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

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.

Figure 1

Overall survival (n = 47)

Figure 2

Overall shunt patency (n = 39)

Figure 3

Survival stratified by diagnostic subgroups (n = 47)Notes: Difference between groups was estimated by a log-rank test. P = 0.006 PV thrombosis versus cirrhosis, and P = 0.02 PV thrombosis versus Budd-Chiari and cirrhosis versus Budd-Chiari. ‘Other’ subgroup is not large enough for statistical significance.

Figure 4

Shunt patency stratified by diagnostic subgroups (color-coded) (n = 39)Notes: Difference between groups was estimated by a log-rank test. P = 0.005 cirrhosis versus Budd-Chiari and P = 0.04 cirrhosis versus PV thrombosis. ‘Other’ subgroup is not large enough for statistical significance.