The emory prospective randomized trial: selective versus nonselective shunt to control variceal bleeding: ten-year follow-up

• Published in: Annals of surgery 1985-06, Vol.201 (6), p.712-722
• Main Authors: MILLIKAN, W. J. JR, WARREN, W. D, HENDERSON, J. M, SMITH, R. B. III, SALAM, A. A, GALAMBOS, J. T, KUTNER, M. H, KEEN, J. H
• Format: Article
• Language: English
• Subjects: Biological and medical sciences; Clinical Trials as Topic; Esophageal and Gastric Varices - complications; Female; Gastroenterology. Liver. Pancreas. Abdomen; Gastrointestinal Hemorrhage - etiology; Gastrointestinal Hemorrhage - surgery; Hepatic Encephalopathy - etiology; Humans; Liver Circulation; Liver Function Tests; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Male; Medical sciences; Middle Aged; Other diseases. Semiology; Portasystemic Shunt, Surgical - adverse effects; Portasystemic Shunt, Surgical - methods; Portasystemic Shunt, Surgical - mortality; Prospective Studies; Random Allocation; Splenorenal Shunt, Surgical
• ISSN: 0003-4932; 1528-1140

From 1971 to 1975, 55 patients with variceal bleeding secondary to cirrhosis were entered into a prospective randomized trial comparing distal splenorenal (selective) and H-graft interposition (nonselective) shunt. This 10-year follow-up documents that selective shunt is better (p less than 0.05) in four of the five variables monitored. Control of bleeding: selective shunt prevented variceal bleeding better than interposition shunt due to the higher (0.05 less than p less than 0.1) occlusion rate (30%) of interposition shunt. Selective shunt maintained postoperative portal perfusion better (p less than 0.01) than patent interposition shunt. Seventy-five per cent of selective shunt survivors have portal perfusion at 10 years: no patient with a patent nonselective shunt perfuses the liver. Quantitative liver function was better preserved (p less than 0.01) 10 years after selective shunt than nonselective shunt. Postoperative encephalopathy occurred in fewer (p less than 0.01) selective (27%) than nonselective (75%) shunt patients over the 10 years. Survival: in the randomized population, the improved survival in the selective shunt subgroup did not reach statistical significance. However, improved survival was confirmed in nonalcoholics. Five of eight nonalcoholics operated with selective shunt are alive at 10 years with patent shunts. No nonalcoholic, of seven total, operated with nonselective shunt survived 10 years with a patent shunt. These data show that selective shunt was superior to nonselective shunt. There was less rebleeding and encephalopathy after distal splenorenal shunt; postoperative portal perfusion and hepatic function were maintained.