A CRITICAL-APPRAISAL OF THE SMALL-DIAMETER PORTACAVAL H-GRAFT

BACKGROUND: The ideal portasystemic shunt should prevent variceal hemo rrhage and preserve portal flow to reduce hepatic encephalopathy. The partial shunting proposed by Sarfeh effectively controls variceal blee ding while preserving prograde hepatic portal flow. PATIENTS AND METHO DS: We analyzed results of the partial portacaval shunt prospectively in 43 patients undergoing small-diameter (8-mm or 10-mm) portacaval H- graft. Patients entered into the study had Child-Pugh class A and clas s B cirrhosis, and all had documented previous variceal hemorrhages. W e used the Sarfeh technique without performing portal collateral ligat ion. RESULTS: Operative mortality was 5%. Acute graft thrombosis occur red in 3 patients, 2 of whom were successfully lysed by urokinase infu sion angiographically, while later graft occlusion occurred in 1 case. Only 1 patient rebled from varices in our late follow-up (14 to 65 mo nths). Prograde portal flow was maintained in 90% of patients undergoi ng repeat angiography 27 +/- 13 months postoperatively. The incidence of all encephalopathy episodes was 16%, with only 1 patient having thi s complication chronically. CONCLUSIONS: The small-diameter portacaval H-graft of Sarfeh is an effective operation for controlling variceal hemorrhage. It preserves hepatic portal perfusion over time in the maj ority of patients, reducing the risk of encephalopathy. The procedure may be particularly suited for alcoholic cirrhotic patients with less advanced liver disease.