A critical appraisal of the small-diameter portacaval H-graft

The ideal portasystemic shunt should prevent variceal hemorrhage and preserve portal flow to reduce hepatic encephalopathy. The partial shunting proposed by Sarfeh effectively controls variceal bleeding while preserving prograde hepatic portal flow.

We analyzed results of the partial portacaval shunt prospectively in 43 patients undergoing small-diameter (8-mm or 10-mm) portacaval H-graft. Patients entered into the study had Child-Pugh class A and class B cirrhosis, and all had documented previous variceal hemorrhages. We used the Sarfeh technique without performing portal collateral ligation.

Operative mortality was 5%. Acute graft thrombosis occurred in 3 patients, 2 of whom were successfully lysed by urokinase infusion angiographically, while later graft occlusion occurred in 1 case. Only 1 patient rebled from varices in our late follow-up (14 to 65 months). Prograde portal flow was maintained in 90% of patients undergoing repeat angiography 27 +/- 13 months postoperatively. The incidence of all encephalopathy episodes was 16%, with only 1 patient having this complication chronically.

The small-diameter portacaval H-graft of Sarfeh is an effective operation for controlling variceal hemorrhage. It preserves hepatic portal perfusion over time in the majority of patients, reducing the risk of encephalopathy. The procedure may be particularly suited for alcoholic cirrhotic patients with less advanced liver disease.