Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1997 Jul;226(1):51–57. doi: 10.1097/00000658-199707000-00007

Shunt surgery during the era of liver transplantation.

L F Rikkers 1, G Jin 1, A N Langnas 1, B W Shaw Jr 1
PMCID: PMC1190906  PMID: 9242337

Abstract

OBJECTIVE: The indications for and the results of portosystemic shunts done in the authors' institution since initiation of a liver transplant program 10 years ago were reviewed. SUMMARY BACKGROUND DATA: With the widespread availability of liver transplantation as definitive treatment of chronic liver disease, the role of shunts in the overall management of variceal bleeding needs to be redefined. METHODS: Seventy-one variceal bleeders with cirrhosis who received a shunt (82% distal splenorenal shunts) because of sclerotherapy failure or because endoscopic treatment was not indicated were reviewed retrospectively. In 44 patients with well-preserved hepatic reserve, the shunt was used as a long-term bridge to transplantation (shunt group 1). The remaining 27 patients with shunts were not transplant candidates mainly because of uncontrolled alcoholism or advanced age (shunt group 2). Survival of both shunt 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 transplant group had a higher operative mortality rate (19%) than did either of the shunt groups (5% and 7%, respectively) (p < 0.02). Kaplan-Meier survival analysis showed better survival in shunt group 1 (seven patients thus far transplanted) than in either the liver transplant group or shunt group 2 during the early years and superior survival of shunt 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 1 have died of late postoperative hepatic failure without benefit of liver transplantation. CONCLUSIONS: A shunt may serve as an excellent long-term bridge to liver transplantation in patients with well-preserved hepatic reserve. Shunt surgery still plays an important role in treatment of selected patients with variceal bleeding who are not present or future transplant candidates.

Full text

PDF

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Brems J. J., Hiatt J. R., Klein A. S., Millis J. M., Colonna J. O., Quinones-Baldrich W. J., Ramming K. P., Busuttil R. W. Effect of a prior portasystemic shunt on subsequent liver transplantation. Ann Surg. 1989 Jan;209(1):51–56. doi: 10.1097/00000658-198901000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Henderson J. M., Gilmore G. T., Hooks M. A., Galloway J. R., Dodson T. F., Hood M. M., Kutner M. H., Boyer T. D. Selective shunt in the management of variceal bleeding in the era of liver transplantation. Ann Surg. 1992 Sep;216(3):248–255. doi: 10.1097/00000658-199209000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Henderson J. M., Kutner M. H., Millikan W. J., Jr, Galambos J. T., Riepe S. P., Brooks W. S., Bryan F. C., Warren W. D. Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis. A prospective, randomized trial. Ann Intern Med. 1990 Feb 15;112(4):262–269. doi: 10.7326/0003-4819-112-4-262. [DOI] [PubMed] [Google Scholar]
  4. Iwatsuki S., Starzl T. E., Todo S., Gordon R. D., Tzakis A. G., Marsh J. W., Makowka L., Koneru B., Stieber A., Klintmalm G. Liver transplantation in the treatment of bleeding esophageal varices. Surgery. 1988 Oct;104(4):697–705. [PMC free article] [PubMed] [Google Scholar]
  5. LaBerge J. M., Somberg K. A., Lake J. R., Gordon R. L., Kerlan R. K., Jr, Ascher N. L., Roberts J. P., Simor M. M., Doherty C. A., Hahn J. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology. 1995 Apr;108(4):1143–1151. doi: 10.1016/0016-5085(95)90213-9. [DOI] [PubMed] [Google Scholar]
  6. Langnas A. N., Marujo W. C., Stratta R. J., Donovan J. P., Sorrell M. F., Rikkers L. F., Shaw B. W., Jr Influence of a prior porta-systemic shunt on outcome after liver transplantation. Am J Gastroenterol. 1992 Jun;87(6):714–718. [PubMed] [Google Scholar]
  7. Martin M., Zajko A. B., Orons P. D., Dodd G., Wright H., Colangelo J., Tartar R. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results. Surgery. 1993 Oct;114(4):719–727. [PubMed] [Google Scholar]
  8. Rikkers L. F., Burnett D. A., Volentine G. D., Buchi K. N., Cormier R. A. Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding. Early results of a randomized trial. Ann Surg. 1987 Sep;206(3):261–271. doi: 10.1097/00000658-198709000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Ring E. J., Lake J. R., Roberts J. P., Gordon R. L., LaBerge J. M., Read A. E., Sterneck M. R., Ascher N. L. Using transjugular intrahepatic portosystemic shunts to control variceal bleeding before liver transplantation. Ann Intern Med. 1992 Feb 15;116(4):304–309. doi: 10.7326/0003-4819-116-4-304. [DOI] [PubMed] [Google Scholar]
  10. Rössle M., Haag K., Ochs A., Sellinger M., Nöldge G., Perarnau J. M., Berger E., Blum U., Gabelmann A., Hauenstein K. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med. 1994 Jan 20;330(3):165–171. doi: 10.1056/NEJM199401203300303. [DOI] [PubMed] [Google Scholar]
  11. Shiffman M. L., Jeffers L., Hoofnagle J. H., Tralka T. S. The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: a conference sponsored by the National Digestive Diseases Advisory Board. Hepatology. 1995 Nov;22(5):1591–1597. [PubMed] [Google Scholar]
  12. Spina G. P., Henderson J. M., Rikkers L. F., Teres J., Burroughs A. K., Conn H. O., Pagliaro L., Santambrogio R. Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. A meta-analysis of 4 randomized clinical trials. J Hepatol. 1992 Nov;16(3):338–345. doi: 10.1016/s0168-8278(05)80666-x. [DOI] [PubMed] [Google Scholar]
  13. Warren W. D., Millikan W. J., Jr, Henderson J. M., Wright L., Kutner M., Smith R. B., 3rd, Fulenwider J. T., Salam A. A., Galambos J. T. Ten years portal hypertensive surgery at Emory. Results and new perspectives. Ann Surg. 1982 May;195(5):530–542. doi: 10.1097/00000658-198205000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES