EXPERIMENTAL, CLINICAL, AND METABOLIC RESULTS OF SIDE-TO-SIDE PORTACAVAL-SHUNT FOR INTRACTABLE CIRRHOTIC ASCITES

BACKGROUND: Intractable ascites, refractory to medical therapy, occurs in approximately 10 percent of patients with ascites from cirrhosis a nd is almost always fatal. Sinusoidal hypertension resulting from hepa tic venous outflow obstruction plays a primary role in the pathogenesi s of cirrhotic ascites and provides the rationale for decompression of the liver by side-to-side portacaval shunt in treatment of intractabl e ascites. This report presents the experimental basis for the use of side-to-side shunt and long-term results of a prospective study in 34 selected patients with intractable cirrhotic ascites. STUDY DESIGN: In the experimental studies, hepatic venous outflow obstruction and mass ive ascites were produced in dogs by ligation of the hepatic veins, an d the effect of portacaval shunts on ascites, thoracic duct lymph flow , and aldosterone secretion were measured. In the clinical study, 34 c arefully selected patients with cirrhosis (91 percent alcoholic) and t ruly intractable ascites (failure of medical therapy for 5 to 24 month s) underwent side-to-side portacaval shunt. The effects on ascites, su rvival, metabolic abnormalities, and quality of life were studied pros pectively during follow-up that was longer than 5 years in all but two patients. Quantitative Child's risk classes in percent of patients we re A in 0, B in 68, and C in 32. RESULTS: In the experimental studies, side-to-side portacaval shunt permanently relieved severe ascites, re duced the 13-fold increase in thoracic duct lymph flow rate to almost normal, and abolished the aldosterone hypersecretory response to minim al hepatic venous outflow obstruction. End-to-side portacaval shunt wa s much less effective. In the clinical study, side-to-side portacaval shunt reduced mean portal vein-inferior vena cava pressure gradient fr om 282 mm saline to 4 mm and permanently relieved all patients of asci tes without subsequent requirement of diuretic therapy. Two patients w ho died of hepatoma, and one who died of heart failure developed termi nal ascites. Thirty-day mortality rate was 6 percent, and long-term su rvival rates at 5, 10, and 15 years were 75 percent, 74 percent, and 7 3 percent. In metabolic studies, side-to-side shunt produced marked di uresis and natriuresis and abolished hypersecretion of aldosterone. Qu ality of life was generally improved as a result of a low incidence of recurrent portal-systemic encephalopathy (6 percent), abstinence from alcohol in 91 percent, improvement in liver function in 81 percent, a nd improvement in Child's risk class. The portacaval anastomosis remai ned permanently patent in every patient. CONCLUSIONS: Side-to-side por tacaval shunt is very effective treatment of intractable ascites from cirrhosis. Our results are attributable to careful selection of patien ts, an organized system of care, and a program of rigorous, lifelong f ollow-up that emphasizes abstinence from alcohol and dietary protein r estriction.