Role of surgical portosystemic shunts in the era of interventional radiology and liver transplantation.

Background: In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension was reviewed.
Methods: This retrospective study analysed the management of patients with portal hypertension in a tertiary liver transplant unit between June 1993 and May 2002. During this 9-year interval, 394 patients underwent endoscopic control of varices, 235 transjugular intrahepatic portosystemic shunts were inserted, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt.
Results: Twenty-nine shunt operations were performed in nine patients with cirrhosis, one patient with congenital hepatic fibrosis and 19 without parenchymal liver disease. There were 12 side-to-side lienorenal, nine mesocaval, three proximal lienorenal, two distal lienorenal, two portacaval and one mesoportal shunts. Encephalopathy was seen in five of 11 patients with a non-selective shunt, but did not occur after side-to-side or selective lienorenal shunt procedures. At a median follow-up of 42.5 months, one mesocaval shunt had thrombosed and one portacaval shunt had stenosed; both were successfully managed by percutaneous intervention. To date, six patients have died; two succumbed to postoperative complications, one of which was related to the shunt.
Conclusion: Patients with Budd-Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in patients with cirrhosis, a side-to-side lienorenal shunt is a good option.
(Copyright 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)