossref 4. Lerner RG, Nelson JC, Corines P, et al: Disseminated intravascular coagulation: Complication of LeVeen peritoneovenous shunts . JAMA 1978;240:2064-2066.Crossref 5. Fulenwider JT, Galambos JD, Smith RB III, et al: LeVeen vs Denver peritoneovenous shunts for intractable ascites of cirrhosis . Arch Surg 1986;121:351-355.Crossref 6. Smadja C, Tridard D, Franco D: Recurrent ascites due to central venous thrombosis after peritoneojugular (LeVeen) shunt . Surgery 1986;100:535-541. 7. Epstein M: Peritoneovenous shunt in the management of ascites and the hepatorenal syndrome . Gastroenterology 1982;82:790-799. 8. Barker HG, Reemtsma K: The portacaval shunt operation in patients with cirrhosis and ascites . Surgery 1960;48:142-154. 9. Welch HF, Welch CS, Carter JH: Prognosis after surgical treatment of ascites: Results of side-to-side shunt in 40 patients . Surgery 1964;56:75-82. 10. Burchell AR, Rousselot LM, Panke WF: A seven-year experience with side-to-side portacaval shunt for cirrhotic ascites . Ann Surg 1968;168:655-670.Crossref 11. Orloff MJ: Pathogenesis and surgical treatment of intractable ascites associated with alcoholic cirrhosis . Ann NY Acad Sci 1970;170:213-238.Crossref 12. Vons C, Smadja C, Bourstyn E, et al: Results of portal systemic shunts in Budd-Chiari syndrome . Ann Surg 1986;203:366-370.Crossref 13. Leveen HH, Wapnick S, Grosberg S, et al: Further experience with peritoneo-venous shunt for ascites . Ann Surg 1976;184:574-581.Crossref 14. Pugh RNH, Murray-Lyon IM, Dawson JL, et al: Transection of the esophagus for bleeding esophageal varices . Br J Surg 1973;60:646-649.Crossref 15. Huguet C, Hannoun L, Opolon P, et al: Place des dérivations portocaves dans le traitement chirurgical des ascites cirrhotiques . Gastroenterol Clin Biol 1981;5:324-331. 16. Bismuth H, Franco D, Hepp J: Portal-systemic shunt in hepatic cirrhosis: Does the type of shunt decisively influence the clinical result? Ann Surg 1974;179:209-218.Crossref 17. Smadja C, Franco D: The LeVeen shunt in the elective treatment of intractable ascites in cirrhosis: A prospective study on 140 patients . Ann Surg 1985;201:488-493.Crossref 18. McDermott WV Jr: The treatment of cirrhotic ascites by combined hepatic and portal decompression . N Engl J Med 1958;259:897-901.Crossref 19. Welch CS, Attarian E, Welch HF: The treatment of ascites by side-to-side portacaval shunt . Bull NY Acad Med 1958;34:249-255. 20. Reichle FA, Owen OE: Hemodynamic patterns in human hepatic cirrhosis: A prospective randomized study of the hemodynamic sequelae of distal splenorenal (Warren) and mesocaval shunts . Ann Surg 1979;190:523-534.Crossref 21. Monnin E, Ferriere M, Blanc P, et al: La myocardiopathie latente des alcooliques chroniques avec ou sans atteinte hépatique . Gastroenterol Clin Biol 1985;9:298-304. 22. Franco D, Smadja C: Prevention of recurrent variceal bleeding: Surgical procedures . Clin Gastroenterol 1985;14:233-257. 23. Favre B, Grange D, Franco D, et al: L'encéphalopathie après dérivation portale: Valeurs diagnostique et prédictive de l'épreuve de sensibilisation électroencéphalographique au diazepan . Gastroenterol Clin Biol 1982;6:526-530. 24. Bell RH, Hyde PVB, Skivolocki WP, et al: Prospective study of portasystemic encephalopathy after emergency portacaval shunt for bleeding varices . Am J Surg 1981;142:144-150.Crossref 25. Mutchnik MG, Lerner E, Conn HO: Portal-systemic encephalopathy and portacaval anastomosis: A prospective, controlled investigation . Gastroenterology 1974;66:1005-1019. 26. Stone WD, Islam NRK, Paton A: The natural history of cirrhosis . Q J Med 1968;145:119-132. 27. Capone RR, Buhac I, Kohberger RC, et al: Resistant ascites in alcoholic liver cirrhosis: Course and prognosis . Dig Dis Sci 1978;23:867-871.Crossref 28. Wapnick S, Grosberg SJ, Evans MI: Randomized prospective matched pair study comparing peritoneovenous shunt and conventional therapy in massive ascites . Br J Surg 1979;66:667-670.Crossref 29. Bories P, Compean-Garcia D, Michel H, et al: The treatment of refractory ascites by the LeVeen shunt: A multi-center controlled trial (57 patients) . J Hepatol 1986;3:212-218.Crossref 30. Resnick RH, Iber FL, Ishihara AM, et al: A controlled study of the therapeutic portacaval shunt . Gastroenterology 1974;67:843-857. 31. Foster JH, Ellison LH, Donovan TJ, et al: Quantity and quality of survival after portosystemic shunts . Am J Surg 1971;121:490-501.Crossref 32. Soterakis J, Resnick RH, Iber FL: Effect of alcohol abstinence on survival in cirrhotic portal hypertension: Report from the Boston Inter-Hospital Liver Group . Lancet 1973;2:65-67.Crossref 33. Pande NV, Resnick RH, Yee W, et al: Cirrhotic portal hypertension: Morbidity of continued alcoholism . Gastroenterology 1978;74:64-69. 34. Chandler JG, Van Meter CH, Kaiser DL, et al: Factors affecting immediate and long-term survival after emergent and elective splanchnic-systemic shunts . Ann Surg 1985;201:476-487.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Should Portosystemic Shunt Be Reconsidered in the Treatment of Intractable Ascites in Cirrhosis?

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References (39)

Publisher
American Medical Association
Copyright
Copyright © 1988 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1988.01400320073015
Publisher site
See Article on Publisher Site

Abstract

Abstract • Fifty-seven cirrhotic patients with intractable ascites had a portosystemic shunt. In 35 patients, a peritoneovenous shunt had previously failed. Forty-six patients were in Pugh's class B and 11 were in class C. There were three operative deaths (5.3%). Fifty-three (98.2%) of the 54 survivors were cleared of ascites. In one patient, ascites persisted because of postshunt heart failure that resulted in a marked increase of caval pressure. Twenty-seven patients (50%) had late encephalopathy, which was severe and disabling in 12 (22%). One- and three-year survival rates were 72% and 36%, respectively. These results suggest that although portosystemic shunts are remarkably effective in dealing with ascites, the high rate of postoperative encephalopathy is a strong argument against their routine use in the management of intractable ascites in cirrhosis. (Arch Surg 1988;123:987-991) References 1. Prokesch RC, Rimland D: Infectious complications of the peritoneo-venous shunt . Am J Gastroenterol 1983;78:235-240. 2. Fulenwider JT, Smith RB III, Redd CS, et al: Peritoneovenous shunts: Lessons learned from an eight-year experience with 70 patients . Arch Surg 1984;119:1133-1137.Crossref 3. Harmon DC, Demirjian Z, Ellman L, et al: Disseminated intravascular coagulation with the peritoneovenous shunt . Ann Intern Med 1979;90:774-776.Crossref 4. Lerner RG, Nelson JC, Corines P, et al: Disseminated intravascular coagulation: Complication of LeVeen peritoneovenous shunts . JAMA 1978;240:2064-2066.Crossref 5. Fulenwider JT, Galambos JD, Smith RB III, et al: LeVeen vs Denver peritoneovenous shunts for intractable ascites of cirrhosis . Arch Surg 1986;121:351-355.Crossref 6. Smadja C, Tridard D, Franco D: Recurrent ascites due to central venous thrombosis after peritoneojugular (LeVeen) shunt . Surgery 1986;100:535-541. 7. Epstein M: Peritoneovenous shunt in the management of ascites and the hepatorenal syndrome . Gastroenterology 1982;82:790-799. 8. Barker HG, Reemtsma K: The portacaval shunt operation in patients with cirrhosis and ascites . Surgery 1960;48:142-154. 9. Welch HF, Welch CS, Carter JH: Prognosis after surgical treatment of ascites: Results of side-to-side shunt in 40 patients . Surgery 1964;56:75-82. 10. Burchell AR, Rousselot LM, Panke WF: A seven-year experience with side-to-side portacaval shunt for cirrhotic ascites . Ann Surg 1968;168:655-670.Crossref 11. Orloff MJ: Pathogenesis and surgical treatment of intractable ascites associated with alcoholic cirrhosis . Ann NY Acad Sci 1970;170:213-238.Crossref 12. Vons C, Smadja C, Bourstyn E, et al: Results of portal systemic shunts in Budd-Chiari syndrome . Ann Surg 1986;203:366-370.Crossref 13. Leveen HH, Wapnick S, Grosberg S, et al: Further experience with peritoneo-venous shunt for ascites . Ann Surg 1976;184:574-581.Crossref 14. Pugh RNH, Murray-Lyon IM, Dawson JL, et al: Transection of the esophagus for bleeding esophageal varices . Br J Surg 1973;60:646-649.Crossref 15. Huguet C, Hannoun L, Opolon P, et al: Place des dérivations portocaves dans le traitement chirurgical des ascites cirrhotiques . Gastroenterol Clin Biol 1981;5:324-331. 16. Bismuth H, Franco D, Hepp J: Portal-systemic shunt in hepatic cirrhosis: Does the type of shunt decisively influence the clinical result? Ann Surg 1974;179:209-218.Crossref 17. Smadja C, Franco D: The LeVeen shunt in the elective treatment of intractable ascites in cirrhosis: A prospective study on 140 patients . Ann Surg 1985;201:488-493.Crossref 18. McDermott WV Jr: The treatment of cirrhotic ascites by combined hepatic and portal decompression . N Engl J Med 1958;259:897-901.Crossref 19. Welch CS, Attarian E, Welch HF: The treatment of ascites by side-to-side portacaval shunt . Bull NY Acad Med 1958;34:249-255. 20. Reichle FA, Owen OE: Hemodynamic patterns in human hepatic cirrhosis: A prospective randomized study of the hemodynamic sequelae of distal splenorenal (Warren) and mesocaval shunts . Ann Surg 1979;190:523-534.Crossref 21. Monnin E, Ferriere M, Blanc P, et al: La myocardiopathie latente des alcooliques chroniques avec ou sans atteinte hépatique . Gastroenterol Clin Biol 1985;9:298-304. 22. Franco D, Smadja C: Prevention of recurrent variceal bleeding: Surgical procedures . Clin Gastroenterol 1985;14:233-257. 23. Favre B, Grange D, Franco D, et al: L'encéphalopathie après dérivation portale: Valeurs diagnostique et prédictive de l'épreuve de sensibilisation électroencéphalographique au diazepan . Gastroenterol Clin Biol 1982;6:526-530. 24. Bell RH, Hyde PVB, Skivolocki WP, et al: Prospective study of portasystemic encephalopathy after emergency portacaval shunt for bleeding varices . Am J Surg 1981;142:144-150.Crossref 25. Mutchnik MG, Lerner E, Conn HO: Portal-systemic encephalopathy and portacaval anastomosis: A prospective, controlled investigation . Gastroenterology 1974;66:1005-1019. 26. Stone WD, Islam NRK, Paton A: The natural history of cirrhosis . Q J Med 1968;145:119-132. 27. Capone RR, Buhac I, Kohberger RC, et al: Resistant ascites in alcoholic liver cirrhosis: Course and prognosis . Dig Dis Sci 1978;23:867-871.Crossref 28. Wapnick S, Grosberg SJ, Evans MI: Randomized prospective matched pair study comparing peritoneovenous shunt and conventional therapy in massive ascites . Br J Surg 1979;66:667-670.Crossref 29. Bories P, Compean-Garcia D, Michel H, et al: The treatment of refractory ascites by the LeVeen shunt: A multi-center controlled trial (57 patients) . J Hepatol 1986;3:212-218.Crossref 30. Resnick RH, Iber FL, Ishihara AM, et al: A controlled study of the therapeutic portacaval shunt . Gastroenterology 1974;67:843-857. 31. Foster JH, Ellison LH, Donovan TJ, et al: Quantity and quality of survival after portosystemic shunts . Am J Surg 1971;121:490-501.Crossref 32. Soterakis J, Resnick RH, Iber FL: Effect of alcohol abstinence on survival in cirrhotic portal hypertension: Report from the Boston Inter-Hospital Liver Group . Lancet 1973;2:65-67.Crossref 33. Pande NV, Resnick RH, Yee W, et al: Cirrhotic portal hypertension: Morbidity of continued alcoholism . Gastroenterology 1978;74:64-69. 34. Chandler JG, Van Meter CH, Kaiser DL, et al: Factors affecting immediate and long-term survival after emergent and elective splanchnic-systemic shunts . Ann Surg 1985;201:476-487.Crossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Aug 1, 1988

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