At present, interest for traditional PSSh has markedly fallen. On one hand, this is due to the widespread use
of minimally invasive techniques, including endovascular interventions, like TIPS, as well as endoscopic
techniques such as ligation and sclerotherapy. On the other hand, introduction of radical treatment in many
countries made a certain influence on the demand of PSSh producing .
Furthermore, Rosemurgy et al.  found that widespread use of TIPS continues although there is a certain
lack of direct evidence of its effectiveness prior to surgical bypass.
Authors presented results of an 18-year follow-up of a prospective randomized study. Patient survival was
significantly greater after traditional PSSh, as it was also for patients with a Child-Pugh class "A" (91 vs. 19
months) and Class "B" (63 vs. 21 months). Adequate shunt patency after PSSh was 45 months, whereas it was
only 22 months after TIPS. The authors state that patients with Child-Pugh functional class "A" and "B" should
have traditional bypass surgery rather than TIPS, leaving TIPS only for patients who present an initially severe
(grade "C") condition .
Interesting results were obtained in a randomized clinical trial that evaluated the efficacy of emergency
TIPS vs PSSh. The study compared efficiency of TIPS vs. PSSh as a way to stop acute bleeding in emergency
situations and was conducted in 154 patients with liver cirrhosis of all Child-Pugh severity groups .
PSSh showed the best results with 97.4 % hemostasis and less frequent encephalopathy. Additionally, life
expectancy was three times greater for patients with PSSh than with TIPS (uncovered). And, despite the
recommendation of many surgeons who suggest that PSSh is a surgery that should be carried out in planned
fashion in order to prevent bleeding, authors recommend the use of this intervention as a means of treatment for
acute bleeding. It should be noted that in another study by Orloff et al.  the advantages of PSSh compared to
endoscopic procedures for bleeding control and recurrence prevention were also demonstrated. Puhl et al. 
believe that PSSh should be considered as an optional method in portal pressure decompression, especially in
patients with insufficient endoscopic or drug therapy, as well as in patients with the absence of transplantation
indications. This also applies to the secondary prevention of rebleeding in patients with good liver function.
According to the interstate archive data analysis made in the United States the following reasons for TIPS
were identified: First of all, during 4 years of observation (2000-2003) in the second most populous state
(Florida), only 165 PSSh where performed (an average of about 41 shunts in a year). On the contrary, TIPS where
performed in 1486 patients among 1321 patients that was nearly 10 times greater. Secondly, number of centers
offering the TIPS procedure was almost 10 times higher (more than 100). In general, mortality after these
procedures was almost identical (11.0% TIPS versus 12.7% PSSh). Thus, the cost of TIPS was significantly lower
($62,000 vs. $107,000). However, conducting analysis, authors claim that if the mortality after TIPS procedure
was due to the severity of patients and did not depended on the level of the surgical hospital, the mortality rate
after the traditional PSSh depended both on the level of the medical center and the surgeon’s experience. Also, in
spite of the advantages of the TIPS procedure, the authors summarized that, in long-term observation, traditional
PSSh gave more superior survival rate prospects .
Finally, a retrospective analysis by Elwood et al.  broth that the Warren procedure should be
considered as the first line approach for patients with high risk of bleeding in Child-Pugh classes "A" and "B",
especially when endoscopic sclerotherapy is ineffective or in those cases where liver transplantation will not be
needed within 5 years.
The effectiveness of the Warren procedure made under recommended readings is higher than that of TIPS.
This option avoids the need of multiple stent patency monitoring and thus resenting . According to several
clinical trials, this TIPS technique can be complicated, in 75-82% of patients, with endovascular graft dysfunction
or thrombosis in a period from 6 months to 1 year after surgery [16, 19].
It should be noted that the accumulated experience of different hepatology schools determines the
selection of a particular method, thereby giving continuity to the centers’ own results. For example, in some
studies only the initial state of compensated liver function is considered as an indication for PSSh. In contrast,
other authors only recommend alternative therapies. Thus, according to Semenova , endoscopic bleeding
prevention is of minimal risk, although it does not allow sustainable long-term results to be achieved. In turn, the
Warren procedure has a clear advantage with respect to long-term effects, but has a higher risk of bleeding. In
this connection, the Warren procedure is preferable for patients with compensated liver cirrhosis without a
history of surgery for PH. When liver cirrhosis is in subcompensation and patient has a history of surgical
treatment for PH, or suffers from severe comorbidity, endoscopic sclerotherapy should be carried out as first
choice of treatment .
To cite this paper: Nazyrov F.G., Devyatov A.V., Babadjanov A.Kh., Raimov S.A., Salimov U.R. 2016. Results of Portosystemic Shunting in Patients with Liver
Cirrhosis. J. Life Sci. Biomed., 6 (3): 44-52.