A 25-Year Experience with Total Portosystemic Shunts and Reappraisal of Colon Exclusion

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Abstract
The results of 43 total shunt procedures for bleeding esophageal varices performed consecutively at 2 community hospitals from 1956-1981, are reviewed. Of 15 patients with immediate preoperative bilirubins > 2.0 mg/dl, 11 died following shunt surgery. Of 28 other shunted patients with immediate preoperative bilirubins of < 2.0 mg/dl, there was only 1 in-hospital death, thus substantiating the contention that the last preoperative serum bilirubin value is the best predictor of operative mortality. Of 10 patients with appreciable ascites verified at the time of operation, there were only 2 survivors, and both of these had preoperative bilirubins of < 2.0 mg/dl. Of the 31 patients who left the hospital, 29 were still living at least 1 yr after operation. All 23 patients operated on prior to 1977 were available for 5-yr follow-up, and there were 14 survivors (60%). Of the 31 patients, 13 (42%) manifested some degree of hepatic encephalopathy, as interpreted by necessity for protein restriction and either Neomycin or Lactulose. Incapacitating postshunt hepatic encephalopathy developed in 1 patient who required recurrent hospitalizations for episodic coma. This patient underwent a total abdominal colectomy and ileorectal anastomosis with elimination of all episodes of encephalopathy for the subsequent 4 1/2 yr. The previous 16 cases in the literature of surgical treatment of postshunt encephalopathy are reviewed, and the efficacy of such colon exclusion is reassessed.