Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1985 Apr;201(4):476–487. doi: 10.1097/00000658-198504000-00013

Factors affecting immediate and long-term survival after emergent and elective splanchnic-systemic shunts.

J G Chandler, C H Van Meter, D L Kaiser, S E Mills
PMCID: PMC1250737  PMID: 3977449

Abstract

The course of 121 shunted cirrhotic patients, managed according to a prospective protocol over a period of 10 years, was analyzed to determine predictors of 30-day and long-term survival. Forty-five per cent of the patients underwent emergent decompression within 12 hours of active bleeding, and 34% of the shunts were selective. Logistic regression linked early mortality to bilirubin and blood-urea nitrogen (BUN) (p = 0.001), and long-term survival to the presence of preoperative ascites and higher levels of alkaline phosphatase (p = 0.027), but neither variable set was a more accurate predictor than Child Class. Emergency shunt patients had greater risk of early death, 44% vs. 17% for patients shunted electively (p = 0.001), but beyond 30 days, their Kaplan-Meier survival curves were identical. Independently, angiographic prograde portal flow was favorably associated with short-term (p = 0.003) but not prolonged survival. The presence of Mallory bodies, fatty metamorphosis, and acute periportal inflammation, alone or in combination, had no prognostic value. Continued post-operative alcohol ingestion jeopardized long-term survival (p = 0.017). Survival of nonalcoholics was enhanced by selective as opposed to total splanchnic decompression (p = 0.009).

Full text

PDF
477

Images in this article

477FIG. 1.
on p.477
483FIG. 6.
on p.483
484FIG. 8.
on p.484

Selected References

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

  1. Adams M., Coon F. B., Poling C. E. Insecticides in the tissues of four generations of rats fed different dietary fats containing a mixture of chlorinated hydrocarbon insecticides. J Agric Food Chem. 1974 Jan-Feb;22(1):69–75. doi: 10.1021/jf60191a011. [DOI] [PubMed] [Google Scholar]
  2. Allison J. G. The role of injection sclerotherapy in the emergency and definitive management of bleeding esophageal varices. JAMA. 1983 Mar 18;249(11):1484–1487. [PubMed] [Google Scholar]
  3. Bell R. H., Jr, Miyai K., Orloff M. J. Outcome in cirrhotic patients with acute alcoholic hepatitis after emergency portacaval shunt for bleeding esophageal varices. Am J Surg. 1984 Jan;147(1):78–84. doi: 10.1016/0002-9610(84)90038-2. [DOI] [PubMed] [Google Scholar]
  4. Campbell D. P., Parker D. E., Anagnostopoulos C. E. Survival prediction in portacaval shunts: a computerized statistical analysis. Am J Surg. 1973 Dec;126(6):748–751. doi: 10.1016/s0002-9610(73)80062-5. [DOI] [PubMed] [Google Scholar]
  5. Cello J. P., Deveney K. E., Trunkey D. D., Heilbron D. C., Stoney R. J., Ehrenfeld W. K., Way L. W. Factors influencing survival after therapeutic shunts. Results of a discriminant function and linear logistic regressions analysis. Am J Surg. 1981 Feb;141(2):257–265. doi: 10.1016/0002-9610(81)90170-7. [DOI] [PubMed] [Google Scholar]
  6. Chandler J. G., Fechner R. E. Hepatopedal flow restoration in patients intolerant of total portal diversion. Ann Surg. 1983 May;197(5):574–583. doi: 10.1097/00000658-198305000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Dicarlo V., Staudacher C., Chiesa R., Andreoni B., Cristallo M., Ronchetti E. The role of cardiovascular hemodynamics and liver histology in evaluating bleeding cirrhotic patients. Ann Surg. 1979 Aug;190(2):218–226. doi: 10.1097/00000658-197908000-00015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Eckhauser F. E., Appelman H. D., O'Leary T. J., Polley T. Z., Bloch D. M., Turcotte J. G. Hepatic pathology as a determinant of prognosis after portal decompression. Am J Surg. 1980 Jan;139(1):105–112. doi: 10.1016/0002-9610(80)90238-x. [DOI] [PubMed] [Google Scholar]
  9. Foster J. H., Ellison L. H., Donovan T. J., Anderson A. Quantity and quality of survival after portosystemic shunts. Am J Surg. 1971 Apr;121(4):490–501. doi: 10.1016/0002-9610(71)90245-5. [DOI] [PubMed] [Google Scholar]
  10. French S. W. Present understanding of the development of Mallory's body. Arch Pathol Lab Med. 1983 Sep;107(9):445–450. [PubMed] [Google Scholar]
  11. GEHAN E. A. A GENERALIZED WILCOXON TEST FOR COMPARING ARBITRARILY SINGLY-CENSORED SAMPLES. Biometrika. 1965 Jun;52:203–223. [PubMed] [Google Scholar]
  12. Gall E. A., Keirle A. M. Portal systemic venous shunt. Pathological factors contributing to postoperative survival. Gastroenterology. 1965 Dec;49(6):656–661. [PubMed] [Google Scholar]
  13. Grendell J. H., Cello J. P., Margaretten W., Heilbron D. C. Impact of preshunt liver histology on survival following portasystemic shunt surgery for bleeding esophageal varices. Dig Dis Sci. 1983 Jan;28(1):44–55. doi: 10.1007/BF01393360. [DOI] [PubMed] [Google Scholar]
  14. Inokuchi K., Kobayashi M., Ogawa Y., Saku M., Nagasue N. Results of left gastric vena caval shunt for esophageal varices: Analysis of one hundred clinical cases. Surgery. 1975 Nov;78(5):628–636. [PubMed] [Google Scholar]
  15. Kanel G. C., Kaplan M. M., Zawacki J. K., Callow A. D. Survival in patients with postnecrotic cirrhosis and Laennec's cirrhosis undergoing therapeutic portacaval shunt. Gastroenterology. 1977 Oct;73(4 Pt 1):679–683. [PubMed] [Google Scholar]
  16. Kerstein M. D., Stevenson T. Factors predicting survival after portosystemic shunt. Am Surg. 1982 Jan;48(1):32–34. [PubMed] [Google Scholar]
  17. Koolpe H. A., Embil W., Koolpe L., Russell E., Williams C. O. Hemodynamic guidelines for surgical therapy of portal hypertension. Ann Surg. 1981 Nov;194(5):553–561. doi: 10.1097/00000658-198111000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. LINTON R. R. The selection of patients for portacaval shunts, with a summary of the results in 61 cases. Ann Surg. 1951 Sep;134(3):433–443. doi: 10.1097/00000658-195109000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Lebrec D., Poynard T., Hillon P., Benhamou J. P. Propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis: a controlled study. N Engl J Med. 1981 Dec 3;305(23):1371–1374. doi: 10.1056/NEJM198112033052302. [DOI] [PubMed] [Google Scholar]
  20. MacDougall B. R., Westaby D., Theodossi A., Dawson J. L., Williams R. Increased long-term survival in variceal haemorrhage using injection sclerotherapy. Results of a controlled trial. Lancet. 1982 Jan 16;1(8264):124–127. doi: 10.1016/s0140-6736(82)90378-6. [DOI] [PubMed] [Google Scholar]
  21. Malt R. A., Szczerban J., Malt R. B. Risks in therapeutic portacaval and splenorenal shunts. Ann Surg. 1976 Sep;184(3):279–288. doi: 10.1097/00000658-197609000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Malt R. B., Malt R. A. Tests and management affecting survival after portacaval and spenorenal shunts. Surg Gynecol Obstet. 1979 Aug;149(2):220–224. [PubMed] [Google Scholar]
  23. Mikkelsen W. P. Therapeutic portacaval shunt. Preliminary data on controlled trial and morbid effects of acute hyaline necrosis. Arch Surg. 1974 Mar;108(3):302–305. doi: 10.1001/archsurg.1974.01350270036007. [DOI] [PubMed] [Google Scholar]
  24. Mikkelsen W. P., Turrill F. L., Kern W. H. Acute hyaline necrosis of the liver. A surgical trap. Am J Surg. 1968 Aug;116(2):266–272. doi: 10.1016/0002-9610(68)90503-5. [DOI] [PubMed] [Google Scholar]
  25. Mosimann F. Acute necrotizing pancreatitis after distal splenorenal shunt. World J Surg. 1983 Jul;7(4):552–553. doi: 10.1007/BF01655949. [DOI] [PubMed] [Google Scholar]
  26. Nordlinger B. M., Nordlinger D. F., Fulenwider J. T., Millikan W. J., Sones P. J., Kutner M., Steele R., Bain R., Warren W. D. Angiography in portal hypertension: clinical significance in surgery. Am J Surg. 1980 Jan;139(1):132–141. doi: 10.1016/0002-9610(80)90242-1. [DOI] [PubMed] [Google Scholar]
  27. Orloff M. J., Bell R. H., Jr, Hyde P. V., Skivolocki W. P. Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcoholic cirrhosis. Ann Surg. 1980 Sep;192(3):325–340. doi: 10.1097/00000658-198009000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Orloff M. J., Chandler J. G., Charters A. C., 3rd, Condon J. K., Grambort D. E., Modafferi T. R., Levin S. E. Comparison of end to side and side to side portacaval shunts in dogs and human subjects with cirrhosis and portal hypertension. Am J Surg. 1974 Aug;128(2):195–201. [PubMed] [Google Scholar]
  29. Simert G., Persson T., Vang J. Factors predicing survival after portacaval shunt: a multiple linear regression analysis. Ann Surg. 1978 Feb;187(2):174–178. doi: 10.1097/00000658-197802000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Smith-Laing G., Scott J., Long R. G., Dick R., Sherlock S. Role of percutaneous transhepatic obliteration of varices in the management of hemorrhage from gastroesophageal varices. Gastroenterology. 1981 May;80(5 Pt 1):1031–1036. [PubMed] [Google Scholar]
  31. Stipa S., Ziparo V., Anzá M., Fabrini G., Lupino R. A randomized controlled trial of mesentericocaval shunt with autologous jugular vein. Surg Gynecol Obstet. 1981 Sep;153(3):353–356. [PubMed] [Google Scholar]
  32. Stone H. H., Strom P. R., Mullins R. J. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983 May;197(5):532–535. doi: 10.1097/00000658-198305000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Sugiura M., Futagawa S. Results of six hundred thirty-six esophageal transections with paraesophagogastric devascularization in the treatment of esophageal varices. J Vasc Surg. 1984 Mar;1(2):254–260. [PubMed] [Google Scholar]
  34. Talman E. A., Johns T. N., Regan W. W. A 25-year experience with total portosystemic shunts and reappraisal of colon exclusion. Ann Surg. 1983 May;197(5):566–573. doi: 10.1097/00000658-198305000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Turcotte J. G., Lambert M. J., 3rd Variceal hemorrhage, hepatic cirrhosis, and portacaval shunts. Surgery. 1973 Jun;73(6):810–817. [PubMed] [Google Scholar]
  36. Walker S. H., Duncan D. B. Estimation of the probability of an event as a function of several independent variables. Biometrika. 1967 Jun;54(1):167–179. [PubMed] [Google Scholar]
  37. 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]
  38. Waxman K., Shoemaker W. C. Physiologic determinants of operative survival after portacaval shunt. Ann Surg. 1983 Jan;197(1):72–78. [PMC free article] [PubMed] [Google Scholar]
  39. Zeppa R., Hensley G. T., Levi J. U., Bergstresser P. R., Hutson D. G., Sr, Livingstone A. S., Schiff E. R., Fink P. The comparative survivals of alcoholics versus nonalcoholics after distal splenorenal shunt. Ann Surg. 1978 May;187(5):510–514. doi: 10.1097/00000658-197805000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]

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

RESOURCES