A ten year prospective experience with semi-elective shunt in selected patients for bleeding oesophageal varices

In a prospective study from 1972 to 1982, 38 patients with bleeding oesophageal varices and relatively good liver function were treated by semi-elective or emergent shunt 2-4 weeks after admission. There were no deaths within 3 months of surgery. This constituted 30% of the total 125 patients admitted with bleeding varices during that period. No referred case for treatment of portal hypertension was included in this study. The procedures performed were end-to-side portacaval shunt in 30 cases, lieno renal shunt in seven cases and interposition mesenterico-caval shunt in one case. All patients were admitted to a special unit with a two stage policy of management. Immediate endoscopic diagnosis and balloon tamponade in those with continued bleeding was followed by shunt in selected cases. Follow-up of the 38 patients showed a cumulative survival at 1 year of 89%, at 3 years of 75% and 5 years of 65%. In four cases (13%) a clinical diagnosis of portal systemic encephalopathy was made, all were controlled by medical management. In four of ten follow-up deaths, liver failure was the cause, in none of these cases was encephalopathy a problem. It is concluded that with a policy of early diagnosis and control of haemorrhage, 30% of a typical series of prospectively studied patients admitted with bleeding varices can be treated without mortality by definitive surgery. There was low incidence of encephalopathy and no cases of incapacitating mental confusion. Centralization of treatment and prospective study is essential for the implementation of such a policy of management.