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. 1986 Oct;204(4):356–363. doi: 10.1097/00000658-198610000-00003

A systematic appraisal of portacaval H-graft diameters. Clinical and hemodynamic perspectives.

I J Sarfeh, E B Rypins, G R Mason
PMCID: PMC1251298  PMID: 3490229

Abstract

Over a period of 10 years, the authors have systematically reduced portacaval H-graft diameters. Their objective was to achieve partial shunting of portal flow without reversal of hepatic flow. This report summarizes their clinical and hemodynamic observations in 68 surviving patients with cirrhosis (mostly alcoholic) and variceal hemorrhage who underwent portacaval H-grafts ranging from 20 to 8 mm diameters. When shunt diameters were reduced to 10 and 8 mm and combined with aggressive portal collateral ablation, portal pressures increased significantly over larger H-grafts. Only 3% of patients with 20-12 mm H-grafts had prograde portal flow after operation, compared with 46 and 82% after 10 and 8 mm H-grafts, respectively (p less than 0.001). The incidence of encephalopathy diminished from 39% in the 20-12 mm H-graft group to 19 and 9% after 10 and 8 mm grafts, respectively (p less than 0.04). None of the patients with 10 or 8 mm PTFE grafts rebled from varices in the follow-up period (4-61 months). It is concluded that partial shunting of portal flow is hemodynamically feasible. It can be achieved in most patients using 8 mm polytetrafluoroethylene (PTFE) portacaval H-grafts combined with portal collateral ablation. Preserving prograde portal flow by partial shunting correlates with reduced encephalopathy rates after operation. Despite maintaining a relatively hypertensive portal system, partial shunts effectively prevent variceal hemorrhage.

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Selected References

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

  1. Balique J. G., Chabert M., Champailler A., Vigne-Rebaud M. A., Espalieu P., Hugonnier G., Cuilleret J. L'anastomose porto-cave latéro-latérale calibrée de Marion: une dérivation tronculaire maintenant un flux portal hépatopète? Gastroenterol Clin Biol. 1985 Apr;9(4):305–311. [PubMed] [Google Scholar]
  2. Bothe A., Jr, Stone M. D., McDermott W. V., Jr Portoazygous disconnection for bleeding esophageal varices. Am J Surg. 1985 Apr;149(4):546–550. doi: 10.1016/s0002-9610(85)80054-4. [DOI] [PubMed] [Google Scholar]
  3. 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]
  4. Conn H. O. Ideal treatment of portal hypertension in 1985. Clin Gastroenterol. 1985 Jan;14(1):259–288. [PubMed] [Google Scholar]
  5. Conn H. O. Propranolol in portal hypertension: problems in paradise? Hepatology. 1984 May-Jun;4(3):560–564. doi: 10.1002/hep.1840040333. [DOI] [PubMed] [Google Scholar]
  6. Galambos J. T., Warren W. D., Rudman D., Smith R. B., 3rd, Salam A. A. Selective and total shunts in the treatment of bleeding varices. A randomized controlled trial. N Engl J Med. 1976 Nov 11;295(20):1089–1095. doi: 10.1056/NEJM197611112952001. [DOI] [PubMed] [Google Scholar]
  7. Gouge T. H., Ranson J. H. Esophageal transection and paraesophagogastric devascularization for bleeding esophageal varices. Am J Surg. 1986 Jan;151(1):47–54. doi: 10.1016/0002-9610(86)90010-3. [DOI] [PubMed] [Google Scholar]
  8. Henderson J. M., Millikan W. J., Jr, Wright-Bacon L., Kutner M. H., Warren W. D. Hemodynamic differences between alcoholic and nonalcoholic cirrhotics following distal splenorenal shunt--effect on survival? Ann Surg. 1983 Sep;198(3):325–334. doi: 10.1097/00000658-198309000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Langer B., Taylor B. R., Mackenzie D. R., Gilas T., Stone R. M., Blendis L. Further report of a prospective randomized trial comparing distal splenorenal shunt with end-to-side portacaval shunt. An analysis of encephalopathy, survival, and quality of life. Gastroenterology. 1985 Feb;88(2):424–429. doi: 10.1016/0016-5085(85)90502-5. [DOI] [PubMed] [Google Scholar]
  10. Maillard J. N., Flamant Y. M., Hay J. M., Chandler J. G. Selectivity of the distal splenorenal shunt. Surgery. 1979 Nov;86(5):663–671. [PubMed] [Google Scholar]
  11. Marion P., Balique J. G., George M., Clement G., Vacca C., Vadot L. Anastomose porto-cave latéro-latérale à débit minimum pour cirrhose hémorragique. Interet de la conservation du flux portal sous contrôle manométrique. Med Chir Dig. 1981;10(3):245–251. [PubMed] [Google Scholar]
  12. McCormack T. T., Sims J., Eyre-Brook I., Kennedy H., Goepel J., Johnson A. G., Triger D. R. Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy? Gut. 1985 Nov;26(11):1226–1232. doi: 10.1136/gut.26.11.1226. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. ORLOFF M. J., WALL M. H., HICKMAN E. B., NEESBY T. INFLUENCE OF ATOMAL SIZE OF PORTACAVAL SHUNTS ON PERIPHERAL BLOOD AMMONIA LEVELS. Ann Surg. 1963 Aug;158:172–181. doi: 10.1097/00000658-196308000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Plate G., Hollier L. H., Gloviczki P., Dewanjee M. K., Kaye M. P. Overcoming failure of venous vascular prostheses. Surgery. 1984 Sep;96(3):503–510. [PubMed] [Google Scholar]
  15. Rypins E. B., Mason G. R., Conroy R. M., Sarfeh I. J. Predictability and maintenance of portal flow patterns after small-diameter portacaval H-grafts in man. Ann Surg. 1984 Dec;200(6):706–710. doi: 10.1097/00000658-198412000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Rypins E. B., Sarfeh I. J. Does portal pressure influence direction of portal flow and encephalopathy rates after 10-mm portacaval shunts in man? J Surg Res. 1984 Aug;37(2):119–122. doi: 10.1016/0022-4804(84)90171-9. [DOI] [PubMed] [Google Scholar]
  17. Sarfeh I. J., Carter J. A., Welch H. F. Analysis of operative mortality after portal decompressive procedures in cirrhotic patients. Am J Surg. 1980 Aug;140(2):306–311. doi: 10.1016/0002-9610(80)90027-6. [DOI] [PubMed] [Google Scholar]
  18. Sarfeh I. J. Comparative study of portacaval and mesocaval interposition shunts. Am J Surg. 1981 Oct;142(4):511–513. doi: 10.1016/0002-9610(81)90386-x. [DOI] [PubMed] [Google Scholar]
  19. Sarfeh I. J. Comparison of the major variceal decompressive operations: one surgeon's experience. Am Surg. 1982 Jun;48(6):261–263. [PubMed] [Google Scholar]
  20. Sarfeh I. J. Portal vein thrombosis associated with cirrhosis: clinical importance. Arch Surg. 1979 Aug;114(8):902–905. doi: 10.1001/archsurg.1979.01370320034006. [DOI] [PubMed] [Google Scholar]
  21. Sarfeh I. J., Rypins E. B., Conroy R. M., Mason G. R. Portacaval H-graft: relationships of shunt diameter, portal flow patterns and encephalopathy. Ann Surg. 1983 Apr;197(4):422–426. doi: 10.1097/00000658-198304000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Sarfeh I. J., Rypins E. B., Fardi M., Conroy R. M., Mason G. R., Lyons K. P. Clinical implications of portal hemodynamics after small-diameter portacaval H graft. Surgery. 1984 Aug;96(2):223–229. [PubMed] [Google Scholar]
  23. Smith R. B., 3rd, Warren W. D., Salam A. A., Millikan W. J., Ansley J. D., Galambos J. T., Kutner M., Bain R. P. Dacron interposition shunts for portal hypertension. An analysis of morbidity correlates. Ann Surg. 1980 Jul;192(1):9–17. doi: 10.1097/00000658-198007000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Warren W. D. Loss of hepatic portal perfusion after selective shunts. Am J Surg. 1981 May;141(5):581–581. doi: 10.1016/0002-9610(81)90055-6. [DOI] [PubMed] [Google Scholar]
  25. Warren W. D., Millikan W. J., Jr, Henderson J. M., Rasheed M. E., Salam A. A. Selective variceal decompression after splenectomy or splenic vein thrombosis. With a note on splenopancreatic disconnection. Ann Surg. 1984 Jun;199(6):694–702. doi: 10.1097/00000658-198406000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Warren W. D., Zeppa R., Fomon J. J. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967 Sep;166(3):437–455. doi: 10.1097/00000658-196709000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]

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