Partial Portacaval Shunt: Narrow Diameter H-Graft

Adam, R., Diamond, T. and Bismuth, H. (1992) Partial portacaval shunt: Renaissance of an old concept. Surgery, 111,610-616. Background. Partial diversion of the portal system aims to redeuce portal pressure sufficiently to prevent variceal hemorrhage but still maintain adwquate hepatic portal flow. Methods. Partial portacaval shunts were performed in 25 patients with cirrhosis with portal hypertension and esophageal varices, either as a primary procedure (n 16) or for failure of endoscopic sclerotherapy (n= 9), with ringed polytetrafluoroethylene prostheses (8, 10, or 12 rnrn). Results. All patients have now been followed up for at least 1 year. The operative mortality rate (2 months) was 4%. In 24 patients who survived beyond the initial perioperative period, there was no recurrence of variceal bleeding. Cumulative shunt patency (up to 4 years) is 96%. Acute encephalopathy was detected in two patients (8%), but no patients had signs of chronic encephalopathy. Intraoperative pressure measurements revealed a signficant correlation between decreasing diameter of the graft and the percentage reduction of the portacavai pressure gradient. Selective angiography, performed 1 year after surgery, revealed that hepatopetal flow was maintained in 70% of patients with a 10 Iron shunt. Conclusions. It is possible to achieve a partial portacaval shunt, related to the diameter of the prosthesis, that preserves hepatopetai flow in the majority ofpatients and is associated with a very low incidence of shunt thrombosis. This effectively prevents recurrent variceal bleeding and significant postoperative encephalopathy. The performance of subsequent orthotopic liver transplantation is not compromised. The technique is recommended, either as a primary procedure or when sclerotherapy has failed, in patients with good liver function who are unlikely to require early liver transplantation (grade A and some grade B cirrhosis). (SURGERY 1992; 111:610-6.)