A prospective evaluation of emergency
portacaval shunt has been conducted during a 12 year period in 138 unselected, consecutive patients with
alcoholic cirrhosis and
bleeding esophageal varies. An extensive diagnostic evaluation was completed within seven hours of hospital admission, and the shunt operation was undertaken within a mean of 8.5 hours. Follow-up study was conducted in a special clinic, and the current status of 97.1 per cent of the patients had
jaundice,
ascites or
encephalopathy alone or in combination on admission. Systemic
intravenous administration of posterior pituitary extract temporarily controlled the
hemorrhage in 94 per cent of the patients, and the emergency
portacaval shunt promptly and permanently controlled the
varix bleeding in 96 per cent of the patients. Contrary to recent proposals, patients with the highest portal perfusion pressure and, presumably, the largest hepatopetal portal flow had the highest survival rate and those who were presumed from pressure measurements to sustain the smallest portal flow diversion from the shunt had the lowest survival rate. The operative survival rate was 51 per cent, the predicted seven year survival rate for those operated upon seven or more years ago was 42.5 per cent.
Encephalopathy requiring
dietary protein restriction developed at some time in 17 per cent of the survivors. Sixty per cent of the survivors abstained from alcohol, and 53 per cent resumed gainful employment or full time housekeeping. Preoperative factors that adversely influenced survial rate were ingestion of alcohol within one month of
bleeding,
ascites, severe muscle-wasting and a small liver. Postoperatively, the single most important factor that compromised long term survival was resumption of
alcoholism. In comparisons with our previous prospective studies, emergency
portacaval shunt resulted in a significantly greater long term survival rate than did either emergency medical
therapy or emergency
varix ligation, followed by elective shunt. It is concluded that emergency
portacaval shunt is the most effective treatment of
bleeding esophageal varices in patients with
alcoholic cirrhosis. Criteria for exclusion of those patients who are unlikely to derive long term benefits from
portacaval shunt remain to be defined by further studies.