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HPB Surgery
Volume 10 (1997), Issue 4, Pages 253-265

Emergency Portacaval Shunts: Is Orloff Correct?

Department of Surgery, University of Wisconsin Hospital and Clinic, H4/710 Clinical Science Center, 600 Highland Avenue, Madison 53792, WI, USA

Copyright © 1997 Hindawi Publishing Corporation. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


A prospective randomized trial was conducted in unselected, consecutive pateints with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamonade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received indentical supportive therapy initially. All patients were followed up for atleast 10 hr. The protocol contained no escape or crossover provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p<0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p<0.001). Mean requirement for blood transfusion was 7.1±2.6 units in the shunt group and 21.4±2.6 units in the medical group (p<0.001). Eighty-one percent of the pateints in the shunt group were discharged alive compared with 45% in the medical group (p=0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p<0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.