Portal-systemic shunting and portal-systemic encephalopathy: A predictable relationship



Objective Results of the first prospective randomized clinical trial comparing partial and total portacaval shunt for variceal hemorrhage are reported. Summary Background Data Total portacaval shunts produce subnormal portal pressures, completely diverting hepatic portal flow. Partial shunts maintain higher pressures and preserve hepatopedal flow. No randomized trials of these two approaches have been performed. Methods Alcoholic patients with cirrhosis (n = 30) and variceal hemorrhage treated at one institution were randomized to receive partial (8-mm diameter portacaval H grafts with collateral ablation, n = 14) or total shunts (16-mm diameter grafts, n = 16). Portography was performed after operation and then yearly. Investigators blinded to shunt type assessed encephalopathy; hospitalizations were reviewed. Results Child's class, age, and operative urgency were similar for the two groups. Two patients (with total shunts) died within 30 days. Hepatopedal flow was maintained in 13 partial and 0 total shunt patients (P < 0.0001). Shunt gradients were 16 ± 5 compared with 6 ± 3 cm saline after partial and total shunts (P < 0.0001). There were no shunt thromboses or variceal hemorrhages. Encephalopathy-free survival was significantly greater after partial shunts (P = 0.013; life table analysis). Five total compared with zero partial shunt patients required hospitalization for coma (P = 0.02). Long-term survival was not different for the two groups of patients. Conclusions Partial shunts control variceal hemorrhage while maintaining hepatopedal flow and elevated portal pressures. By minimizing encephalopathy rates, partial shunts provide improved quality of survival compared with total shunts.