IMPACT OF SHUNT SURGERY FOR VARICEAL BLEEDING IN THE NATURAL-HISTORY OF ASCITES IN CIRRHOSIS - A RETROSPECTIVE STUDY

Despite the efficacy of shunt surgery in the treatment of variceal ble eding, less effective nonoperative therapies are being substituted bec ause surgical shunt does not modify survival and increases hepatic enc ephalopathy. However, the real impact of shunt surgery on the natural history of ascites and its complications has not been established. The course of 204 Child-Pugh A and B cirrhotic patients with variceal ble eding included in three controlled trials of our units who survived fi rst hospitalization was updated. Ninety-eight patients (group I) were treated by portacaval (56 patients) or distal splenorenal (42 patients ) shunt, whereas 106 (group II) were treated by nonshunt procedures (s clerotherapy in 89 patients and staple transection in 17 patients). As expected, the 5-yr probability of variceal rebleeding was lower (13% vs. 44%) and hepatic encephalopathy higher (50% vs. 28%) in group I th an in group II, and survival was similar (67% vs. 60%). Shunt surgery had a great impact on the natural history of ascites and its complicat ions. The probability of occurrence of ascites (15% vs. 73%; p < 0.000 1), spontaneous bacterial peritonitis (2% vs. 21%; p < 0.0001) and hep atorenal syndrome (4% vs. 21%; p < 0.01) was greatly reduced. These be neficial effects accounted for the lower percentage patients requiring readmissions (51% vs. 70%; p = 0.02) and shorter total time spent in hospital (14 +/- 22 vs. 26 +/- 39 days/patient; p = 0.01) in group I. These data indicate that shunt surgery, in addition to reducing the pr obability of rebleeding, markedly decreases the probability of ascites , spontaneous bacterial peritonitis and hepatorenal syndrome developme nt. Therefore, ascites and its complications should be considered in a ny therapeutic trial assessing the efficacy of surgical or percutaneou s portacaval anastomosis on variceal bleeding.