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Current Indications and Long-Term Outcomes of Surgical Portosystemic Shunts in Adults

  • Original Article
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Journal of Gastrointestinal Surgery

Abstract

Background

Surgical portosystemic shunts are rare. We reviewed indications, operative details, and outcomes of patients undergoing surgical portosystemic shunt procedures.

Methods

We retrospectively reviewed clinical data of consecutive patients between 1997 and 2018 from a single institution. Clinical characteristics and outcomes were compared between two groups: patients with portomesenteric venous thrombosis (PMVT) vs those with cirrhosis. Endpoints included 30-day mortality, shunt-related complications, patency, and survival.

Results

There were 99 patients, 45 male and 54 female, with a mean age of 46 ± 18 years, enrolled in the study. There were 63 patients (63%) with PMVT and 36 patients (36%) with cirrhosis. Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for more diabetes among those with cirrhosis (p < 0.05). There were no significant differences in procedural metrics and intra-procedure complications between groups, except that patients with PMVT underwent more non-selective shunts than those with cirrhosis (63% vs. 30%, p < 0.001). There were two 30-day deaths (2%), with no difference in mortality and MAEs between groups. On univariate analysis, cholangiopathy and PMVT were associated with graft thrombosis (HR = 9.22, 95% CI 1.22–70.27) while race, smoking, cardiac comorbidity, type of operative shunt, configuration of the shunt, and use of conduit were not (p > 0.05). Patients with PMVT had significantly lower 1-, 5-, and 10-year primary (77%, 71%, and 71% vs. 97%, p = 0.009) and secondary patency (88%, 76%, and 72% vs. 96%, p = 0.027) compared with those with cirrhosis. The 1-, 5-, and 10-year survival rates were 94%, 84%, and 61% for patients with PMVT compared with 88%, 58%, and 26% for those with cirrhosis (non-adjusted HR 0.40, 95% CI 0.19–0.84, p = 0.01, age-adjusted HR 0.51, 95% CI 0.24–1.09, p = 0.08). The survival of patients with PMVT without liver disease trended higher than those with liver disease; however, when adjusted for age, the survival gap narrowed, and the difference was not statistically significant (p = 0.19), survival being lowest for those with PMVT and liver disease.

Conclusions

Surgical portosystemic shunts are safe and effective for symptom relief in selected patients with portal hypertension. The odds of graft thrombosis is 9 times higher in patients with PMVT. Overall survival is similar in patients with PMVT or cirrhosis.

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Authors and Affiliations

  1. Department of Vascular Surgery, Hepatobiliary Pancreatic Surgery, Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Indrani Sen, Lavanya Yohanathan & Jussi M. Kärkkäinen

  2. Department of Vascular and Endovascular Surgery, Gonda Vascular Center, Hepatobiliary Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    David M. Nagorney

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  1. Indrani Sen
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  2. Lavanya Yohanathan
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Correspondence to Indrani Sen.

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Electronic Supplementary Material

ESM 1

Supplemental. a) Distribution of operative numbers performed for PMVT and cirrhosis over the study quartiles. b) Clinical success (symptom relief) according to index symptom. c) Lowest survival in patients with both PMVT and liver disease (green line- numbers very small with no statistical significance, presented only for pictorial representation of trends.) (JPG 426 kb)

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Sen, I., Yohanathan, L., Kärkkäinen, J.M. et al. Current Indications and Long-Term Outcomes of Surgical Portosystemic Shunts in Adults. J Gastrointest Surg 25, 1437–1444 (2021). https://doi.org/10.1007/s11605-020-04643-1

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