EMERGENCY SHUNT - ROLE IN THE PRESENT MANAGEMENT OF VARICEAL BLEEDING

Objective: To evaluate the results of selective and nonselective emerg ency portosystemic shunts in patients with acute variceal hemorrhage. Design: Retrospective review. Setting: University medical center and V eterans Affairs medical center. Patients: Forty-two consecutive patien ts who underwent emergency portosystemic shunts from 1978 through 1994 . All patients had chronic liver disease (29 [69%] had alcoholic cirrh osis) and half had Child's class C disease. Sixteen patients were acti vely 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 cl ass C disease and with active bleeding at the time of surgery were sig nificantly higher in the nonselective shunt group. Main Outcome Measur es: Operative mortality; early postoperative rebleeding, shunt patency , encephalopathy, and ascites; and long-term survival. Results: Operat ive mortality rates were higher in patients with Child's class C disea se (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 under went distal splenorenal shunt (10% [2/20]). All shunts were patent aft er surgery, and no patient had rebleeding during the early postoperati ve interval. Early postoperative ascites and encephalopathy rates were similar after nonselective shunt and distal splenorenal shunt. Long-t erm survival was superior in the lower-risk distal splenorenal shunt g roup. 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 blee ding can be temporarily controlled by nonoperative means, distal splen orenal shunt is an effective and safe emergency procedure. The mortali ty rate remains high for patients with Child's class C disease undergo ing portal decompression.