criteria for selection of patients for emergency portacaval shunt

Criteria for Selection of Patients for Emergency Portacaval

Shunt

Marshall J. Orloff, MD, San Diego, California

Lester R. Duguay, MD, San Diego, California

Louis D. Kosta, MD, San Diego, California

Alcoholic cirrhosis is a highly lethal disease, and bleeding from esophageal varices is one of its most lethal manifestations. Substantial evidence indicates that patients who survive an episode of varix hemorrhage have at least a 90 per cent chance of bleeding again, and of dying as a consequence, unless the portal hypertension is relieved. The fate of survivors of a bout of bleeding varices who qualified for portacaval shunting by accepted criteria but were de- liberately not subjected to operation is shown com- paring studies by Mikkelson [1] and Orloff. Both of the studies were prospective in conduct and involved patients with alcoholic cirrhosis. The study of Mik- kelsen [1] was restricted to patients classified as Child’s group A and some of the patients had bled more than once before entering the program. Of these 35 patients, 95 per cent had rebleeding and 83 per cent died because of rebleeding; five year mortality was 90 per cent. The study of Orloff was confined to patients who survived their first episode of varix bleeding, and all of the patients were followed up until death. Of Orloff’s 27 patients, 93 per cent had rebleeding and 74 per cent died because of rebleeding; five year mortality was 100 per cent (all patients were dead within 2 years). Thus, the results of the two studies were similar.

The portosystemic shunt has been the only de- finitive treatment devised for bleeding esophageal varices in patients with alcoholic cirrhosis. There is no effective alternative form of therapy. In such patients, esophageal varices rarely disappear sponta- neously or following medical treatment. Therefore, the decision not to perform a portosystemic shunt does not involve a choice between competing forms of effective treatment. Instead, the decision is based

From the Department of Surgery, School of Medicine, University of California, San Diego. This work was supported in part by US Public Health Service Grant 18AM12261.

Reprint requests should be addressed to Marshall J. Orloff, MD, Depart- ment of Surgery, University of California Medical Center, San Diego, 225 West Dickinson Street, San Diego, California 92103.

Presented at the Forty-Eighth Annual Meeting of the Pacific Coast Surgical Association, Palm Springs, California, February 20-23, 1977.

on the expectation that the patient will not survive a shunt operation for very long if at all and, therefore, cannot be helped substantially by any type of therapy, and has little hope of prolonged survival.

It might be argued that there is little to lose in performing a portosystemic shunt in all patients with alcoholic cirrhosis who bleed from esophageal varices. However, the potential weaknesses in such an argu- ment are that operating on everyone might involve an excessive and costly use of medical resources and might impose needless suffering on some patients who have no chance of survival. Therefore, continu- ous efforts have been made to identify criteria for selecting patients for whom the shunt will provide a better chance of survival than nonoperative management. Unfortunately, there is neither general agreement nor solid supporting data regarding such selection criteria, despite some thirty-two years of widespread experience with the portosystemic shunt.

In 1962, we initiated a prospective study of the emergency portacaval shunt in unselected, consec- utive patients with bleeding esophageal varices due to alcoholic cirrhosis. One of several objectives of this study was to identify solid criteria by which patients could be selected for or excluded from emergency portacaval shunt. By operating on a21 patients, re- gardless of their condition, it was hoped that criteria for selection would become apparent. An extensive diagnostic workup was completed within 7 hours of admission to the emergency department, operation was undertaken within 8 hours, and a program of life-long follow-up was conducted in our Portal Hy- pertension Clinic so that the current status of 97.3 per cent of the patients is known. Detailed data on every patient were continuously entered into a computer program and were analyzed statistically for an influence on survival. By June 1975,146 bleeding cirrhotic patients had undergone emergency portacaval shunt. This report presents an analysis of the preoperative factors that did or did not influence survival in this group of 146 patients.

146 The American Journal of Surgery

Emergency Portacaval Shunt

Material and Methods

Study and Treatment Plan

The study and treatment plan has been described in detail previously [Z-4], and it was uniformly applied to all patients with alcoholic cirrhosis and bleeding esophageal varices admitted to our hospitals between 1962 and 1975. Briefly, the diagnostic workup was completed within 7 hours of admission to the emergency department and consisted of a history, physical examination, a battery of blood tests, esophagogastroduodenoscopy, barium contrast upper gastrointestinal roentgenograms, hepatic vein catheterization for wedged pressure measurements, hepatic venography, selective arteriography involving the splenic, superior mesenteric, left gastric and hepatic arteries, systemic hemodynamic measurements of cardiac output, cardiac index and peripheral vascular resistance, radio- isotope liver and spleen scanning, determination of hepatic blood flow with technetium 99m (gsmTc)-sulfur colloid, chest roentgenogram and electrocardiogram.

Initial therapy, while the diagnostic workup was in progress, consisted of systemic intravenous vasopressin (Pituitrinm), blood transfusions of which at least 2,000 ml was fresh blood, gastric lavage, cathartics and enemas, neomycin by both nasogastric tube and enema, and intravenous fluids containing dextrose, vitamins, and po- tassium chloride. No patient was treated by esophageal balloon tamponade.

The emergency portacaval shunt operation was started between the seventh and eighth hours after initial contact in almost all of the patients and was performed through a right subcostal incision. Pressures in the portal vein and inferior vena cava were measured before and after construction of the portacaval anastomosis, and many patients had direct measurements of blood flow and blood oxygen content in the hepatic artery and portal vein. A wedge liver biopsy was obtained as a part of every operation. Side- to-side portacaval shunt was performed in 114 patients, end-to-side portacaval shunt in 29 patients, and another type of shunt in 3 patients.

Postoperatively, all of the patients were managed in an intensive care unit for at least one week. Cardiovascular, pulmonary, hepatic, renal, and hematologic functions and fluid and electrolyte balance were monitored continuously. Neomycin therapy, cathartics, and enemas were continued for three days. Metabolic alkalosis, delerium tremens, and the hyperdynamic cardiovascular state were treated ap- propriately. Oral feeding was usually started on the fourth postoperative day and consisted of a 4,000 calorie, 200 mg sodium, high carbohydrate, bland diet with a protein content that was increased at three day intervals from 20 gm to 80 gm per day if no signs of encephalopathy devel- oped.

After discharge from the hospital, the patients were observed regularly in our Portal Hypertension Clinic, at least monthly for the first year and every three months thereafter. In addition to the usual serial determinations of clinical status, liver function, renal function, and fluid and electrolyte balance, the patients were admitted to the

hospital each year for needle liver biopsy, gastrointestinal roentgenography, catheterization of the shunt and hepatic veins, splanchnic arteriography, radioisotopic measurements of liver blood flow, liver scanning, and determinations of cardiac output. Only four patients have been lost to follow-up, three of them during the second postoperative year. The current status of 97.3 per cent of the group of 146 patients is known.

Data Collection and Analysis

Beginning with the moment of admission to the emergency department and continuing through the life-long follow-up examinations, detailed data obtained on every patient from the history, physical examination, laboratory tests, roentgenographic studies and operative findings were recorded on standard forms and entered into a computer program that sorted the information as the study was in progress. A total of 182 categories of data on each patient, 74 of them related to the preoperative period, were collected and entered into the computer program. Many of the items of information were collected repetitively. The categories of preoperative data, individually and in various combinations, were analyzed for an effect on patient survival. Statistical significance was determined by the chi square method and Student t test, and a confidence level of 95 per cent or greater was considered statistically significant.

Results

Overall Results (Table I)

Of the 146 unselected patients with bleeding esophageal varices who underwent an emergency portacaval shunt, 78 survived the operation, an early survival rate of 53.4 per cent. Follow-up observations of the survivors have been conducted for periods ranging from 22 months to 14.5 years. The predicted age-adjusted ten year survival rate, calculated ac- cording to the actuarial or life table method, is 30 per cent of the original group of 146 patients and the twelve year survival rate is the same. The actual ten

TABLE I Long-Term Results oi Emergency Portacaval Shunt in 146 Cirrhotic Patients

Per Cent of Group

Operative Survival Predicted 10 Year Survival Actual 10 Year Survival (40 patients) Encephalopathy in Survivors Abstinence from Alcohol in Survivors Patency of Portacaval Shunt General Status of Survivors

Excellent or Good Fair Poor

Full-Time Employment or Housework

53 30 37 26 59 99

57 33 10 57

Volume 134, July 1977 147

Orloff, Duguay, and Kosta

year survival rate of the 40 patients who were operated on ten or more years ago is 37 per cent.

During the preoperative period, systemic intravenous administration of vasopressin controlled the varix bleeding temporarily in 95 per cent of the patients and allowed sufficient time to complete the diagnostic workup. Emergency portacaval shunt promptly and permanently stopped the varix hemorrhage in 97 per cent of the patients. The corrected free portal pressure (obtained by subtracting the pressure in the inferior vena cava from the pressure in the portal vein) averaged 266 mm of saline before and 23 mm of saline after construction of the portacaval anastomosis. The “skin-to-skin” operating time averaged 4.2 hours and was less than 5 hours in 87 per cent of the patients. The volume of blood transfusion required before and during operation averaged 5,154 ml. Liver biopsies showed cirrhosis of the alcoholic type in every patient.

Encephalopathy requiring dietary protein re- striction occurred at one time or another in 26 per cent of the survivors of the shunt operation. Patency of the portacaval shunt has been demonstrated in 99.3 per cent of the entire group of 146 patients by yearly angiography or autopsy. Of the survivors, 59 per cent have not consumed alcohol at any time during the follow-up period, and their survival rate is 84 per cent compared to a rate of 58 per cent for those who have resumed ingestion of alcohol. On the basis of clinical and laboratory examinations five years postoperatively, the general status of the survivors was excellent or good in 57 per cent, fair in 33 per cent, and poor in 10 per cent, all but one of whom resumed chronic alcoholism. Without regard to the factor of age, 57 per cent of the survivors are gainfully employed or doing full-time housework.

Preoperative Factors That Significantly Decreased Survival (Table ii)

Data related to 74 preoperative factors were obtained from the history, physical examination, laboratory tests, hemodynamic studies, and roentgenographic examinations. Only three of these factors had a statistically significant effect on survival, namely, the presence of ascites on admission, a serum glutamic oxalacetic transaminase @GOT) level of 100 units or greater, and a requirement for blood transfusion of 5,000 ml or more before and during operation. The survival rate of patients who had ascites on admission was 40 per cent; whereas of those who did not have ascites it was 68 per cent, a significant difference (p < 0.01). A past history of ascites in patients who did not have ascites on admission did not correlate with survival (78 per cent survival with positive history of ascites, 65 per cent survival with negative history of ascites).

Patients with an SGOT level of 100 units or greater had a 40 per cent survival rate, whereas those with an SGOT level below 100 units had a 64 per cent survival rate, a significant difference (p < 0.05). The elevated SGOT level usually reflected acute alcoholic liver injury superimposed on cirrhosis and correlated with the microscopic finding of acute alcoholic hepatitis in the operative liver biopsies. Patients with an SGOT level greater than 300 units had a survival rate of only 33 per cent.

Patients whose varix hemorrhage was of such magnitude as to require blood transfusions in a volume of 5,000 ml or more before and during operation had a 37 per cent survival rate, whereas patients who required less than 5,000 ml of blood transfusion had a 65 per cent survival rate. The difference in survival rates was significant (p < 0.01).

Although the presence of any of these three factors was associated with a significantly lower survival rate than that associated with their absence, it should be emphasized that approximately 40 per cent of patients survived in their presence. This survival rate is substantially higher than that obtained with medical therapy in our previous prospective studies of unselected patients [4,5]. Therefore, none of these factors constitute contraindications to emergency portacaval shunt.

Preoperative Factors That Did Not Significantly influence Survival

Many factors that have been alleged to be of im- portance in selecting patients for portacaval shunt had no statistically significant effect on survival. In fact, none of the 71 remaining preoperative factors that were analyzed had an influence on the response to emergency portacaval shunt. Table III shows the survival rates associated with several of these unin- fluential factors, Although the survival rates were lower in the presence of some of these factors than in

TABLE II Preoperative Factors That Significantly Decreased Survival of 146 Bleeding Cirrhotic Patients who Underwent Emergency Portacaval Shunt

Number of Per Cent Patients Survival P

Ascites on Admission Present Absent

SGOT Level on Admission 2 100 units < 100 units

Blood Transfusion Volume 15000 ml <5000 ml

77 40 <O.Ol 69 66

45 40 co.05 66 64

60 37 <O.Ol 66 65



their absence; the differences were not statistically significant.

Neither age nor sex had a significant effect on mortality. The survival rates of patients in their sixth and seventh decades of life were identical. The notion that a patient who has survived several bleeding episodes is a better risk than one who is bleeding for the first time was not substantiated in this study. It made no difference in regard to survival whether a patient had been drinking alcohol within 48 hours of the onset of bleeding or had not ingested alcohol for over a month. One third of the patients continued to drink alcohol after vomiting blood yet, surprisingly, did not reduce their chances of surviving thereby.

The presence of clinical jaundice, confirmed by measurements of the serum bilirubin concentration, did not affect the outcome. Nine patients had a serum bilirubin level greater than 10 mg/lOO ml and 43 per cent of them survived. The presence of encephalopathy on admission was associated with a higher mortality rate than the absence of this com- plication, but the increase was not statistically significant. A history of previous episodes of encephalopathy did not influence survival. The same was true of severe muscle wasting and a shrunken liver, both of which have been generally considered foreboding signs. Surprisingly, delerium tremens, either present at admission or in the past history, had no effect on survival.

The liver function tests, either individually or collectively, were of little help in predicting survival. There was no correlation between the survival rate and the results of any single liver function test, except the SGOT level mentioned previously. The liver index is a composite of the results of several liver function tests. Survival was decreased significantly only at the upper limit of hepatic functional abnor- mality, that is, a liver index of greater than 3.4, which reflects terminal dysfunction and was found in only 6.8 per cent of the patients. It is noteworthy that all such patients had ascites, jaundice, and severe muscle wasting. The presence of metabolic alkalosis did not affect the outcome.

The hemodynamic studies provided no information of predictive value regarding survival. The mean wedged hepatic vein pressure (corrected by subtracting the inferior vena cava pressure) was similar in survivors and nonsurvivors. The same was true of the portal vein pressure measured at operation. As has been noted previously, almost all of the patients had a hyperdynamic cardiovascular state with an increased cardiac output and cardiac index, a decreased systemic vascular resistance, and substantial arteriovenous admixture. However, there was no significant difference in the magnitude of the he-

Volume 134, July 1977

TABLE III Preoperative Factors That Did Not Significantly Influence Survival of 146 Bleeding Cirrhotic Patients Who Underwent Emergency Portacaval Shunt

Number of Per Cent Patients Survival

Historlcal Data (1) Age

22-49 years 50-69 years

(2) Sex Male Female

(3) Bleeding episode 1 22

(4) Abstinence from alcohol I2 days 3-30 days >30 days

Physical Findlngs (1) Clinical jaundice

Present Absent

(2) Encephalopathy Present Absent

(3) Muscle wasting Severe (3+ to 4+) Mild-moderate (0 to 2-I)

(4) Liver size Small Large

(5) Delerium tremens At admission or history Absent

Biochemical Data (1) Liver Index (0 to 4.0)

>3.4 3.0-3.4 2.0-2.9 <2.0

(2) BSP retention >30% in 45 minutes 130% in 45 minutes

(3) Serum albumin level <3.0 gm/lOO ml 23.0 gm/lOO ml

(4) Metabolic alkalosis Arterial blood pH 27.50 Arterial blood pH <7.50

Hemodynamic Data (mean) (1) Wedged hepatic vein pressure

(corrected, mm saline) (2) Cardiac output (Vmin) (3) Systemic vascular resistance

(dynes/se&cm*)

78 64 68 41

102 44

53 45

88 52 58 55

83 52 25 48 22 64

69 54 77 53

29 41 117 56

38 42 103 58

22 46 118 54

36 53 110 54

10 10’ 33 55 55 55 27 78

98 53 27 67

58 53

70 53

50 55

51 55

Nonsurvivors Survivors

329 312

8.76 7.88 200 174

l Only these comparisons were statistically significant. t Liver index was calculated by averaging the weights assigned

to various test results as follows:

0 1.0 2.0 3.0 4.0

Bilirubin (mg/lOO ml) <l.O <1.5 <3.0 <5.5 >5.5 Prothrombin (%) >80 61-80 41-60 21-40 <21 BSP retention (%) <4 <lO <20 <30 300r >


modynamic abnormalities between those who survived and those who died.

Combination of Ascites, Jaundice, Encephalopathy, and Severe Muscle Wasting

Numerous combinations of preoperative factors were analyzed for an effect on survival and none was found. The combination of ascites, jaundice, encephalopathy, and severe muscle wasting reflects the most advanced stage of alcoholic cirrhosis, and 14 patients had these severe manifestations of hepatic dysfunction on admission. In addition, all of these patients had a liver index greater than 3.0, and eight of them had an SGOT level greater than 100 units. The survival rate of 36 per cent of these patients after emergency portacaval shunt was not significantly different from the survival rate of 40 per cent obtained in 77 patients who had ascites alone. However, all 14 of these end-stage cirrhotic patients were dead within one year of operation whereas 32 per cent of the 77 with ascites alone survived one year (p < 0.01). It is apparent that there is nothing to be gained from operating on the end-stage cirrhotic patient. Our analysis indicates that the combined presence of ascites, jaundice, encephalopathy, and severe muscle wasting is the only clear contraindication to emergency portacaval shunt.

Comments

The treatment of bleeding esophageal varices in patients with alcoholic cirrhosis has many similarities to the treatment of cancer. As in most patients with cancer, surgical therapy (portosystemic shunting) is the only effective treatment available for varix hemorrhage. At the same time, the shunt operation is imperfect, as are most operations for cancer, and surgical therapy of both of these morbid conditions is followed by some untoward sequelae and by death of many patients from the underlying disease despite a technically successful operation. Nevertheless, the long-term survival rate resulting from portosystemic shunt compares favorably with the survival rates obtained with the surgical treatment of most po- tentially curable visceral cancers. The decision not to perform a portosystemic shunt is similar to that made in patients with inoperable cancer, since it reflects the conviction that the patient cannot be helped substantially by any form of treatment and that there is little hope of long-term survival. Non- operative management of bleeding varices associated with alcoholic cirrhosis and of most cancers results in similarly dismal five year survival rates.

During the past quarter century a number of at- tempts have been made to identify criteria for the selection of patients for elective therapeutic portosystemic shunt. Criteria based on the results of liver function tests [6], clinical examinations, hemodynamic studies [ 7,8], needle liver biopsies [1,9] and various combinations of these investigations [lO,ll] have been proposed. In general, these proposals have had as their objectives a reduction in operative mortality rate and an increase in long-term survival. None of these proposals have established a decisive basis for withholding operative treatment from a cirrhotic patient who has bled from esophageal varices, and none have received widespread adop- tion.

The most widely discussed selection criteria are those described by Child [IO] who has classified patients into good risk (group A), moderate risk (group B), and poor risk (group C) categories on the basis of a composite of the levels of serum bilirubin and albumin, the presence of ascites and neurologic disor- der (encephalopathy), and the state of nutrition. Not surprisingly, many workers have found a correlation between these risk categories and survival. However, the Child classification has been used largely for retrospective analyses of results of surgical therapy rather than as a basis for deciding which patients should or should not be subjected to a portacaval shunt. The critical question that has not been an- swered in regard to each category of the Child classification concerns whether patients have a higher or lower survival rate after portosystemic shunt than after nonoperative management. The crucial determination is not the absolute survival rate but the comparative survival rates between shunt and no shunt in comparable patients.

Surgical treatment of most diseases is aimed at Our statistical analysis of 74 preoperative factors achieving a low absolute mortality rate. However, the in 146 unselected patients with alcoholic cirrhosis

absolute mortality rate has little meaning unless it is viewed in the context of the natural history of the disease. Particularly in highly lethal conditions such as bleeding esophageal varices, the evaluation of surgical treatment must be based on a determination of whether or not it provides a higher survival rate and greater qualitative benefits than do nonsurgical therapy or no treatment at all. In this regard, emergency portacaval shunt must be considered a very effective form of treatment. Our long-term prospective studies of emergency shunt and of medical therapy (followed by elective shunt in survivors) in unselected patients with bleeding varices due to alcoholic cirrhosis indicate that the duration and quality of life are substantially greater after the emergency operat,ion [2-51.



and bleeding esophageal varices who underwent

emergency portacaval shunting revealed only three

factors that significantly decreased survival. These were the presence of ascites on admission, an SGOT

level of IOU units or more, and a requirement for blood transfusion amounting to 5,000 ml or more.

However, these three factors clearly do not constitute contraindications to operation, since their presence was associated with a survival rate of approximately 40 per cent, which is considerably higher than that

observed in our earlier studies of nonoperative treatment. None of the other factors identified by the

history, physical examination, laboratory tests, roentgenographic studies, and hemodynamic mea-

surements had a statistically significant influence on

survival. The only clear contraindication to emer-

gency portacaval shunt identified by our analysis was

the cotnbination of ascites, jaundice, encephalopathy. and severe muscle wasting. Although 36 per cent of the 14 patients with this constellation of findings survived the operation, all of them died within one year.

The results of this study are applicable with cer- tainty only to patients with alcoholic cirrhosis and varix hemorrhage who are candidates for emergency

portacaval shunt. However, it is likely that they are also applicable to the small segment of the bleeding

cirrhotic population that has recovered from an ep-

isode of varix hemorrhage and is being considered for

elective therapeutic portacaval shunt.

Summary

A compmer program analysis of the effect on survival of 74 preoperative factors was performed as

part of a prospective study of the emergency portacaval shunt in 146 unselected patients with bleeding

esophageal varices due to alcoholic cirrhosis. Only

ascites, a serum glutamic oxalacetic transaminase

level of 100 units or more, and a requirement for 5,000 ml or more of blood transfusion were associated with a statistically significant decrease in survival. How- ever, none of these factors are contraindications to operation because their presence permits a survival rate of 37 to 40 per cent. The only contraindication to emergency portacaval shunt is the combined

presence of ascites, jaundice, encephalopathy, and severe muscle wasting, a constellation that was in- compatible with survival beyond one year.

References

1. Mikkelsen WP: Therapeutic portacaval shunt. Prel:minary data on controlled trial and morbid effects of acute hyaline ne- crosis. Arch Surg 108: 303, 1974.

2. Orloff MJ: Emergency portacaval shunt: a comparative study of shunt, varix ligation and nonsurgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Ann Surg 166: 456, 1967.

3. Orloff MJ, Chandler JG, Charters AC III, Condon JK, Grambort DE, Modafferi TR, Levin SE: Emergency portacaval shunt treatment for bleeding esophageal varices: prospective study in unselected patients with alcoholic cirrhosis. Arch,Surg 108: 293, 1974.

4. Orloff MJ, Charters AC Ill, Chandler JG. Condon JK, Grambort DE, Modafferi TR, Levin SE, Brown NB, Sviokla SC, Knox ffi: Portacaval shunt as emergency procedure in unselected patients with alcoholic cirrhosis. Surg Gynecol O&ret 141: 59, 1975.

5. Orloff MJ: A comparative study of emergency transesophageal ligation and nonsurgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Surgery 52: 103, 1962.

6. Linton RR: Selection of patients for portacaval shunts, with summary of 61 cases. Ann Surg 134: 433, 1951.

7. Warren WD, Restrepo JE, Respess JC, Muller WH Jr: The im- portance of hemodynamic studies in management of portal hypertension. Ann Surg 158: 387, 1963.

8. Siegel JH, Goldwyn RM, Farrell EJ, Gallin P, Friedman HP: Hy- perdynamic states and the physiologic determinants of survival: in patients with cirrhosis and portal hypertension. Arch Surg 108: 282, 1974.

9. Mikkelsen WP, Kern WH: The influence of acute hyaline ne- crosis on survival after emergency and elective portacaval shunt, D 233. Portal Hvoertension (Child CG Ill, ed). Phila- delphia, WB Saunders; ‘1974.

10. Child CG Ill, Turcotte JG: Surgery and portal hypertension, p 49. The Liver and Portal Hypertension (Child CG Ill, ed). Philadelphia, WB Saunders, 1964.

11. Wantz GE, Payne MA: Experience with portacaval shunt for portal hypertension. N EnglJ Med 265: 721, 1961.

Discussion

F. William Blaisdell (San Francisco, CA): I was particularly surprised by the lack of correlation with many aspects of liver function, such as jaundice, which we have considered absolute contraindications to operation in the past. Even the far-advanced cirrhotics with jaundice, ascites, and muscle wasting survived operation in reasonable numbers in this excellent series. A 40 per cent survival rate is excellent. I would wonder whether this group of cases does not inadvertently contain some preselection. Yet it appeared to me from the tables that it represented a cross section of the average type of cirrhotic we see in municipal county hospitals. One of the few defects in the paper is that the cases were not broken down by Child’s classification or some other standard classification so that this particular series of cases could easily be compared with others. If these should represent a select group of cirrhotics, then of course, results would not be as remarkable.

The follow-up was superb. I noticed only two patients were lost to follow-up. This is a particularly difficult group to follow, as Doctor Cohn and I noted when we attempted to follow some sixty-six cirrhotics who survived gastrointestinal hemorrhage. We were able to locate only forty of these, despite the help of the coroner’s office and the State Department of Public Health. Any series that can maintain a 97 per cent follow-up on alcoholics is especially remarkable.

Volume 134, July 1977 151


The most impressive aspect of this paper, and one about which another paper should be written, is how you got fifty-nine alcoholics to stop drinking. I would like to ask Doctor Orloff what his secret is, because no one-and I mean no one-has ever approached that type of statistic before, and that is far more remarkable than operating on 140 patients.

I note that one of the major risk factors that resulted in higher mortality was blood loss greater than 5,090 ml. I note the Sengstaken tube is not used, yet I would have thought it to have been the ideal instrument to stop the hemorrhage immediately when the cirrhotic entered the emergency room and was being prepared for operation. I wonder why you apparently have a bias against balloon tubes, and whether if you had used such a tube you might not have controlled the preoperative hemorrhage a little more effectively. While surgical Pituitrin is reasonably effective, it is a more indirect way of controlling hemorrhage. Cer- tainly you do not stop hemorrhage using this method as quickly as with balloon tamponade.

I noted that the side-to-side shunt was used by prefer- ence; yet, just the few statistics you gave, though not significant in terms of numbers, suggested that the end-to- side portacaval shunt was associated with better survival. When you are dealing with a 47 per cent mortality, it seems to me the appropriate thing to do would be to use the simpler operation.

At the present time we are using mesocaval shunting as the standard operation for massive gastrointestinal hemorrhage, and in our experience at San Francisco General Hospital, this has been associated with half the mortality of conventional end-to-side portacaval shunting.

I have learned a lot from this report, most especially that you can operate on acutely bleeding cirrhotics successfully. If you are going to operate on them, the point is they should be taken directly from the emergency room to the operating room. In our experience and in our environment, the patients who fail the initial course of medical management constitute an extremely high risk group of patients.

Marshall J. Orloff (closing): The answer to the first question that Doctor Blaisdell raised is that ours is not a selected group. On admission, 53 per cent had ascites, of whom 47 per cent had jaundice and 20 per cent presented with encephalopathy. Ninety-two per cent were in Child’s groups B and C. It was a rare patient who was in group A. Therefore, it was pretty much a cross section of patients who would come to any general hospital.

The question about how to induce abstinence in patients is really one of the most critical questions we face, but one which few surgeons consider in dealing with this disease.

We have a very deliberate follow-up program. Every patient is seen monthly for the first year and then every three months for life. All of the patients are readmitted to

the hospital for a two day period every year for life. If a patient misses an appointment, a secretary calls the patient, and we have even gone so far as to go out to the home to find the patient.

I believe we have the highest abstinence rate of any alcoholism treatment program in the world today, not because we know something that nobody else knows, but simply because we are very tenacious about following the patients and trying to rehabilitate them. It is quite clear, I think, that a substantial number of alcoholic patients can be rehabilitated and returned.to useful living. I think this feature of our program makes more difference than any other one; yet I think there are few surgeons or physicians who have been willing to engage in such a program.

Regarding the influence of blood loss on survival, our statistics showed that Pituitrin controlled the bleeding once the patient entered the emergency room in 95 per cent of the cases, so that heavy blood loss was usually blood loss prior to admission and included patients who came in in shock, having vomited a large quantity of blood, and required substantial blood replacement to get them back to a stable point. In fact, we really have had very little prob- lem with continued bleeding once the patients have received Pituitrin, provided operation is performed within 8 hours. The reason why we prefer Pituitrin to balloon tamponade is not just because it works as effectively, but also because balloon tamponade is associated with many more complications than is intravenous Pituitrin.

Finally, regarding the question about the side-to-side versus end-to-side shunt, I must emphasize at the start that the two operations are comparable in every respect that we have investigated. We have performed nine studies on the side-to-side versus the end-to-side shunt in animals and humans, including studies of survival, liver function, am- monia tolerance, and encephalopathy, and have been un- able to detect any difference between the two. Therefore, we must conclude that aside from a theoretical bias in favor of the side-to-side shunt, I cannot say to anyone that he should use side-to-side rather than end-to-side shunting. We continue to use the side-to-side shunt because we be- came so familiar with the operation that we really do it as rapidly and as well as the end-to-side operation.

As to mesocaval H graft shunting, which hemodynami- tally is identical to the side-to-side shunt, the attractive- ness of that operation is that it is relatively simple to perform. The worldwide thrombosis rate of H grafts as of one month ago was 32 per cent. I have operated on seven patients with thrombosed mesocaval H grafts, and I am very skeptical about the long-term durability of that operation, even though it is a simple and rapid way to go. Perhaps I will be proved wrong when experience with a large number of them accumulates, but at this point my conclusion is to let others do the testing and to evaluate the results before considering a change to the mesocaval H graft.


criteria for selection of patients for emergency portacaval shunt

Documents