Emergency portacaval anastomosis (EPCA): The long-awaited trial

Authors

  • Harold O. Conn M.D.

    1. Veterans Administration Medical Center West Haven, Connecticut 06516 and Yale University School of Medicine New Haven, Connecticut 06510
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Abstract

A prospective randomized trial was conducted in all comers with cirrhosis and bleeding varices comparing 1) emergency portacaval shunt (EPCS) performed within 8 hr of admission, with 2) emergency medical therapy (EMT) followed in 2–6 wks by elective portacaval shunt in survivors. All patients received identical supportive therapy initially, and the EMT group received vasopressin in continuous infusion and, if necessary, esophageal balloon tamponade to control varix bleeding. No patients refused to participate in the trial, and there were no escape or cross-over provisions in the protocol. Randomization resulted in 21 patients receiving EPCS and 22 patients receiving EMT. All patients were followed up for at least 3 yrs.

Mean age was 48 yrs in each group. Cirrhosis was caused by alcoholism in 95% of each group. On admission, there were similar incidences in the 2 groups of ascites (EPCS–52%, EMT–50%), jaundice (EPCS–48%, EMT–50%), encephalopathy (EPCS–33%, EMT–14%), severe muscle wasting (EPCS–48%, EMT–59%), hyperdynamic state (82% in both groups), SGOT ≥ 100 u (EPCS–33%, EMT–36%), ICG retention ≥ 50% (EPCS–24%, EMT–23%), and ingestion of alcohol within 7 d of bleeding (EPCS–62%, EMT–59%). Child's risk classes in the EPCS group were A–10%, B–38%, and C–52%, while in the EMT group they were A–41%, B–32%, and C–27%, suggesting that the EPCS group had somewhat more severe liver disease.

There were highly significant differences (p < 0.01) in the results obtained by the 2 forms of treatment. Bleeding was permanently controlled in 100% of patients who underwent EPCS, but in 45% who received EMT. Mean requirement for blood transfusion was 5.8 u in the EPCS group and 15.5 u in the EMT group. 81% of the EPCS patients survived to leave the hospital compared to 45% of the EMT group. The 3-yr survival rate was 67% following EPCS compared to 27% following the combination of EMT and elective shunt. It is concluded that EPCS is significantly more effective than EMT followed by elective shunt in the treatment of bleeding varices in alcoholic cirrhosis.

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