What are the indications for surgical portosystemic shunt in portal hypertension?

Indications for Surgical Portosystemic Shunt in Portal Hypertension

Surgical portosystemic shunts are now primarily reserved for patients with good liver function (Child-Pugh A or B) who fail endoscopic therapy, and for patients with non-cirrhotic portal hypertension, particularly extrahepatic portal vein thrombosis, where they represent the only effective long-term therapy. 1

Primary Indications for Shunt Procedures

TIPS (Transjugular Intrahepatic Portosystemic Shunt) - First-Line Shunt Approach

TIPS has largely replaced surgical shunts as the preferred decompressive procedure in cirrhotic patients. The established indications include:

Variceal Bleeding

• Rescue/Salvage TIPS: Strongly recommended for gastro-esophageal variceal bleeding refractory to endoscopic and drug therapy 2, 3
• Early/Pre-emptive TIPS: Should be performed within 72 hours in high-risk patients with Child's C disease or MELD ≥19 who are hemodynamically stable 2, 3
• Secondary prevention: For patients with rebleeding despite optimal secondary prophylaxis (combination of non-selective beta-blockers plus endoscopic band ligation) 4, 5

Refractory Ascites

• TIPS is strongly recommended for selected patients with refractory or recurrent ascites who have failed standard diuretic therapy and large-volume paracentesis 2, 3

Budd-Chiari Syndrome

• TIPS is recommended for patients who fail medical therapy with anticoagulation or hepatic vein interventions 2

Surgical Shunts - When to Consider

Surgical shunts remain superior to TIPS in specific patient populations:

Optimal Candidates for Surgical Shunts

• Cirrhotic patients with low operative risk and good liver function (Child-Pugh A and B) should be regarded as candidates for surgical shunts until definitive randomized trial results comparing them to modern covered-stent TIPS are available 1
• Portal flow-preserving techniques are preferred: Selective distal splenorenal shunt (Warren procedure) or partial portocaval small-diameter interposition shunt (Sarfeh procedure) 1

Non-Cirrhotic Portal Hypertension

• Surgical shunts are the definitive treatment for extrahepatic portal vein thrombosis, providing freedom from recurrent bleeding, eliminating need for repeated endoscopies, and improving hypersplenism without deteriorating liver function or causing encephalopathy 1
• This represents the strongest indication for surgical over TIPS approaches 1

Emergency Situations

• End-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or TIPS insertion fails to stop bleeding 1

Contraindications to Shunt Procedures

Absolute Contraindications

• Significant pulmonary hypertension 2, 6
• Heart failure or severe cardiac valvular insufficiency 2, 6
• Rapidly progressive liver failure 2
• Severe or uncontrolled hepatic encephalopathy 6
• Uncontrolled systemic infection or sepsis 6
• Unrelieved biliary obstruction 6

Relative Contraindications

• Bilirubin >50 μmol/L 3
• Platelets <75×10⁹/L 3
• Pre-existing encephalopathy 3
• Active infection 3

Pre-Procedure Evaluation Algorithm

All patients must undergo comprehensive assessment before shunt placement:

• Cardiac evaluation: Assess for diastolic dysfunction, ejection fraction, and pulmonary hypertension 2, 6
• Liver function assessment: Child-Pugh score and MELD score calculation 2
• Renal function: Baseline creatinine and assessment for hepatorenal syndrome 2, 6
• Encephalopathy screening: Both overt and covert forms 2
• Nutritional assessment: Evaluate for sarcopenia, which increases encephalopathy risk 2, 6
• Vascular imaging: Specialized scans of liver and portal/hepatic vessels 2
• Coagulation studies: Though INR is unreliable in liver disease; use thromboelastography when available 7

Common Pitfalls and How to Avoid Them

Patient Selection Errors

• Avoid TIPS in patients with MELD >15 (or >12 in HCV patients), as clinical response rates are lower and complication rates higher 8
• Do not perform shunts in patients with very advanced liver disease, multi-organ failure, or severe encephalopathy, as outcomes are not improved 6

Technical Considerations

• Portal vein thrombosis is NOT an absolute contraindication to TIPS; discuss these patients with experienced units 2
• Always use PTFE-covered stents for TIPS, as they have superior patency rates compared to bare metal stents 7, 9

Post-Procedure Monitoring

• Doppler ultrasound at one week post-TIPS in patients with prothrombotic conditions 7
• Routine surveillance every 6-12 months with Doppler ultrasound 7
• Target portal pressure gradient <12 mmHg or ≥20% reduction from baseline for variceal bleeding 7

Alternative Procedures When Shunts Are Not Feasible

Gastroesophageal devascularization and direct variceal ablative procedures should be restricted to patients who fail endoscopic therapy and have no shuntable portal tributaries 1