Prospective Randomized Trial of Emergency Portacaval Shunt and Emergency Medical Therapy in Unselected Cirrhotic Patients With Bleeding Varices

Abstract

A prospective randomized trial was conducted in unselected, consecutive patients with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamponade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received identical supportive therapy initially. All patients were followed up for at least 10 yr. The protocol contained no escape or cross-over provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p < 0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p < 0.001). Mean requirement for blood transfusion was 7.1 +/- 2.6 units in the shunt group and 21.4 +/- 2.6 units in the medical group (p < 0.001). Eighty-one percent of the patients in the shunt group were discharged alive compared with 45% in the medical group (p = 0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p < 0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.

The Role of the Distal Splenorenal Shunt in the Sclerotherapy Era?

“…This factor is the major difference between this study and our previously published study .I n the Emory study only one patient randomized to sclerotherapy died as a direct result of rebleeding, and 12 were successfully salvaged by surgical management. In contrast, in the present study 8 …”

Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices

“…Moreover, emergency surgery, whether derivation or devascularization procedures, carries such high morbidity and mortality rates that it has been abandoned in most centers. [24][25][26][27][28] Bleeding esophageal or gastric varices can be injected with the tissue-adhesive cyanoacrylate, as described in a few uncontrolled studies. 29,30 This technique has not been popularized mainly because of the expertise it requires, particularly in avoiding damage to the endoscope and because of potentially severe complications.…”

Acute variceal bleeding: general management

“…Hospital and 30 day mortality was not significantly different. Finally Orloff et al reported, in a small study [82] , that portacaval shunt, performed in less than 8 hours from admission, was significantly better than medical treatment (vasopressin/balloon tamponade) in the control of acute variceal bleeding. Survival was also better in the shunted patients but the difference was not statistically significant.…”