"To select better--to shunt better" prerequisites for better shunt therapy in liver cirrhosis. Review

Essentially 3 facts are responsible for the poor clinical outcome after porta-caval shunt in liver cirrhosis today: 1. Further reduction of hepatic blood flow, 2. total or nearly complete deprivation of the liver of portal venous blood supply with essential substances and functions and 3. insufficient criteria for selection. Since there exists no alternative procedure in decompressing bleeding varices in the end, porta-caval anastomoses will have to be performed also in the future. Therefore all efforts must be undertaken to improve the operative and longterm results, including a better preoperative selection and a better shunting. Determination of "functional" liver volume, knowledge of hepatic arterial reaction and preoperative determination of the intrahepatic shunt-flow might be very promising aspects in the selection today. In porta-caval surgery a differentiated choice of the available shunting methods to be applied, especially techniques for selective decompression and liver arterialization, may improve the results. Finally, the aim in each case should be a porta-caval shunt adapted to the individual situation of the cirrhotic patient.