Correction of amino-acid imbalance in postoperative portosystemic shunts

We report on 22 cirrhotic patients suffering from portal hypertension and bleeding esophageal varices. Sixteen of them underwent H mesocaval shunt with internal jugular vein graft and 6 spleno-renal shunts. Mortality was 13.2%. All the patients were treated postoperatively with parenteral and oral nutritional support with solutions containing no aromatic amino-acids, following Fischer's formula. We determined Fischer's index (formula; see text); normal value 2.67 +/- 0.22) on the day of operation (1.6 +/- 0.22), on the 8th postoperative day (2.32 +/- 0.49), and on the 15th postoperative day (1.85 +/- 0.37). Only 1 patient suffered from hepatic encephalopathy in the immediate postoperative period. Three months after operation Fischer's index was 1.20 +/- 0.11 and only 2 patients with an index below 1 suffered from chronic encephalopathy. We conclude that there is a correlation between Fischer's index and the presence of post-shunt hepatic encephalopathy. The proposed policy of parenteral nutrition improves the values of Fischer's index in the immediate postoperative period and we believe that nutritional support should be included routinely as an adjuvant therapy in portosystemic shunts in cirrhotic patients.