Small-diameter portacaval H-graft shunt: A paradigm shift back to surgical shunting in the management of variceal bleeding in patients with preserved liver function

Small-diameter portacaval H-graft (SDPHG) shunts are partial portosystemic shunts that control variceal bleeding while preserving nutrient blood flow to the liver, minimizing postoperative encephalopathy and liver failure. Since July 1, 1997, we placed SDPHG shunts in 18 patients (age, 52.1 ± 2.6 years; range, 35 to 72 years) with cirrhosis (Child's class A, B, and C in 6, 10, and 2 patients, respectively) and refractory variceal bleeding who were not candidates for transplantation. Ten procedures (55.6%) were urgent or emergent. SDPHG shunts effectively reduced the portacaval pressure gradient (18 ± 3 v 5 ± 2 mm Hg; P < .05). Surgical times (210 ± 11 minutes), estimated blood losses (358.3 ± 107.8 mL), transfusion requirements (0 transfusions in 10 patients; 55.6%; mean, 0.9 ± 0.3 units), and postoperative hospitalization (7.7 ± 1.0 days) were excellent. Surgical mortality (30 days) was 0%. During 14.0 ± 1.9 months (range, 1.1 to 29.1 months) of follow-up, 4 patients (22.2%) died, including both patients with Child's class C cirrhosis. The cumulative 1-year survival rate was 82.1% (Child's class A, B, and C, 83.3%, 90%, and 0%, respectively). Long-term survivors had significantly lower preoperative Child-Pugh scores compared with nonsurvivors (7.8 ± 0.3 v 9.5 ± 1.0; P < .05). Postoperative encephalopathy developed in 3 survivors (20%). Fifteen patients (83.3%) have not experienced rebleeding; shunt failure led to rebleeding in only 1 patient (5.6%). SDPHG shunt placement can be performed with low morbidity and surgical mortality. Nontransplantation candidates with Child's class A and B cirrhosis have excellent long-term survival with this safe, effective, and definitive treatment for refractory variceal bleeding.