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Emergency Shunt: Role in the Present Management of Variceal Bleeding

Emergency Shunt: Role in the Present Management of Variceal Bleeding Abstract Objective: To evaluate the results of selective and non-selective 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 portal decompression.(Arch Surg. 1995;130:472-477) References 1. Langer BF, Greig PD, Taylor BR. Emergency surgical treatment of variceal hemorrhage . Surg Clin North Am . 1990;70:307-315. 2. Rikkers LF, Jin G. Surgical management of acute variceal hemorrhage . World J Surg . 1994;18:193-199.Crossref 3. Rikkers LF, Burnett DA, Volentine GD, Buchi KN, Cormier RA. Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding . Ann Surg . 1987;206:261-271.Crossref 4. Orloff MJ, Bell RH, Hyde PV, Skivolocki WP. Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcoholic cirrhosis . Ann Surg . 1980;192:325-337.Crossref 5. Orloff MJ, Orloff MS, Rambotti M, Girard B. Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Ann Surg . 1992;216:256-268.Crossref 6. Orloff MJ, Orloff MS, Rambotti M, Girard B. Emergency portacaval shunt for bleeding esophageal varices in 400 unselected patients with cirrhosis: three decades of experience . Gastroenterology . 1994;106:A956. 7. Orloff MJ, Bell RH, Orloff MS, Hardison WGM, Greenburg AG. Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices . Hepatology . 1994;20: 863-872.Crossref 8. Henderson JM. A perspective on emergency portacaval shunt . Hepatology . 1994; 20:1090-1091.Crossref 9. Terblanche J, Branman PC, Kahn D. Failure of repeated injection sclerotherapy to improve long-term survival after esophageal variceal bleeding . Lancet . 1983; 2:1328-1334.Crossref 10. Potts JR, Henderson JM, Millikan WJ, Warren WD. Emergency distal splenorenal shunts for variceal hemorrhage refractory to nonoperative control . Am J Surg . 1984;148:813-816.Crossref 11. Peterson K, Giles GR. Distal splenorenal (Warren) shunt in the management of actively bleeding esophageal varices . Br J Surg . 1986;73:618-620.Crossref 12. Nagasue N, Kohno H, Ogawa Y, et al. Appraisal of distal splenorenal shunt in the treatment of esophageal varices: an analysis of prophylactic, emergency, and elective shunts . World J Surg . 1989;13:92-99.Crossref 13. Orozco H, Juarez F, Santillan P, et al. Ten years of selective shunts for hemorrhagic portal hypertension . Surgery . 1988;103:27-31. 14. Rikkers LF, Jin G. Selective variceal decompression: current status . HPB Surg . 1991;5:1-15.Crossref 15. Soutter DI, Langer B, Taylor BR, et al. Emergency portasystemic shunting in cirrhotics with bleeding varices: a comparison of portacaval and mesocaval shunts . HPB Surg . 1989;1:107-118.Crossref 16. Smith RB, Warren WD, Salam AA, et al. Dacron interposition shunts for portal hypertension . Ann Surg . 1980;192:9-17.Crossref 17. LaBerge JM, Ring EJ, Gordon RL, et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients . Radiology . 1993;187:413-420.Crossref 18. Rossle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent: shunt procedure for variceal bleeding . N Engl J Med . 1994;330:165-171.Crossref 19. Helton WS, Belshaw A, Althaus S, et al. Critical appraisal of the angiographic portacaval shunt (TIPS) . Am J Surg . 1993;165:566-571.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Emergency Shunt: Role in the Present Management of Variceal Bleeding

Archives of Surgery , Volume 130 (5) – May 1, 1995

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1995.01430050022002
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: To evaluate the results of selective and non-selective 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 portal decompression.(Arch Surg. 1995;130:472-477) References 1. Langer BF, Greig PD, Taylor BR. Emergency surgical treatment of variceal hemorrhage . Surg Clin North Am . 1990;70:307-315. 2. Rikkers LF, Jin G. Surgical management of acute variceal hemorrhage . World J Surg . 1994;18:193-199.Crossref 3. Rikkers LF, Burnett DA, Volentine GD, Buchi KN, Cormier RA. Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding . Ann Surg . 1987;206:261-271.Crossref 4. Orloff MJ, Bell RH, Hyde PV, Skivolocki WP. Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcoholic cirrhosis . Ann Surg . 1980;192:325-337.Crossref 5. Orloff MJ, Orloff MS, Rambotti M, Girard B. Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Ann Surg . 1992;216:256-268.Crossref 6. Orloff MJ, Orloff MS, Rambotti M, Girard B. Emergency portacaval shunt for bleeding esophageal varices in 400 unselected patients with cirrhosis: three decades of experience . Gastroenterology . 1994;106:A956. 7. Orloff MJ, Bell RH, Orloff MS, Hardison WGM, Greenburg AG. Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices . Hepatology . 1994;20: 863-872.Crossref 8. Henderson JM. A perspective on emergency portacaval shunt . Hepatology . 1994; 20:1090-1091.Crossref 9. Terblanche J, Branman PC, Kahn D. Failure of repeated injection sclerotherapy to improve long-term survival after esophageal variceal bleeding . Lancet . 1983; 2:1328-1334.Crossref 10. Potts JR, Henderson JM, Millikan WJ, Warren WD. Emergency distal splenorenal shunts for variceal hemorrhage refractory to nonoperative control . Am J Surg . 1984;148:813-816.Crossref 11. Peterson K, Giles GR. Distal splenorenal (Warren) shunt in the management of actively bleeding esophageal varices . Br J Surg . 1986;73:618-620.Crossref 12. Nagasue N, Kohno H, Ogawa Y, et al. Appraisal of distal splenorenal shunt in the treatment of esophageal varices: an analysis of prophylactic, emergency, and elective shunts . World J Surg . 1989;13:92-99.Crossref 13. Orozco H, Juarez F, Santillan P, et al. Ten years of selective shunts for hemorrhagic portal hypertension . Surgery . 1988;103:27-31. 14. Rikkers LF, Jin G. Selective variceal decompression: current status . HPB Surg . 1991;5:1-15.Crossref 15. Soutter DI, Langer B, Taylor BR, et al. Emergency portasystemic shunting in cirrhotics with bleeding varices: a comparison of portacaval and mesocaval shunts . HPB Surg . 1989;1:107-118.Crossref 16. Smith RB, Warren WD, Salam AA, et al. Dacron interposition shunts for portal hypertension . Ann Surg . 1980;192:9-17.Crossref 17. LaBerge JM, Ring EJ, Gordon RL, et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients . Radiology . 1993;187:413-420.Crossref 18. Rossle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent: shunt procedure for variceal bleeding . N Engl J Med . 1994;330:165-171.Crossref 19. Helton WS, Belshaw A, Althaus S, et al. Critical appraisal of the angiographic portacaval shunt (TIPS) . Am J Surg . 1993;165:566-571.Crossref

Journal

Archives of SurgeryAmerican Medical Association

Published: May 1, 1995

References