Small-diameter H-graft portacaval shunt for variceal hemorrhage: experience at King Chulalongkorn Memorial Hospital.
BACKGROUND
Portosystemic shunts remain to be a good means for preventing recurrent variceal hemorrhage in a certain number of patients who fail to respond to other therapeutic modalities. Total portal decompression is no longer recommended owing to the high incidence of postoperative encephalopathy and liver failure. Distal splenorenal shunt is too technically demanding. A small-diameter H-graft portacaval shunt (SDHGPCS) which partially decompresses the portal system and was popularized by Sarfeh et al and associates in 1983 seems to be a good alternative for its simplicity to construct and impressive results.


METHODS
SDHGPCS with an 8 mm. PTFE graft has been performed to prevent recurrent variceal hemorrhage in cirrhotic patients who failed to respond to long term pharmacotherapy and endoscopic therapy during the last 3 years at our institution. Data analysis included: causes of cirrhosis, patients' Child-Pugh classification, operative time, operative blood transfusion, and results of treatment.


RESULTS
Nine cirrhotic patients were entered into the present study. Three patients (33.3%) were in Child-Pugh class A and 6 (66.7%) were in Child-Pugh class B. Three patients had ringed PTFE grafts and 6 had non-ringed PTFE grafts. The operative time ranged from 225 to 420 minutes (mean 303, median 285 minutes). There was no perioperative (30 days) death. One postoperative intraabdominal hemorrhage was successfully treated by relaparotomy. Two patients were lost to follow up at 3 and 10 months after the operations. Four patients are alive and well at 12, 24, 30 and 35 months after the operations. One patient developed hepatic encephalopathy at 35 months postoperation which was thought to be secondary from progression of the hepatic parenchymal disease. One patient developed recurrent variceal hemorrhage at 30 months postoperation from portal vein thrombosis and was successfully treated by endoscopic variceal sclerotherapy (EVS). One patient died from carcinoma of the larynx 3 months after SDHGPCS and 2 died from end stage liver disease at 30 and 45 months after SDHGPCS.


CONCLUSIONS
SDHGPCS is an effective mean to prevent recurrent variceal hemorrhage. The procedure is simple and practical to perform in hospitals with low volume of portosystemic shunt operations. The authors recommended SDHGPCS as an alternative in prevention of recurrent variceal hemorrhage in cirrhotic patients who fail to respond to other therapeutic modalities.
Sriussadaporn
Suvit
S
Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. Suvit.s@chula.ac.th
Pak-art
Rattaplee
R
Sriussadaporn
Sukanya
S
D000328:Adult; D000368:Aged; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications; D008297:Male; D008875:Middle Aged; D011167:Portacaval Shunt, Surgical; D013785:Thailand