CHANGING PATTERN OF PORTASYSTEMIC SHUNT SURGERY

Objective: Analysis of changes in the pattern of portasystemic shunt s urgery. Design: Single centre retrospective study. Setting: University hospital, The Netherlands. Patients: 74 patients receiving portasyste mic shunts during a 15 year period, with complete follow up. Main outc ome measures: Severity of disease, type of operation, early mortality, long term survival and development of encephalopathy. Results: The nu mber of portasystemic shunts undertaken during the study period declin ed, with a rise in the proportion of emergency operations. Early morta lity was 1/38 (3%) in patients with Child A disease, 2/27 (7%) in thos e with Child B, and 5/9 (56%) in those with Child C (p < 0.0005, chi s quare). Early mortality was highest (p = 0.004, Fisher's exact test) a fter emergency operations with 6/20 (30%), compared with 2/54 (4%) fol lowing elective shunt surgery. The 5-year cumulative survival was 77% in patients with Child A, 58% in patients with Child B, and 11% in pat ients with Child C disease (p < 0.001, log rank). Survival was signifi cantly less in patients with alcoholic liver cirrhosis (p < 0.05, log rank). Postoperative encephalopathy was treated clinically in 16/73 (2 2%) patients, and developed irrespective of the type of decompression. Conclusions: With the increasing importance of other treatments of po rtal hypertension and variceal haemorrhage the pattern of portasystemi c shunt surgery has changed. Despite a steady decline in the number of elective decompressions, that of acute operations has been constant o ver the years. These procedures had a considerable early mortality. Th e severity of the liver disease was a strong determinant of long term survival, as was the presence of alcoholic liver cirrhosis. Postoperat ive encephalopathy was common and was independent of the shunt techniq ue used. In elective cases portasystemic shunting techniques, that wil l not interfere with a subsequent hepatic transplantation, are preferr ed.