Long-term Results of Emergency Portacaval Shunt for Bleeding Esophageal Varices in Unselected Patients with Alcoholic Cirrhosis

Abstract

A prospective evaluation of emergency protacaval shunt has been conducted in 180 unselected, consecutive patients with cirrhosis and bleeding varices who were operated on between 1963 and 1978. An extensive diagnostic work-up was completed within three to seven hours of admission to the emergency department, and the shunt operation was undertaken within a mean of 7.81 hours. A program of lifelong follow-up was conducted such that the current status of 97% of the patients is known. On each patient, 220 categories of data were collected and entered into a computer program for analysis. On admission, 49% of the patients had jaundice, 53% had ascites, 19% had encephalopathy, 30% had severe muscle wasting and 100% had abnormal BSP retention. Administration of a bolus dose of vasopressin by the systemic intravenous route temporarily controlled the varix hemorrhage in 95% of patients, and emergency shunt permanently controlled the bleeding in 98%. Maximum perfusion pressure in the portal vein prior to shunt did not correlate with survival rate or incidence of encephalopathy after shunt. The operative survival rate was 58%, the five-year actuarial survival rate is 38% and the 12-year actuarial survival rate is 30%. Encephalopathy was observed in 31.5% of the patients, but was severe enough to require chronic dietary protein restriction in only 7%. The portacaval shunt remained patent in 99% of patients. Of the survivors, 48% abstained from alcohol, 60% resumed gainful employment or housekeeping, and two-thirds were judged to be in excellent or good condition after one and five years. Preoperative factors that adversely influenced survival rate were ascites, SGOT >/= 100 units, BSP retention >50%, hypokalemic alkalosis, blood transfusion requirement >/= 5 L, and consumption of alcohol within seven day[unk] of admission. In comparison with our previous prospective studies, emergency portacaval shunt produced a significantly greater long-term survival rate than either emergency medical therapy or emergency varix ligation, followed by elective shunt. During the past four years, 80% of 49 unselected patients have survived emergency shunt, and the four year actuarial survival rate is 69%.

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…106,107 A surgical group has reported almost universal control of bleeding and a low mortality with the performance of portocaval shunt within 8 hours of onset of bleeding in unselected cirrhotic patients collected over a 30-year period. 108 This approach has not been validated by other groups and is not widely practiced. More recently, a small study has suggested that early TIPS placement (within 24 hours of hemorrhage) is associated with a significant improvement in survival in "high-risk" patients (defined as those with an HVPG Ͼ20 mmHg) with acute variceal hemorrhage.…”

Portal-Systemic Encephalopathy in Emergency Treatment of Cirrhosis and Bleeding Esophageal Varices

“…Because of the over-riding importance of emergency treatment of variceal bleeding, from 1958 to 2011 we conducted and reported studies of emergency therapy in patients with cirrhosis (Orloff, 1967;Orloff et al, 1980;Orloff et al, 1992); Orloff et al, 1994;Orloff et al, 1995a;Orloff et al, 2009a;Orloff et al, 2009b;Orloff et al, 2011a;Orloff et al, 2011b;Orloff et al, 2010;Orloff et al, 2011c;Orloff et al, 2011d;Orloff et al, 2011e;Orloff et al, 2011f;Orloff et al, 2011g;Orloff et al, 2011h;Orloff et al, 2011i). Our studies have been distinguished by three features that, together, make them different from other reported investigations.…”

“…The question is, can cirrhotic patients tolerate an operation of this magnitude when it is performed as an emergency in the face of bleeding? To answer this question, we have conducted prospective studies of emergency PCS (EPCS) over the past 47 years, as follows: (1) an unrandomized study of 400 unselected patients who underwent EPCS; (2) a RCT of EPCS versus emergency medical therapy involving 43 patients at our Veterans Administration Hospital; (3) an unrandomized study of 94 unselected, consecutive patients with Child's class C cirrhosis; (4) a RCT of portacaval shunt versus endoscopic sclerotherapy in 518 unselected patients bleeding from gastric varices; (5) a n u n r a n d o m i z e d s t u d y i n 1 2 p a t i e n t s w i t h u n c o n t r o l l a b l e b l e e d i n g f r o m p o r t a l hypertensive gastropathy; (6) a NIH grant supported RCT of EPCS versus emergency endoscopic sclerotherapy (EST) that enrolled 211 patients who have had more than 10 years of follow-up or until death; and (7) a NIH grant supported RCT of TIPS versus EPCS that enrolled 154 patients who have been followed up for 5-10 years (Orloff, 1967;Orloff et al, 1980;Orloff et al, 1992;Orloff et al, 1994;Orloff et al, 1995a;Orloff et al, 2009a;Orloff et al, 2009b;Orloff et al, 2011a;Orloff et al, 2011b;Orloff et al, 2010;Orloff et al, 2011c;Orloff et al, 2011d;Orloff et al, 2011e;Orloff et al, 2011f;Orloff et al, 2011g;Orloff et al, 2011h;Orloff et al, 2011i;Orloff & Bell, 1983;Bell, et al, 1981;Orloff, 1968;Orloff, 1969;Orloff et al, 1974;Orloff et al, 1975;Orloff & Bell, 1986;Orloff et al, 1995b;Orloff et al, 1997) . The unique features of our studies that, together, make them different from other reported investigations are as follows: (1) EPCS was undertaken within 24 h of initial contact of the patient with our institution in one study and within 8 h in the other six studies; (2) the patients were unselected, which means that all patients with bleeding varices, regardless of their condition ("all comers"), were entered in the studies and treated; (3) the studies were prospective, which means that the p...…”

Untitled

“…This is a major operation, especially in the emergency situation when the mortality can be up to 50°, even in experienced units. In most cases the risk is unacceptably high, though long-term survival may be achieved in significant numbers (55). For more stable patients several studies have failed to show any statistically significant improvement in long-term survival.…”