Surgical shunts and tips for variceal decompression in the 1990s

Background. In the 1990s, liver transplantations and transjugular intrahepa tic portosystemic shunts (TIPS) have become the most common methods to deco mpress portal hypertension. This center has continued to use surgical shunt s for variceal bleeding in good-risk patients who continue to bleed through endoscopic and pharmacologic treatment. This article reports this center's experience with surgical shunts and TIPS shunts from 1992 through 1999. Methods. Sixty-three patients (Child A, 43 patients; Child B, 20 patients) received surgical shunts: distal splenorenal, 54 patients; splenocaval, 4 p atients; coronary caval, 1 patient; and mesocaval, 4 patients. Sixty-two pa tients had refractory variceal bleeding, and 1 patient had ascites with Bud d-Chiari syndrome. Two hundred patients (Child A, 24 patients; Child B, 62 patients; Child C, 114 patients) received TIPS shunts. One hundred forty-ni ne patients had refractory variceal bleeding, and 51 patients had ascites, hydrothorax, or hepato renal syndrome. Data were collected by prospective d atabases, protocol follow-up, and phone contact. Results. The 30-day mortality rate was 0% for surgical shunts and 26% for T IPS shunts; the overall survival rate was 86% (median follow-up, 36 months) for surgical shunts and 53% (median following-up, 40 months) for TIPS shun ts. For surgical shunts, the portal hypertensive rebleeding rate was 6.3%; the overall rebleeding rate was 14.3%. For TIPS shunts, the overall rebleed ing rate was 25.5% (30-day, 9.4%; late, 22.4%). There were 4 reintervention s for surgical shunts (6.3%); the reintervention rate for TIPS shunts in th e bleeding group was 33%, and the reintervention rate in the ascites group was 9.5%. Encephalopathy was severe in 3.1% of the shunt group and mild in 17.5%; this was not systematically evaluated in the TIPS shunts patients. Conclusions. Surgical shunts still have a role for patients whose condition was classified as Child A and B with refractory bleeding; who achieve exce llent outcomes with low morbidity and mortality rates. TIPS shunts have bee n used in high-risk patients with significant early and late mortality rate s and have been useful in the control of refractory bleeding and as a bridg e to transplantation. The comparative role of TIPS shunts versus surgical s hunt in patients whose condition was classified as Child A and B is under s tudy in a randomized controlled trial.