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.