SELECTIVE SHUNTS IN SELECTED OLDER CIRRHOTIC-PATIENTS WITH VARICEAL HEMORRHAGE

Whereas portal systemic shunts pose significant problems in many patie nts, they have long been thought to have particular risks when underta ken in older cirrhotic patients, with devastating encephalopathy repor tedly common in older patients undergoing nonselective shunt surgery. With advances in anesthesia management and perioperative monitoring an d the advent of selective shunting, we postulated that both the operat ive and long-term outcomes might be improved. In this context, we revi ewed our recent experience with selective shunts [distal splenorenal ( DSRS) and small-diameter interposition portacaval grafts (IPCG)] in pa tients over the age of 60 years with variceal bleeding. Nineteen conse cutive cirrhotic patients over 60 years of age undergoing elective or urgent selective shunt surgery for variceal hemorrhage since 1986 were identified. Sixteen patients underwent DSRS, and 3 underwent IPCG. Th e etiologies of the cirrhosis were multiple, with 12 of 19 classified as Child's B or C disease. There were no operative deaths, and all but one patient returned home following the surgery. No patient has had r ecurrent bleeding or required further surgery for portal hypertension- related problems. Three of 19 developed encephalopathy, and 4 of 19 di ed of liver failure within 1 year of surgery. Of the 14 patients still alive and well (mean postoperative survival: 44 months, range: 4 to 7 4 months), all remain free of encephalopathy and live independently. B ased on this experience, it would appear that one can anticipate satis factory short- and long-term outcomes after selective shunt surgery in selected patients with variceal bleeding over the age of 60 years. Th ese patients with portal hypertension should not, therefore, be reject ed for shunt surgery based on age alone.