The Emory Prospective Randomized Trial

Abstract

From 1971-1975, 55 patients with variceal bleeding secondary to cirrhosis were entered into a perspective randomized trial comparing distal splenorenal (selective) and H-graft interposition (nonselective) shunt. This 10-yr follow-up documents that selective shunt is better (P < 0.05) in 4 of the 5 variables monitored. In control of bleeding selective shunt prevented variceal bleeding better than interposition shunt due to the higher (0.05 < P < 0.1) occlusion rate (30%) of interposition shunt. Selective shunt maintained postoperative portal perfusion better (P < 0.01) than patent interposition shunt. Of selective shunt survivors 75% have portal perfusion at 10 yr; no patient with a patent nonselective shunt perfuses the liver. Quantitative liver function was better preserved (P < 0.01) 10 yr after selective shunt than nonselective shunt. Postoperative encephalopathy occurred in fewer (P < 0.01) selective (27%) than nonselective (75%) shunt patients over the 10 yr. The improved survival in the selective shunt subgroup did not reach statistical significance. Improved survival was confirmed in nonalcoholics. Five of 8 nonalcoholics operated with selective shunt were alive at 10 yr with patent shunts. No nonalcoholic, of 7 total, operated with nonselective shunt survived 10 yr with a patent shunt. Selective shunt was superior to nonselective shunt. There was less rebleeding and encephalopathy after distal splenorenal shunt; postoperative portal perfusion and hepatic function were maintained.