Selective shunts: the Johannesburg experience.

Area of Science:

• Gastroenterology
• Surgical Innovation
• Hepatology

Background:

• Portal hypertension is a serious complication of liver disease, often leading to variceal bleeding.
• Selective shunts are surgical procedures aimed at decompressing the portal venous system.
• The Warren shunt is a common selective shunt procedure, but alternative techniques exist.

Purpose of the Study:

• To report on a 15-year experience with 141 selective shunt operations for portal hypertension.
• To evaluate the outcomes, including mortality, survival, rebleeding, and encephalopathy, associated with selective shunts.
• To compare results between different patient groups (alcoholic vs. non-alcoholic, cirrhotic vs. non-cirrhotic).

Main Methods:

• A retrospective review of 141 selective shunt procedures (127 elective, 14 emergency) over 15 years.
• Detailed analysis of patient demographics, including etiology of portal hypertension (alcoholic vs. non-alcoholic cirrhosis).
• Assessment of surgical outcomes, including hospital mortality, long-term survival, variceal rebleeding rates, shunt patency, and postoperative encephalopathy.

Main Results:

• Hospital mortality and long-term survival were better in non-alcoholic patients compared to alcoholics.
• Variceal rebleeding was infrequent (4% with Warren procedures) and often linked to shunt failure.
• Postoperative encephalopathy occurred in 13% of patients, notably absent in non-cirrhotic individuals. Prograde portal venous perfusion was preserved in 77% of patients.

Conclusions:

• Selective shunts can yield highly satisfactory results in carefully selected patients with portal hypertension.
• Adequate patient preparation is crucial for optimizing outcomes.
• While effective, shunt failure and rebleeding remain potential complications, particularly with alternative shunt types.