Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant

Authors

  • Ilia Gur,

    Corresponding author
    1. Division of Surgical Oncology, Oregon Health and Science University, Portland, OR, USA
    • Correspondence

      Ilia Gur, General Surgery, Sutter Gould Medical Foundation, 2545 W. Hammer Lane, STE 2200, Stockton, CA, 95209 USA. Tel: + 209 941 0127. Fax: + 209 951 2438. E-mail: driliagur@gmail.com

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  • Brian S. Diggs,

    1. Division of General Surgery, Oregon Health and Science University, Portland, OR, USA
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  • Susan L. Orloff

    1. Division of Abdominal Organ Transplant, Oregon Health and Science University, Portland, OR, USA
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  • This manuscript was presented at the annual AHPBA meeting, Miami, 20–24 February 2013.

Abstract

Background

The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined.

Objectives

This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD).

Methods

A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted.

Results

Subgroups of patients with cirrhosis (53%), Budd–Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child–Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd–Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy.

Conclusions

Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.

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