Acta med. scand. Vol. 199, pp. 167-173, 1976
Survival after Portacaval Shunt: Who and how? R. Amman, R. Olsson and T. Schersten From the Department of Internal Medicine 11 and Surgery, Sahlgrenska sjukhuset, University of Goteborg, Goteborg, Sweden
ABSTRACT. In a series of 74 portacaval-shunted patients no statistically significant differences in long-term survival or in incidence of postoperative encephalopathy have been observed between electively and emergency operated patients, between patients with slight and moderate impairment of liver function (groups A and B according to Child) or between patients with alcoholic and non-alcoholic cirrhosis. Patients older than 60 years had a higher risk of postoperative encephalopathy and a borderline significantly lower survival rate six months after the operation. Among the patients with more than six months’ survival, about 50 % returned to work. The value of portacaval (PC) shunt has often been questioned even though there is no doubt that it is effective in preventing bleeding from oesophageal varices. Its clinical value was questioned when it was shown that prophylactic PC shunt decreases rather than increases the survival rate (4,5 , 12, 19). The explanation of this disappointing finding was that the shunted patients showed an increased rate of hepatocellular failure. Since prophylactic shunting means operating on a large number of patients who would never have bled from their varices if left unoperated (16), there still remained the possibility of a beneficial effect of therapeutic shunt. Two controlled clinical trials have been reported in recent years, both showed a trend towards enhanced survival of the operated patients (13, 20). Conn (3) combined the data from these studies and found that the difference came “within a hairsbreadth of achieving statistical significance at the 5 % level”. Hodever, many questions still remain unanswered. The two studies above were almost completely restricted to patients with alcoholic cirrhosis, and thus the value of PC shunt in other forms of cirrhosis is still not clear. One may also ask
to what extent the American experiences can be applied to a Scandinavian population. No controlled Scandinavian study is available and will probably not be performed due to the great difficulties involved. Uncontrolled, published experiences from Scandinavia are also rare. As far as we know, none has appeared since 1957 when Ekman published his results in 29 PC-shunted cirrhotic patients (7). Possible advances in the postoperative management of the patient in recent years, which may have changed the results of PC shunt, was a further reason for the present investigation. Other purposes were to study whether there are differences in outcome that can be related to the preoperative degree of liver insufficiency and whether the postoperative long-term survival in alcoholic cirrhosis differs from that in non-alcoholic cirrhosis. Finally, we wanted to know the quality of life of the operated patients, since conservative treatment is often advocated after variceal bleeding because of fear of encephalopathy or expectance of postoperatively continued alcohol abuse.
MATERIAL The material comprised 74 patients (65 males) who were operated o n with PC shunt during 1961-74 in the Sahlgren’s Hospital. Thirty-two shunts were performed as emergency operations (i.e. the bleeding was not controlled by conservative measures such as vasopressin or the Sengstaken tube) and 42 as elective operations. The distribution of emergency and elective operations among the patients, classified according to Child (2), and clinical and laboratory data are given in Table I. The etiology of the cirrhosis was considered to be alcoholic abuse in 48 patients. Three patients had known chronic active hepatitis and two a history of acute hepatitis. Two patients had hemochromatosis, one had porphyria cutanea tarda and one probably had a secAcra med. scand. 199
168
R . Arnman et al.
Table I. Clinical and laboratory classification of emergency or electively operated patients with cirrhosis in terms of hepatic functional reserve Liver function groups
Emergency operations (n) Elective operations (n) Serum bilirubin (mg/100 ml) Serum albumin (gll00 ml) Ascites Neurological disorder
A
B
C
22
18
2
16
13
3
3.5 None
3.0-3.5 Easily controlled
None
Minimal
€3.0 Poorly controlled Advanced, “coma”
ondary biliary cirrhosis. In 17 patients the etiology was unknown. In 1 1 of the 32 emergency operations the PC shunt was performed at the first bleeding episode. Nine of the 42 elective operations were performed after the first bleeding.
RESULTS The postoperative mortality during 30 days after the PC shunt was 19% in the elective group and 27% in the emergency group. In group A, the mortality was 16%, in group B 23% and in group C 75% (3/4 patients). The causes of the postoperative deaths in the group A patients were circulatory insufficiency, thrombosed shunt with rebleeding, anemic liver infarction, ileus and, in two patients, peritonitis.
I OD
When calculating the long-term survival, the only surviving group C patient, who died 10 months after the operation, was omitted. As shown in Fig. I , the difference in survival between electively and emergency operated patients was small and not statistically significant. Similarly, when comparing patients in groups A and B (combined elective and emergency operations) no statistically significant differences between the groups were detected (Fig. 2). The survival was almost identical in patients with alcoholic and non-alcoholic cirrhosis (Fig. 3). No statistically significant differences in survival were detected between patients older than 60 years (mean age 64.7 and 65.5 years for the elective and emergency groups) and patients younger than 60 years (mean age 49.0 and 49.2 years, respectively) at the time of the operation, neither when considering elective and emergency operations separately nor when the two materials were considered together (Fig. 4). However, at six months the difference in survival rate was of borderline significance. In the two controlled therapeutic PC shunt studies cited above there was a trend favoring operation in the patients with a single variceal bleeding. However, in our material the patients with only one major episode of ruptured varices before operation did not survive longer than those with more than one bleeding (Fig. 5). The causes of death are given in Table 11. Twenty-three per cent of the deaths were not related to the liver. Almost 10% of the operated patients died of renewed variceal bleeding.
R
Fig. I. Survival in group A and B patients, electively (EL, -) or emergency (EM, , . .)operated. The figures at the bottom of the diagram indicate number of patients “at risk”. NUMBER
OF PATIENTS
4y3y
‘tt-f
A d a med. w a n d . 199
29 28
I 3y
26
2
3
4
5 Years
Survival afrer portacaval shunt
169
Fig. 2. Survival in elective-
ly and emergency operated patients in liver function groups A (-) or B (. . .) at operation. 2
1
7
38 36
NUMBER A
O F / / / ?
PAllENlS B
31 30
28
22
3
4
,? 20
7
Portasysternic encephalopathy (PSE) appeared postoperatively in 19 of the 60 patients (30%) who had no PSE prior to the operation, and in 11 of the 14 (80%) who had PSE preoperatively (Table III), a difference which is statistically highly significant. In 9 of the patients the PSE was a terminal event of short duration (Fig. 6), in 2 patients it was restricted to a short period postoperatively, and in 2 patients a single short period of PSE occurred during a 44-year survival. Thus, several or prolonged episodes of PSE occurred in 17 patients (23%), 13 of whom had had no PSE before the operation. Seven of these 13 patients (54%) were classified as
5 Yeors
19
19
belonging to group A preoperatively. There was no difference in the overall incidence of postoperative PSE between patients in group A (29%) and group B (30%) who had no PSE preoperatively. The total incidence of postoperative PSE was significantly higher in patients above 60 years of age (63 %) at the operation than in younger patients (27%). In those patients who had no PSE preoperatively the agerelated difference (48 vs. 23 %) was close to statistical significance. No significant difference in incidence of postoperative PSE was detected between patients with alcoholic and non-alcoholic cirrhosis. Thirteen of
Fig. 3. Survival in patients
with cirrhosis probably caused by ethanol (E, -) compared to cirrhosis probably not caused by ethanol (N-E, . . .>.
1. NUMBER Of PAllENlS
I
E
44
43
4-Ed~43
'z3
2
3
4
32
28
27 4 0
43
4 2
5 Yeors
25 49
Actu med. scund. 199
170
R . Arnrnan et al.
Fig.4. Survival in patients
aged >60 (-) at the operation compared to patients aged 60 25 2 3
the alcoholic and six of the non-alcoholic patients who survived more than 6 months after the operation had had an occupation before the operation. Seven of the alcoholic and three of the nonalcoholic patients were able to return fo work postoperatively. An attempt was made to evaluate the effect of abstinence from alcohol on survival in those patients with alcoholic cirrhosis who survived the first postoperative month. Presumably reliable information was obtained in 29 patients. Thirteen of these were probably abstinent postoperatively. No difference at all existed in survival during the first 2 years, thereafter the groups were too small to
permit comparisons. In this small material, no differences were detected in the incidence of abstinence between group A and group B patients.
DISCUSSION Many difficulties arise in the handling of a patient with bleeding oesophageal varices. The greatest is probably the decision to recommend surgery or not. Acute surgical intervention with an emergency PC shunt has generally been reported to have a much higher per- and postoperative mortality (about 50%) than an elective operation (6, 8, 17, 22). The
Fig. 5. Survival in patients with only one major bleeding episode (1 BL, -) before the PC shunt compared to patients with more than one bleeding(>Z BL, . .).
.
NUMBER PA TlEN 1.5
Acta med. scnnd. 199
I
2
3 18
60 919
Survival after Portacaval Shunt: Who and how? R. Amman, R. Olsson and T. Schersten From the Department of Internal Medicine 11 and Surgery, Sahlgrenska sjukhuset, University of Goteborg, Goteborg, Sweden
ABSTRACT. In a series of 74 portacaval-shunted patients no statistically significant differences in long-term survival or in incidence of postoperative encephalopathy have been observed between electively and emergency operated patients, between patients with slight and moderate impairment of liver function (groups A and B according to Child) or between patients with alcoholic and non-alcoholic cirrhosis. Patients older than 60 years had a higher risk of postoperative encephalopathy and a borderline significantly lower survival rate six months after the operation. Among the patients with more than six months’ survival, about 50 % returned to work. The value of portacaval (PC) shunt has often been questioned even though there is no doubt that it is effective in preventing bleeding from oesophageal varices. Its clinical value was questioned when it was shown that prophylactic PC shunt decreases rather than increases the survival rate (4,5 , 12, 19). The explanation of this disappointing finding was that the shunted patients showed an increased rate of hepatocellular failure. Since prophylactic shunting means operating on a large number of patients who would never have bled from their varices if left unoperated (16), there still remained the possibility of a beneficial effect of therapeutic shunt. Two controlled clinical trials have been reported in recent years, both showed a trend towards enhanced survival of the operated patients (13, 20). Conn (3) combined the data from these studies and found that the difference came “within a hairsbreadth of achieving statistical significance at the 5 % level”. Hodever, many questions still remain unanswered. The two studies above were almost completely restricted to patients with alcoholic cirrhosis, and thus the value of PC shunt in other forms of cirrhosis is still not clear. One may also ask
to what extent the American experiences can be applied to a Scandinavian population. No controlled Scandinavian study is available and will probably not be performed due to the great difficulties involved. Uncontrolled, published experiences from Scandinavia are also rare. As far as we know, none has appeared since 1957 when Ekman published his results in 29 PC-shunted cirrhotic patients (7). Possible advances in the postoperative management of the patient in recent years, which may have changed the results of PC shunt, was a further reason for the present investigation. Other purposes were to study whether there are differences in outcome that can be related to the preoperative degree of liver insufficiency and whether the postoperative long-term survival in alcoholic cirrhosis differs from that in non-alcoholic cirrhosis. Finally, we wanted to know the quality of life of the operated patients, since conservative treatment is often advocated after variceal bleeding because of fear of encephalopathy or expectance of postoperatively continued alcohol abuse.
MATERIAL The material comprised 74 patients (65 males) who were operated o n with PC shunt during 1961-74 in the Sahlgren’s Hospital. Thirty-two shunts were performed as emergency operations (i.e. the bleeding was not controlled by conservative measures such as vasopressin or the Sengstaken tube) and 42 as elective operations. The distribution of emergency and elective operations among the patients, classified according to Child (2), and clinical and laboratory data are given in Table I. The etiology of the cirrhosis was considered to be alcoholic abuse in 48 patients. Three patients had known chronic active hepatitis and two a history of acute hepatitis. Two patients had hemochromatosis, one had porphyria cutanea tarda and one probably had a secAcra med. scand. 199
168
R . Arnman et al.
Table I. Clinical and laboratory classification of emergency or electively operated patients with cirrhosis in terms of hepatic functional reserve Liver function groups
Emergency operations (n) Elective operations (n) Serum bilirubin (mg/100 ml) Serum albumin (gll00 ml) Ascites Neurological disorder
A
B
C
22
18
2
16
13
3
3.5 None
3.0-3.5 Easily controlled
None
Minimal
€3.0 Poorly controlled Advanced, “coma”
ondary biliary cirrhosis. In 17 patients the etiology was unknown. In 1 1 of the 32 emergency operations the PC shunt was performed at the first bleeding episode. Nine of the 42 elective operations were performed after the first bleeding.
RESULTS The postoperative mortality during 30 days after the PC shunt was 19% in the elective group and 27% in the emergency group. In group A, the mortality was 16%, in group B 23% and in group C 75% (3/4 patients). The causes of the postoperative deaths in the group A patients were circulatory insufficiency, thrombosed shunt with rebleeding, anemic liver infarction, ileus and, in two patients, peritonitis.
I OD
When calculating the long-term survival, the only surviving group C patient, who died 10 months after the operation, was omitted. As shown in Fig. I , the difference in survival between electively and emergency operated patients was small and not statistically significant. Similarly, when comparing patients in groups A and B (combined elective and emergency operations) no statistically significant differences between the groups were detected (Fig. 2). The survival was almost identical in patients with alcoholic and non-alcoholic cirrhosis (Fig. 3). No statistically significant differences in survival were detected between patients older than 60 years (mean age 64.7 and 65.5 years for the elective and emergency groups) and patients younger than 60 years (mean age 49.0 and 49.2 years, respectively) at the time of the operation, neither when considering elective and emergency operations separately nor when the two materials were considered together (Fig. 4). However, at six months the difference in survival rate was of borderline significance. In the two controlled therapeutic PC shunt studies cited above there was a trend favoring operation in the patients with a single variceal bleeding. However, in our material the patients with only one major episode of ruptured varices before operation did not survive longer than those with more than one bleeding (Fig. 5). The causes of death are given in Table 11. Twenty-three per cent of the deaths were not related to the liver. Almost 10% of the operated patients died of renewed variceal bleeding.
R
Fig. I. Survival in group A and B patients, electively (EL, -) or emergency (EM, , . .)operated. The figures at the bottom of the diagram indicate number of patients “at risk”. NUMBER
OF PATIENTS
4y3y
‘tt-f
A d a med. w a n d . 199
29 28
I 3y
26
2
3
4
5 Years
Survival afrer portacaval shunt
169
Fig. 2. Survival in elective-
ly and emergency operated patients in liver function groups A (-) or B (. . .) at operation. 2
1
7
38 36
NUMBER A
O F / / / ?
PAllENlS B
31 30
28
22
3
4
,? 20
7
Portasysternic encephalopathy (PSE) appeared postoperatively in 19 of the 60 patients (30%) who had no PSE prior to the operation, and in 11 of the 14 (80%) who had PSE preoperatively (Table III), a difference which is statistically highly significant. In 9 of the patients the PSE was a terminal event of short duration (Fig. 6), in 2 patients it was restricted to a short period postoperatively, and in 2 patients a single short period of PSE occurred during a 44-year survival. Thus, several or prolonged episodes of PSE occurred in 17 patients (23%), 13 of whom had had no PSE before the operation. Seven of these 13 patients (54%) were classified as
5 Yeors
19
19
belonging to group A preoperatively. There was no difference in the overall incidence of postoperative PSE between patients in group A (29%) and group B (30%) who had no PSE preoperatively. The total incidence of postoperative PSE was significantly higher in patients above 60 years of age (63 %) at the operation than in younger patients (27%). In those patients who had no PSE preoperatively the agerelated difference (48 vs. 23 %) was close to statistical significance. No significant difference in incidence of postoperative PSE was detected between patients with alcoholic and non-alcoholic cirrhosis. Thirteen of
Fig. 3. Survival in patients
with cirrhosis probably caused by ethanol (E, -) compared to cirrhosis probably not caused by ethanol (N-E, . . .>.
1. NUMBER Of PAllENlS
I
E
44
43
4-Ed~43
'z3
2
3
4
32
28
27 4 0
43
4 2
5 Yeors
25 49
Actu med. scund. 199
170
R . Arnrnan et al.
Fig.4. Survival in patients
aged >60 (-) at the operation compared to patients aged 60 25 2 3
the alcoholic and six of the non-alcoholic patients who survived more than 6 months after the operation had had an occupation before the operation. Seven of the alcoholic and three of the nonalcoholic patients were able to return fo work postoperatively. An attempt was made to evaluate the effect of abstinence from alcohol on survival in those patients with alcoholic cirrhosis who survived the first postoperative month. Presumably reliable information was obtained in 29 patients. Thirteen of these were probably abstinent postoperatively. No difference at all existed in survival during the first 2 years, thereafter the groups were too small to
permit comparisons. In this small material, no differences were detected in the incidence of abstinence between group A and group B patients.
DISCUSSION Many difficulties arise in the handling of a patient with bleeding oesophageal varices. The greatest is probably the decision to recommend surgery or not. Acute surgical intervention with an emergency PC shunt has generally been reported to have a much higher per- and postoperative mortality (about 50%) than an elective operation (6, 8, 17, 22). The
Fig. 5. Survival in patients with only one major bleeding episode (1 BL, -) before the PC shunt compared to patients with more than one bleeding(>Z BL, . .).
.
NUMBER PA TlEN 1.5
Acta med. scnnd. 199
I
2
3 18
60 919
