Post-shunt resource consumption favors small-diameter prosthetic H-graft portacaval shunt over TIPS for patients with poor hepatic reserve.
OBJECTIVE
To define the role of surgical shunting for patients with poor hepatic reserve (Child's class C) in the era of TIPS.


BACKGROUND
Most physicians prefer TIPS to surgical shunting for patients with poor hepatic reserve because of anticipated poor long-term survival.


METHODS
Sixty-two patients of Child's class C with bleeding varices not amenable to endoscopic sclerotherapy or banding were prospectively randomized to undergo TIPS or 8-mm prosthetic H-graft portacaval shunt (HGPCS) from 1993 to 1999. Resource consumption and survival after shunting were determined.


RESULTS
Twenty-nine patients underwent TIPS and 33 underwent HGPCS. After HGPCS, survival at 3 years was favorable but not statistically superior. TIPS was more often associated with shunt stenoses/occlusions, recurrent hemorrhage, shunt revisions, and shunt failure. Long-term follow-up documented that after HGPCS, patients required fewer hospital and ICU days and fewer units of RBCs transfused. After HGPCS, cost of care was less, as was the median cost of care per day of survival.


CONCLUSIONS
For Child's class C patients undergoing HGPCS or TIPS, long-term survival is similar, though favoring HGPCS. Similarly, measures of resource consumption and cost of care following hospital discharge favor HGPCS. HGPCS should be preferentially applied for acceptable patients without access to convenient capable post-shunt care or without definitive plans for imminent transplantation.
Rosemurgy
Alexander S
AS
Department of Surgery, University of South Florida, Tampa General Hospital, 1 Davis Boulevard, Box 1289, Room F-145, Tampa, FL 33601, USA. arosemur@hsc.usf.edu
Zervos
Emmanuel E
EE
Bloomston
Mark
M
Durkin
Alan J
AJ
Clark
Whalen C
WC
Goff
Stephanie
S
D000328:Adult; D000368:Aged; D019917:Blood Vessel Prosthesis Implantation; D019299:Decompression, Surgical; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data; D004932:Esophageal and Gastric Varices / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011167:Portacaval Shunt, Surgical; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D011184:Postoperative Period; D011446:Prospective Studies