Distal splenorenal shunt in children.

The distal splenorenal end-to-side anastomosis (Warren shunt) decompresses esophageal varices while maintaining high portal hypertension and avoiding reduction of portal venous blood inflow to the liver. The Warren shunt was performed in seven consecutive patients with portal hypertension, including post-necrotic cirrhosis, portal thrombosis, and schistosomiasis, all with recurrent esophageal bleeding. Five shunts remained patent and two thrombosed. There was no mortality. If long-term follow-up evaluations indicate its effectiveness in preventing esophageal hemorrhage, the distal selective splenorenal shunt would be the more physiologic and safer procedure in children with portal hypertension.     

Selective shunts for portal hypertension: Current role of a 21-year experience

The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child- Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function. (Liver Transpl Surg 1997 Sep;3(5):475-80)     

Small-diameter mesocaval shunts: A 10-year evaluation

The use of small-diameter portosystemic shunts for the treatment of bleeding esophageal varices caused by portal hypertension has emerged as an outgrowth of the development of polytetrafluoroethylene vascular grafts, which allow the use of a narrow lumen. We report our experience with this type of graft over a 10-year period. Thirty-three patients with good liver function (Child-Pugh class A) were electively operated. The average age of these patients was 45 years (range 17 to 71 years). Twenty-nine patients had liver cirrhosis, one had portal fibrosis, and three had idiopathic portal hypertension. Operative mortality was 3%, and the rebleeding rate was 15%. Postoperative encephalopathy was observed in 14 patients (11%), three of whom had grade III to IV encephalopathy. The remaining 11 patients, had mild encephalopathy that was easily controlled. Postoperative angiography showed shunt patency in 81% of the patients, reduction in portal vein diameter in 33% of the patients, and portal vein thrombosis in 6%. Good postoperative quality of life was observed in 63% of the patients. Survival according to the Kaplan-Meier actuarial method was 81% at 12 months, 56% at 60 months, and 36% at 10 years. These shunts are a good alternative for patients being considered for surgery in whom other portal blood flow preserving procedures (i.e., selective shunts, devascularization with esophageal transection) are not feasible.     

Surgical treatment of portal hypertension

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.     

Current state of portosystemic shunt surgery

BACKGROUND: A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective, and durable procedures to treat variceal bleeding in patients with low operative risk and good liver function. DISCUSSION: In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) and a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or transjugular intrahepatic portosystemic shunt insertion fails to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) should be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.     

Selective shunts: the Johannesburg experience

My personal 15-year experience with 141 selective shunts (127 elective, 14 emergency) for portal hypertension is reported. Alcoholic cirrhosis comprised 54% of elective operations, and of the nonalcoholic patients, 22% were cirrhotic and 24% were noncirrhotic. Adequate and, if necessary, prolonged (mean 6 weeks) in-hospital preparation resulted in Hospital mortality and long-term actuarial survival were better in nonalcoholics compared with alcoholics, but there was no significant difference between cirrhotic nonalcoholics and alcoholics. Variceal rebleeding was rare (4% of Warren procedures) and, when present, was usually related to shunt failure. Gastric fundal variceal rebleeding did not occur in 44 patients undergoing splenopancreatic disconnection. Postoperative encephalopathy occurred in 13% of patients; however, it did not occur at all in noncirrhotic patients. Prograde portal venous perfusion was preserved in 77% of patients. Fifteen alternate selective operations to the Warren shunt were performed, usually because of antecedent splenectomy. Shunt failure and variceal rebleeding occurred more frequently with these more vulnerable shunts, but 66% had a satisfactory outcome. Selective shunts have produced highly satisfactory results in appropriately selected patients.     

Personal reflections on the surgical treatment of portal hypertension

Reports, early in this century, on the treatment of portal hypertension by surgical diversion of the portal blood flow about the liver were largely ignored because of the anticipated high mortality. Whipple, Blakemore and Lord in the early 1940's described a technique of performing a splenorenal or portacaval shunt with an epithelial lined vitallium tube. Blalock, whom I assisted, was one of the first outside of the Whipple Group to successfully perform such an operation. Although he used the vitallium tube technique in his first cases he soon became convinced that the results were better with a direct suture anastomosis. Venous shunts, which seemed such a logical way to treat portal hypertension, were widely and quickly adopted. Little attention was paid to the problem of portal encephalopathy which had been described in experimental animals years before by Pavlov. As some of the follow up studies on these shunted patients began to appear it was evident that this was a common and at times a severe problem. Some of the earliest doubts about the shunt operation were expressed by surgeons in Japan. The most successful methods developed to date for the treatment of portal hypertension provided a shunt for blood from the esophageal variceal region while at the same time preserving portal blood flow through the liver. Two of these methods have been the distal or selective splenorenal shunt proposed by Warren & Zeppa and the coronary caval shunt first described by Inokuchi. These methods, although somewhat more difficult technically than end to side portacaval shunts, reduce portal hypertension and preserve blood flow through the liver thereby lowering significantly the incidence of encephalopathy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Personal reflections on the surgical treatment of portal hypertension

Reports, early in this century, on the treatment of portal hypertension by surgical diversion of the portal blood flow about the liver were largely ignored because of the anticipated high mortality. Whipple, Blakemore and Lord in the early 1940's described a technique of performing a splenorenal or portacaval shunt with an epithelial lined vitallium tube. Blalock, whom I assisted, was one of the first outside of the Whipple Group to successfully perform such an operation. Although he used the vitallium tube technique in his first cases he soon became convinced that the results were better with a direct suture anastomosis. Venous shunts, which seemed such a logical way to treat portal hypertension, were widely and quickly adopted. Little attention was paid to the problem of portal encephalopathy which had been described in experimental animals years before by Pavlov. As some of the follow up studies on these shunted patients began to appear it was evident that this was a common and at times a severe problem. Some of the earliest doubts about the shunt operation were expressed by surgeons in Japan. The most successful methods developed to date for the treatment of portal hypertension provided a shunt for blood from the esophageal variceal region while at the same time preserving portal blood flow through the liver. Two of these methods have been (1) the distal or selective splenorenal shunt proposed by Warren & Zeppa and (2) the coronary caval shunt first described by Inokuchi. These methods, although somewhat more difficult technically than end to side portacaval shunts, reduce portal hypertension and preserve blood flow through the liver thereby lowering significantly the incidence of encephalopathy. The vascular stapling instrument developed by Professor Inokuchi in the 1950's has allowed him to perform this and other types of difficult vascular surgery with excellent results.     

A quarter of a century of portasystemic shunting for oesophageal varices

Seventy-three patients who had received portasystemic shunts were reviewed to assess the current role of this procedure in the treatment of portal hypertension. Survival at 1, 5 and 10 years was 85%, 68% and 45% respectively. Survival was significantly greater (P less than 0.001) in Child's grade A patients compared with Child's grade B patients and in non-alcoholics compared with alcoholics. Previously absent encephalopathy developed in 43% of those with non-selective shunts compared with 21% of those with selective shunts. Six of the 12 patients who experienced recurrent variceal haemorrhage had associated shunt thrombosis: five of these required further shunts or oesophageal transection to control their bleeding and the other patient died before further surgery could be instituted. Shunt surgery still has a role in the treatment of a small number of carefully selected patients with portal hypertension.     

Sugiura procedure outside Japan. The Mexican experience

In the last 10 years, we operated on 231 patients with hemorrhagic portal hypertension. Most of these patients had some form of liver disease. We performed various surgical procedures: 47 conventional shunts with H grafts and terminolateral portacaval shunts with arterialization of the portal stump, 139 selective Warren shunts, and in those patients in whom a selective portasystemic shunt could not be performed for technical reasons, esophagogastric devascularization in the form of the Sugiura procedure. Forty-five patients were treated with the Sugiura procedure as a one stage or two stage procedure. A total of 68 emergency and elective operations were performed. The operative mortality rate for the emergency thoracic operation was 41 percent and for the abdominal operation, 42 percent. The overall operative mortality rate in the emergency group was 41 percent. The incidence of recurrent variceal bleeding and encephalopathy was 0 in the surviving patients. The survival rate at 3 year follow-up was 40 percent. The elective group was made up of 24 patients. Eighteen patients had a two stage procedure and 6 patients had a one stage procedure. The operative mortality rate for the abdominal operation was 11 percent, whereas that for the thoracic operation was 7 percent. The operative mortality rate for the one stage procedure was 16 percent. The overall operative mortality rate in the elective group was 10.8 percent. None of these patients had recurrent variceal bleeding and encephalopathy developed in only one (5 percent). The encephalopathy was easily controlled with medical treatment. The 3 year survival rate was 83 percent. We conclude that the Sugiura procedure is an effective procedure to treat hemorrhagic portal hypertension when a selective shunt cannot be performed.     

Spleno-renal distal and proximal shunts for hypersplenism due to hepatic cirrhosis

The secondary hypersplenism appears from 30-50% in liver cirrhosis with portal hypertension. The mechanism of the complication is the splenic congestion as the result of the progress of the portal hypertension. Between 1997-2005, 16 patients with hypersplenism due to liver cirrhosis were operated in the service. The aim of the operation was to decompress the portal hypertension, by spleno-renal shunt (Warren), in 6 patients, truncular shunts in 2 patients, and splenectomy with spleno-renal shunts in 8 patients. No postoperative death was noted on the series. The platelets number and the white blood cells, destroyed by the reticuloendothelial system of the spleen, were counted in the first month and the first year, as well as the spleen volume. In patients with non-splenectomy operations the improvement of the blood elements number was remarked in the first week, but the volume of the spleen remained increased during 1-6 month. In patients with splenectomy the platelets and the white cells dramatically increased, with the risk of coagulation disfunction. The survival rate at five years was 12 patients.     

Liver transplantation in patients with patent splenorenal shunts

Patent distal splenorenal shunts (Warren shunt) have been reported to cause decreases in the portal perfusion pressure and the total hepatic blood flow. Such hemodynamic alterations could have adverse effects on the transplanted liver. The experience with hepatic replacement in four patients with patent Warren shunts is reported. Operative findings were phlebosclerotic portal veins of small size and diminished portal blood flows. Hepatofugal collateral channels created by the construction of the Warren shunt were eliminated by division of the shunt and splenectomy in three patients and splenectomy alone in the other. All patients recovered; thus the presence of a patent Warren shunt should not be a contraindication for hepatic transplantation.     

Shunts for portal hypertension

Eighty-nine patients underwent 95 portasystemic shunts for portal hypertension at our institutions between June 1963 and March 1981. Ninety-three shunts were performed for bleeding varices. Procedures that were performed included 11 Warren shunts, 29 Linton shunts, 28 interposition mesocaval shunts, 26 classic portacaval shunts, and one umbilical to saphenous vein shunt. Thirty-six shunts were performed in Child class A patients (5.5% operative mortality), 37 in Child class B (16.2% operative mortality), and 22 in Child class c patients (36.3% operative mortality). Five-year survival for Child A patients was 74 per cent, 17.4 per cent for Child B patients and 26.3 per cent for Child C patients. Twelve of 14 patients (15.7%) who had recurrent postoperative upper gastrointestinal bleeding were found to have occluded shunts (two Warren, six Linton, one mesocaval, and three portacaval). Of 21 patients who became encephalopathic postoperatively, 17 had alcoholic liver disease. In 15 of these alcoholic patients who survived the immediate postoperative period, encephalopathy correlated directly with continued alcohol consumption. Several conclusions can be drawn from our data: portasystemic shunts can be performed with acceptable morbidity and mortality; rebleeding generally indicates shunt occlusion; encephalopathy can be correlated with continued alcohol consumption after shunting; there appears to be little difference in survival and rebleeding in the various shunt procedures; the poor survival figures for Child B and C patients must make one seriously consider alternative procedures in these poor-risk candidates.     

Noncirrhotic portal vein thrombosis. Physiology before and after shunts.

Controversy exists concerning the proper therapy for bleeding gastroesophageal varices secondary to noncirrhotic portal vein thrombosis. Disparity of opinion exists regarding the significance of hepatic portal blood flow and the consequences of total portal-systemic shunts in this condition. One patient is presented who developed severe, crippling encephalopathy 20 years after a central splenorenal shunt. This was associated with loss of portal flow to the liver and marked nitrogen intolerance. Closure of the shunt resulted in restoration of hepatic portal flow via collateral veins (HPI 0.36), clearance of encephalopathy and return to near normal protein tolerance. An additional patient was studied with hyperammonemia and early suggestive signs of encephalopathy eight years following a mesocaval shunt. Four patients were evaluated before and after selective distal splenorenal shunts. All had "cavernous transformation" of the portal vein with angiographic evidence of portal flow to the liver. Postoperative angiograms revealed continued hepatic portal perfusion and a patent shunt in each patient. Radionuclide imaging postoperatively gave an estimated portal fraction of total hepatic blood flow (HPI) of .39 and .60 in two of the four patients. We conclude that 1) there is significant hepatic portal perfusion in noncirrhotic portal vein thrombosis (cavernous transformation), 2) loss of this hepatic portal flow following total shunts can lead to severe encephalopathy, 3) the selective distal splenorenal shunt maintains hepatic portal perfusion and is the procedure of choice when there is a patent splenic vein and surgical intervention is indicated.     

Distal splenorenal versus lienorenal shunt for acute variceal haemorrhage: is the selective shunt an advance?

Retrospective analysis of 81 patients (average age 48 years) undergoing lienorenal shunt (28) or distal splenorenal (Warren) shunt (53) surgery over a 15-year period (1971-1986) revealed important predictive factors for survival, but showed no significant differences between the two shunt groups in terms of accepted follow-up data over a period of up to 15 years. In 52 patients (64%) active haemorrhage was occurring at the time of operation, or was temporarily controlled by tamponade, and 17 of the 18 deaths (22% operative mortality) occurred in this group. Patients in whom prolonged conservative resuscitation had been attempted fared worse (64% survival), as did patients with poor hepatic reserve (Pugh grade C: 32% survival). Twenty-two patients (27%) rebled within 30 days, 18 following urgent shunts, and 12 died. Seven (11%) of the long-term survivors have suffered recurrent variceal haemorrhage with a clear relationship to shunt or portal system thrombosis. Portasystemic encephalopathy occurred in 13 survivors (20%) with six requiring hospital treatment.     

Portal diversion for portal hypertension in early childhood.

Twenty-three children under 6 years of age with portal hypertention were treated by portal diversion. Fourteen had cavernomatous transformation of the portal vein and 9 had an intrahepatic block due to cirrhosis (8) or congenital hepatic fibrosis (1). Portal-systemic shunts were central splenorenal in 20 patients, side-to-side portacaval in 2 and mesocaval in one. In 20 of the 21 peripheral shunts, the veins used for the anastomosis were less than 10 mm in diameter. There was no operative mortality. Thrombosis of the shunt occurred in 3 children (13%) and was responsible for recurrent bleeding in one who was treated later with success by a mesocaval shunt. The two other children with a thrombosed shunt are waiting, at the present time, for a mesocaval anastomosis. The volume of blood flowing through the shunt was small initially and the fall in pressure gradient was slight: therefore intraoperative angiography appeared to be a better way to assess the patency of shunts done at an early age than pressure or flow measurements. The figures recently reported by Clatworthy, with a mortality rate of 12% directly or indirectly related to repeated hemorrhage, are for us a forceful argument for early adequate management of portal hypertension in children. Until now, portal-systemic shunts have been complicated by a high frequency of thrombosis and have given discouraging results. Our results suggest that it is possible to perform portal diversion successfully on diminutive veins (down to 4 mm). From this experience early portal diversion appears to represent the treatment of choice for portal hypertension in childhood.     

Prophylactic distal splenorenal shunt for child's class A and B patients at high risk of bleeding

During recent 17 years, prophylactic distal splenorenal shunt was carried out on 29 patients. Patients were composed of 18 males and 11 females. Age ranged from 34 to 66 years with an average of 52.4. All patients had risky esophagogastric varices; varices larger than 5 mm in diameter and or varices with red color signs such as cherry red spots endoscopically. Underlying liver disease were cirrhosis of the liver in 27, chronic hepatitis in one, and idiopathic portal hypertension in one. Twenty-three patients were in Child's class A and six were in class B. Thirteen patients underwent the original Warren shunt but the remaining 16 had modified distal splenorenal shunts with expanded polytetrafluoroethylene interposition. Portal-azygos disconnection was routinely performed. One patients (3.4%) died of hepatic failure on the 6th postoperative day. Four patients (14.3%) developed hepatic encephalopathy of mild to moderate degree but no patients have suffered from variceal bleeding until now. The 5-, 10-, and 15-year survival rates were all 85.5 per cent. It is concluded that distal splenorenal shunt is a safe and reliable method to prevent variceal bleeding in a selected group of patients.     

Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt

BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portal-systemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). RESULTS: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected. CONCLUSION: PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.     

The changing spectrum of treatment for variceal bleeding.

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.     

Ten Years Portal Hypertensive Surgery at Emory: Results and New Perspectives

Five hundred four Shunt procedures have been done at Emory University Hospitals between 1971 and 1981 to decompress bleeding esophageal varices. This paper reviews how far the experiences of a prospective randomized study (55 patients) of distal splenorenal shunts against total shunts is supported by the nonrandomized experience (449 patients), and outlines our current methods of management dictated by this experience. The overall operative mortality for 348 selective shunts is 4.1% and for 156 nonselective shunts, 14.1%. The five-year survival following Selective shunt is 59%, and following nonselective shunt is 49%: more than half the selective shunt patients are alive, in contrast to the median survival of 44.5 months for patients having nonselective shunts. Following Selective shunt, the survival in nonalcoholic patients is significantly better than the median survival of alcoholic patients of 57 months. Encephalopathy, reported at three years after surgery in the randomized patients was significantly (p < 0.001) lower after selective shunt (12%) compared to nonselective shunt (52%): in the same population at seven years, all patients with patent nonselective shunts have clinical or subclinical encephalopathy, but only 30% of the selective shunt patients have subclinical encephalopathy. Shunt patency, immediately after surgery, is 93% following selective shunt, with only two documented late thromboses: nine of nine patients, at a mean of seven years, retain patency in the randomized study. Shunt occlusion increases with time after interposition nonselective shunts: seven of 13 are occluded at a mean follow-up of seven years in the randomized study. Portal venous perfusion is retained in 93% of patients seven to ten days after selective shunt, but in no patient with a patent nonselective shunt. Late portal perfusion is maintained in nine of the eleven patients in the randomized group studied at a mean of seven years after selective shunt. Restoration of portal perfusion has led to clearing of encephalopathy and improvement in hepatic function in six patients. The following conclusions are made: (1) selective shunts can be done with low operative mortality, and long-term patency with excellent control of bleeding; (2) hepatic portal venous perfusion has been maintained after selective shunt for ten years, and this is vital for preventing encephalopathy and maintaining hepatic function; (3) long-term survival after selective shunt is better than any reported series for nonselective shunt; and (4) selective shunts are the operative procedure of choice for variceal decompression and nonselective shunts should rarely be performed for elective decompression.