Chapter 89 - Portal shunting procedures

Summary

Decompressive portosystemic shunts play a significant role in the treatment of patients with portal hypertension and gastroesophageal varices. The main indication for portal shunting procedures is the prevention of recurrent variceal bleeding in patients with cirrhosis and portal hypertension after failure of endoscopic interventions (banding, sclerotherapy). Portal shunting procedures are not indicated for prophylaxis against variceal bleeding in patients who have not yet bled. In these patients, medical management (non-selective beta-blockers) and endoscopic therapies are utilized. The ideal candidates for shunt procedures are Child–Turcotte–Pugh (Child's) class A or B patients who have favorable venous anatomy. The procedures themselves can be divided into two main categories: total shunts and selective distal splenorenal (Warren) shunt.

With total shunts, the entire portal venous blood flow is shunted away from the liver into the systemic venous circulation. This includes end-to-side and side-to-side portacaval shunts, central splenorenal shunts, Marion–Clatworthy mesocaval shunts, interposition mesocaval shunts, and radiologically placed transjugular intrahepatic portosystemic shunts (TIPS). The small graft portacaval interposition shunt is a modification designed to achieve partial rather than total diversion of portal venous flow. If patients who require total shunts are potential candidates for liver transplantation, mesocaval rather than portacaval shunts should be chosen to preclude dissection in the liver hilum, which would complicate subsequent liver transplantation.