Dacron® Interposition Shunts for Portal Hypertension An Analysis of Morbidity Correlates

Abstract

Analysis of 79 Dacron interposition shunts performed at Emory University from 1971 to 1977 identified a number of preoperative characteristics that correlate with short-term and long-term morbidity. Initial hospital mortality was related to the degree of elevation of the bilirubin and serum glutamic oxaloacetic transaminase (SGOT), to the presence of encephalopathy and to the urgency of the shunt procedure. Cumulative survival correlated best with the preoperative SGOT and bilirubin values, but other variables, including the Child's classification, preoperative encephalopathy, serum albumin, and the age of the patient at the time of operation, also exhibited significant associations. The hospital mortality of 13% and cumulative mortality of 48% in this series are in substantial agreement with similar reports in the literature. This experience differs widely from that described by most authors, however, in two other important respects: 1) significant hepatic encephalopathy has been observed in 45% of these hospital survivors, and 2) almost one-quarter of these patients have experienced spontaneous shunt closure. Thus, major shunt related complications have occurred in 70% of the patients to date. This incidence of undesirable consequences raises a serious question concerning the continued use of the Dacron interposition shunt for elective portal decompression.

Liver Transplantation in a Randomized Controlled Trial of Emergency Treatment of Acutely Bleeding Esophageal Varices in Cirrhosis

“…Sixth, regular follow-up was 100% and was for 9.4 to more than 10 years until death. Seventh, the direct side-to-side PCS remained permanently patent and functioning in 98% of patients, a rate that is consistent with our past experience with more than 2500 side-to-side PCS, with a failure rate of 2%, substantially lower than reported shunt occlusion rates of 12% to 29% for conventional portal-systemic shunts, 14% to 23% for distal splenorenal shunts [38], 24% to 53% for mesocaval interposition shunts [39][40][41], and greater than 50% for transjugular intrahepatic portosystemic shunts (TIPS) [42][43][44][45][46][47].…”

Improving Survival in Patients With Cirrhosis Undergoing Major Abdominal Operations

“…Utilization of this protocol has resulted in very low morbidity and mor¬ tality (11%) rates in our patients undergoing side-to-side portacaval shunting procedures.6 More recent follow-up on 152 patients with shunts showed an elective mortality rate of 3.5%.8 Similar results have been reported by others utilizing differing types of shunting operations. 4,5 In the present study, 51 patients with cirrhosis under¬ went major abdominal operations, with an 8% mortality and a 28% morbidity rate. Emergency operation in 16 patients had a 19% mortality, while elective operation was associated with a 3% death rate.…”

“…This change should include (1) at least as strong an awareness of and respect for the patients' liver disease as for their primary surgical problem, (2) avoidance of emergency operative procedures, (3) careful preoperative preparation, (4) intraoperative control of collateral circulatory blood flow by vasopressin infusion, (5) control of operative blood loss by liberal use of electrocautery, and (6) close management of postoperative fluid and electrolyte balance. It is only with careful attention to all these points that a significant decrease in mortality and morbidity can be achieved in patients with these extremely complicated conditions.…”

Budd–Chiari Syndrome Revisited: 38 Years’ Experience with Surgical Portal Decompression

“…Fifty-nine of these 65 patients (91%) underwent operation <18 weeks after the onset of symptoms. The remaining six patients underwent portal decompression surgery 19,21,23,25,26, and 78 weeks after becoming ill. Twelve of the 77 patients were referred to us with advanced cirrhosis, 11-21 months after the onset of symptoms (mean, 15.9 months). These patients were referred too late for portal decompression; they required liver transplantation.…”