PERITONEOVENOUS SHUNTING OF INTRACTABLE ASCITES IN PATIENTS WITH CIRRHOSIS - IMPROVING RESULTS AND PREDICTIVE FACTORS OF FAILURE

Background. The clinical results of peritoneovenous shunting have not been entirely satisfactory in spite of dramatic improvement of renal function and decrease of ascites. The purpose of this study is to determine whether certain modifications improved our results. Methods. A modified LeVeen shunt was electively inserted in 56 patients who had cirrhosis with intractable ascites. In 24 patients (42.9%) the Child-Pugh's score was less than 9, and in 32 patients the score was 9 or above. Fourteen patients (25%) had previous variceal bleeding, and 15 patients (26.8%) had previous spontaneous bacterial peritonitis (SBP). LeVeen shunt was modified by the addition of a titanium venous catheter tip. Prophylactic antibiotic therapy was administered to all patients. Results. No operative deaths occurred, and one patient had severe postshunt coagulopathy. Five patients (8.9%) experienced recurrent ascites resulting from blockage of the shunt. The cumulative rate of shunt blockage was 5.6% at 1 year and 12% at 2 years. Seventeen patients (30.3%) have recently had variceal bleeding. The cumulative risk of variceal bleeding was significantly higher in patients with a previous hemorrhage than in those patients without (p < 0.05). Eight patients (14.3%) had SBP after operation. The cumulative risk of SBP was higher in patients with a history of SBP than in those patients without, although the difference was not significant. Fifty-five percent of late deaths were related to variceal bleeding or to SBP. Overall cumulative 1- and 2-year survival rates were 67.2% and 55.2%, respectively. It was 82% and 71% in patients without previous variceal bleeding or SBP. Conclusions. These data suggest that peritoneovenous shunting might be beneficial only in selected patients. Previous variceal bleeding and/or SBP indicate liver transplantation in suitable patients.