This report describes an experience with operative restoration of hepatopedal portal blood flow in five patients intolerant of total splanchnic shunting. Portal flow was reestablished by takedown of the total shunt and construction of a selective, distal
splenorenal shunt, or by isolation and arterialization of the hepatic limb of the shunted portal vein. In two patients, shunt revision was undertaken electively for
chronic encephalopathy, which had been unresponsive to
low-protein diet, intestinal antibiosis and oral
lactulose. Eighteen and 48 months after operation, both patients have had no
encephalopathy on an unrestricted
protein intake, and work actively as homemakers. Needle liver biopsies showed enhanced mitotic activity in the early postoperative period, suggesting hepatocyte regeneration. In three patients, shunt conversion or arterialization was undertaken in desperate circumstances, characterized by
liver failure (
bilirubin greater than 10 mg/dl,
albumin less than 2.5 g/dl, prothrombin time greater than 16 sec),
coma, and
respirator dependency. Although the patients showed immediate, marked improvement in mentation, all three died of intraabdominal
hemorrhage in the first few postoperative days, in spite of maximum blood product support. Two conclusions can be drawn from this limited experience: (1) at a time of election, restoration of hepatopedal portal flow can be accomplished with considerable benefit in patients with side-to-side portacaval or hemodynamically equivalent shunts, and (2) similar procedures in patients with
fulminant liver failure are unlikely to succeed.