Selective shunts for portal hypertension: current role of a 21-year experience

The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child-Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function.