Splenorenal shunt: an ideal procedure in the Pacific

HYPOTHESIS: Splenorenal shunt, an accepted treatment to prevent recurrent variceal bleeding, is an ideal procedure for patients with psychosocial issues or limited access to tertiary medical centers. METHODS: We retrospectively reviewed the medical records of 34 patients (32 distal splenorenal shunts and 2 central splenorenal shunts) treated from January 1, 1995, through December 31, 2001, for demographic data, substance abuse status, psychosocial factors, previous treatments, Child class, length of hospital stay, operative transfusions, complications, and outcome. RESULTS: Of the 34 patients, 17 were from surrounding Pacific islands (as many as 3800 miles away from Honolulu, Hawaii). Sixteen patients were Child class A, and 18 were Child class B. Twenty-four patients were either homeless, actively involved in substance abuse, or being treated for psychiatric problems, and 20 patients were either uninsured or insured by third-party payers that did not cover liver transplantation. Four patients underwent distal splenorenal shunt for a failed transjugular intrahepatic portosystemic shunt. Patients received a mean of 1.3 U of packed red blood cells (range, 0-5 U), and 15 received no blood transfusions. Mean length of hospital stay was 12.7 days (9 days postoperatively). Perioperative mortality was 8.8%. Three patients rebled postoperatively, 2 because of gastric ulcers and 1 because of an inadequate shunt. The 1-year survival rate was 95% in the 20 patients for whom data were available. CONCLUSIONS: Splenorenal shunt is an important treatment for noncompliant patients or patients living in remote areas where access to specialized treatments, such as endoscopy, transjugular intrahepatic portosystemic shunt, ultrasonography, and liver transplantation, is limited. We can achieve acceptable morbidity and mortality in this group of patients, although follow-up can be difficult.