Narrow Versus Wide Diameter Portacaval H-Graft Shunts

arterioportal fistula after blunt hepatic trauma: case reports.plications associated with the use of peritoneal drains in liver traumas. Mandatory laparotomy for gunshot wounds penetrating the abdomen. Am. Objective. Results ofthe first prospective randomized clinical trial comparing partial and total portacaval shunt for variceal hemorrhage are reported. Summary Background Data. Total portacaval shunts produce subnormal portal pressures, completely diverting hepatic portal flow. Partial shunts maintain higher pressures and preserve hepatopedal flow. No randomized trials ofthese two approaches have been performed. Methods. Alcoholic patients with cirrhosis (n = 30) and variceal hemorrhage treated at one institution were randomized to receive partial (8-mm diameter portacaval H grafts with collateral ablation, n = 14) or total shunts (16-mm diameter grafts, n = 16). Portography was performed after operation and then yearly. Investigators blinded to shunt type assessed encephalopathy; hospitalizations were reviewed. Results. Child's class, age and operative urgency were similar for the two groups. Two patients (with total shunts) died within 30 days. Hepatopedal flow was maintained in 13 partial and 0 total shunt patients (p < 0.0001). Shunt gradients were 16 + 5 compared with 6 + 3 cm saline after partial and total shunts (p < 0.0001). There were no shunt thromboses or variceal hemorrhages. Encephalopathy-free survival was significantly greater after partial shunts (p = 0.013; life table analysis). Five total compared with zero partial shunt patients required hospitalization for coma (p = 0.02). Long-term survival was not different for the two groups ofpatients. Conclusions. Partial shunts control variceal hemorrhages while maintaining hepatopedal flow and elevated portal pressures. By minimizing encephalopathy rates, partial shunts provide improved quality ofsurvival compared with total shunts. Partial portal decompression does it really work? This carefully conducted prospective randomized controlled trial comparing partial to total portal decompression presents the most persuasive data yet available that partial decompression offers a significant advantage compared to total portal systemic shunt. This study needed to be done, and the authors are to be commended for a well designed and carefully executed studyI. As two of the major