Peritoneovenous Shunting as Compared with Medical Treatment in Patients with Alcoholic Cirrhosis and Massive Ascites

The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. In a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P≤0.01 for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P<0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P<0.001] and 5.0 vs. 3.1 weeks in Group 2 [P<0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting. (N Engl J Med 1989; 321:1632–8.) ASCITES in patients with alcoholic cirrhosis is usually treated by the administration of diuretic agents and the restriction of sodium and water. Such therapy may not be successful and can cause serious adverse effects. The insertion of a peritoneovenous shunt usually relieves the ascites promptly. 1 The use of this device is controversial because the patients continue to be at risk for other complications of cirrhosis, as well as added problems due to the shunt. 2 One previous study, in which the patients were randomly assigned to receive either medical or surgical therapy, 3 resulted in the prolongation of survival and the more . .