Document Detail

Three decades of experience with emergency portacaval shunt for acutely bleeding esophageal varices in 400 unselected patients with cirrhosis of the liver.
MedLine Citation:
PMID:  7874335     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Emergency treatment of acute bleeding is of singular and paramount importance in the therapy of portal hypertension and esophagogastric varices. Accordingly, for more than three decades we have conducted prospective studies of emergency therapy, and particularly of emergency portacaval shunt (EPCS). STUDY DESIGN: Emergency portacaval shunt was performed upon 400 patients with cirrhosis of the liver and acutely bleeding esophagogastric varices according to three principles: operation within eight hours of initial contact; unselected patients, meaning that no patient with variceal bleeding caused by hepatic disease was excluded from EPCS, and prospective study, meaning that a well-defined protocol was consistently used and data were collected on-line. Patients were divided into an early group of 180 treated from 1963 to 1978 and a recent group of 220 treated from 1978 to July, 1990, with similar characteristics, but strikingly different outcome. Follow-up rates at one, five, and ten years were 100, 98, and 97 percent, respectively; 96 percent of patients underwent EPCS five or more years ago. Proof of acute variceal bleeding and of cirrhosis of the liver (alcoholic in 95 percent) was obtained in every patient. Child's risk classes determined quantitatively were A in 11 percent of the patients, B in 65 percent, and C in 24 percent. All patients had a direct portacaval shunt, side-to-side in 85 percent, which reduced the mean portal vein to inferior vena cava pressure gradient from 271 to 21 mm saline solution. RESULTS: All but four patients (99 percent) had immediate and permanent control of variceal bleeding. Thrombosis of the shunt occurred in only two patients (0.5 percent). Survival rates at 30 days, five years, ten years, and 15 years in the early group were 58, 40, 30, and 30 percent, respectively, while in the recent group they were 85, 78, 71, and 57 percent, respectively (p < 0.0001). Other striking gains in the recent group were abstention from alcohol, improvement in liver function and improvement in Child's class, all in 70 percent of patients. Recurrent portal-systemic encephalopathy occurred in 9 percent of the early group and 8 percent of the recent group. CONCLUSIONS: Emergency portacaval shunt substantially improved survival and quality of life of patients with cirrhosis of the liver and bleeding varices. Our results are attributable to rapid and simplified diagnosis, prompt operation, an organized system of care, and rigorous, lifelong follow-up evaluation that emphasized abstinence from alcohol and dietary protein control. Transplantation of the liver is infrequently required in patients whose bleeding is permanently controlled.
M J Orloff; M S Orloff; S L Orloff; M Rambotti; B Girard
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Publication Detail:
Type:  Journal Article; Research Support, U.S. Gov't, P.H.S.    
Journal Detail:
Title:  Journal of the American College of Surgeons     Volume:  180     ISSN:  1072-7515     ISO Abbreviation:  J. Am. Coll. Surg.     Publication Date:  1995 Mar 
Date Detail:
Created Date:  1995-03-31     Completed Date:  1995-03-31     Revised Date:  2006-11-15    
Medline Journal Info:
Nlm Unique ID:  9431305     Medline TA:  J Am Coll Surg     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  257-72     Citation Subset:  AIM; IM    
Department of Surgery, University of California, San Diego Medical Center, 92103-8999.
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MeSH Terms
Blood Pressure / physiology
Esophageal and Gastric Varices / prevention & control,  surgery*
Follow-Up Studies
Gastrointestinal Hemorrhage / prevention & control,  surgery*
Hepatic Encephalopathy / etiology
Hypertension, Portal / complications,  physiopathology
Liver Cirrhosis, Alcoholic / complications*,  physiopathology
Middle Aged
Portacaval Shunt, Surgical* / adverse effects,  methods
Portal Vein / physiopathology
Prospective Studies
Quality of Life
Survival Rate
Treatment Outcome
Vena Cava, Inferior / physiopathology
Comment In:
J Am Coll Surg. 1995 Mar;180(3):337-9   [PMID:  7874345 ]

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