EXPERIMENTAL, CLINICAL, AND METABOLIC RESULTS OF SIDE-TO-SIDE PORTACAVAL SHUNT
FOR INTRACTABLE CIRRHOTIC ASCITES
MJ Orloff, MD, FACS, MS Orloff, MD, FACS, SL Orloff, MD, and B Girard, BS.
[From the Department of Surgery, University of California, San Diego, Medical Center; San
Diego, California]/P>
BACKGROUND Intractable ascites, refractory to medical therapy, occurs in approximately 10 percent
of patients with ascites from cirrhosis, and is almost uniformly fatal. Sinusoidal hypertension
resulting from hepatic venous outflow obstruction plays a primary role in the pathogenesis
of cirrhotic ascites, and provides the rationale for decompression of the liver by
side-to-side portacaval shunt in treatment of intractable ascites. This report presents the
experimental basis for the use of side-to-side shunt, and longterm results of a prospective
study in 34 selected patients with intractable cirrhotic ascites.
STUDY DESIGN In the experimental studies, hepatic venous outflow obstruction and massive ascites
were produced in dogs by ligation of the hepatic veins, and the effect of portacaval shunts
on ascites, thoracic duct lymph flow, and aldosterone secretion were measured. In the
clinical study 34 carefully selected patients with cirrhosis (91 percent alcoholic) and truly
intractable ascites (failure of medical therapy for five to 24 months) were treated by
side-to-side portacaval shunt and the effects on ascites, survival, metabolic abnormalities,
and quality of life were studied prospectively during follow-up that was longer than five
years in all but two. Quantitative Child's risk classes in percents of patients were A in 0, B in
68, and C in 32.
RESULTS In the experimental studies, side-to-side portacaval shunt permanently relieved severe
ascites, reduced the thirteenfold increase in thoracic duct lymph flow rate to almost normal,
and abolished the aldosterone hypersecretory response to minimal hepatic venous outflow
obstruction. End-to-side portacaval shunt was much less effective. In the clinical study,
side-to-side portacaval shunt reduced mean portal vein-inferior vena cava pressure
gradient from 282 mm saline to 4 mm, and permanently relieved all patients of ascites
without subsequent requirement of diuretic therapy. Two patients who died of hepatoma, and
one who died of heart failure developed terminal ascites. Thirty-day mortality rate was six
percent, and long-term survival rates at 5, 10, and 15 years were 75, 74, and 73 percent
respectively. In metabolic studies, side-to-side shunt produced marked diuresis and
natriuresis and abolished hypersecretion of aldosterone. Quality of life was generally
improved as a result of a low incidence of recurrent portal-systemic encephalopathy (6
percent), abstinence from alcohol in 91 percent, improvement in liver function in 81
percent, and improvement in Child's risk class. The portacaval anastomosis remained
permanently patent in every patient.
CONCLUSIONS Side-to-side portacaval shunt is very effective treatment of intractable ascites from
cirrhosis. Our results are attributable to careful selection of patients, an organized system of
care, and a program of rigorous, lifelong followup that emphasizes abstinence from alcohol,
and dietary protein restriction.
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Journal of the American College of Surgeons June 1997,
Volume 184 Number 6
