SHUNT SURGERY DURING THE ERA OF LIVER-TRANSPLANTATION

Objective The indications for and the results of portosystemic shunts done in the authors' institution since initiation of a liver transplan t program 10 years ago were reviewed. Summary Background Data With the widespread availability of liver transplantation as definitive treatm ent of chronic liver disease, the role of shunts in the overall manage ment of variceal bleeding needs to be redefined. Methods Seventy-one v ariceal bleeders with cirrhosis who received a shunt (82% distal splen orenal shunts) because of sclerotherapy failure or because endoscopic treatment was not indicated were reviewed retrospectively, in 44 patie nts with well-preserved hepatic reserve, the shunt was used as a long- term bridge to transplantation (shunt group 1). The remaining 27 patie nts with shunts were not transplant candidates mainly because of uncon trolled alcoholism or advanced age (shunt group 2). Survival of both s hunt groups was compared to that of 180 adult patients with a history of variceal bleeding who underwent transplantation soon after referral . Results Because of their more advanced liver disease, the liver tran splant group had a higher operative mortality rate (19%) than did eith er of the shunt groups (5% and 7%, respectively) (p < 0.02). Kaplan-Me ier survival analysis showed better survival in shunt group 1 (seven p atients thus far transplanted) than in either the liver transplant gro up or shunt group 2 during the early years and superior survival of sh unt group 1 and the liver transplant group as compared to shunt group 2 during the later years of the analysis. Only two patients from shunt group I have died of late postoperative hepatic failure without benef it of liver transplantation. Conclusions A shunt may serve as an excel lent long-term bridge to liver transplantation in patients with well-p reserved hepatic reserve. Shunt surgery still plays an important role in treatment of selected patients with variceal bleeding who are not p resent or future transplant candidates.