A prospective evaluation of emergency protacaval shunt has been conducted in 180 unselected, consecutive patients with
cirrhosis and
bleeding varices who were operated on between 1963 and 1978. An extensive diagnostic work-up was completed within three to seven hours of admission to the emergency department, and the shunt operation was undertaken within a mean of 7.81 hours. A program of lifelong follow-up was conducted such that the current status of 97% of the patients is known. On each patient, 220 categories of data were collected and entered into a computer program for analysis. On admission, 49% of the patients had
jaundice, 53% had
ascites, 19% had
encephalopathy, 30% had severe muscle wasting and 100% had abnormal BSP retention. Administration of a bolus dose of
vasopressin by the systemic intravenous route temporarily controlled the
varix hemorrhage in 95% of patients, and emergency shunt permanently controlled the
bleeding in 98%. Maximum perfusion pressure in the portal vein prior to shunt did not correlate with survival rate or incidence of
encephalopathy after shunt. The operative survival rate was 58%, the five-year actuarial survival rate is 38% and the 12-year actuarial survival rate is 30%.
Encephalopathy was observed in 31.5% of the patients, but was severe enough to require chronic
dietary protein restriction in only 7%. The
portacaval shunt remained patent in 99% of patients. Of the survivors, 48% abstained from alcohol, 60% resumed gainful employment or housekeeping, and two-thirds were judged to be in excellent or good condition after one and five years. Preoperative factors that adversely influenced survival rate were
ascites,
SGOT >/= 100 units, BSP retention >50%, hypokalemic
alkalosis,
blood transfusion requirement >/= 5 L, and consumption of alcohol within seven day[unk] of admission. In comparison with our previous prospective studies, emergency
portacaval shunt produced a significantly greater long-term survival rate than either emergency medical
therapy or emergency
varix ligation, followed by elective shunt. During the past four years, 80% of 49 unselected patients have survived emergency shunt, and the four year actuarial survival rate is 69%.