Preoperative Parameters Influencing Survival in Patients with Elective Portacaval Shunts

Abstract

In 145 patients submitted to elective portacaval anastomosis for intrahepatic block and followed up for periods ranging from 1 to 9 years, long-term survival has been analysed in its relation to the 4 classical preoperative parameters – age, liver size, hepatic histology, and hepatic function. No relation was detected between age at time of operation and mortality. Patients whose livers were of normal size had a better survival than those whose livers were atrophic or hypertrophic, but there was no difference in survival between the groups with atrophic and hypertrophic livers, respectively. Histological change and impairment of hepatic function were related to mortality in the first postoperative year only.

Portal-Systemic Shunts in Patients with Cirrhosis

“…This surgical procedure was considered beneficial [10, 44. 78] for the following reasons: ( I) the posthemorrhagic mortality in patients with cirrho sis is very high [23,59]; (2) after one hemorrhage the risk of recurrence has been reported to be high [2]; each recurrence is said to have a high death rate [2]; (3) in patients with portacaval shunt, digestive hemorrhage is rare [30]; (4) operative mortality is moderate (10% or less) [78]; (5) the 5-year survival rate of patients with alcoholic cirrhosis and portacaval shunt ranges from 30 to 50% [3,27,51,78,88]. These arguments suggest the following remarks: (1) the posthemorrhagic mortality in patients with cirrhosis without portacaval shunt reported in the medical literature concerns all the patients with cirrho sis and hemorrhage whatever the degree of hepatic impairment: the natural history of digestive bleedingsand of survival in patients in whom a shunt could have been indicated and has not been performed is poorly known; (2) from four retrospective studies [14,25,66,81] including 142 patients, the 5-year survival rate of patients who were proposed for a surgical procedure and who have not been operated on for unclear reasons is near 35%.…”

“…On clinical and biological findings, patients are usually divided into three groups, so-called 'good, mild and poor operative risk' [10,34], The age of patients is a criteria for some authors [34,39,84], not for others [11,27,51,80], Neither the volume of oesophageal varices [63,65] nor the free hepatic venous pressure -wedged hepatic venous pressure (or free portal venous pressure) gradient had never been taken into consideration [73] until recently [42]. The fact that the source of the bleeding is either a rupture of oesophag eal varices or acute gastric erosions has not been, until now, a criteria to perform or not a shunt [79], The aetiology of cirrhosis could be of prognostic significance; for instance the 5-year survival rate in patients with portacaval shunt and alcoholic cirrhosis is 30-50% [3, 27.…”