Surgical methods for the prevention of first and recurrent variceal bleeding.

Variceal bleeding should be managed by sclerotherapy for control of acute bleeding, and as the initial method in preventing recurrence. Surgery is required for the 30-40% who fail sclerotherapy. The surgical choices are selective variceal decompression, total portal systemic shunt, devascularization procedures, liver transplantation. Distal splenorenal shunt (DSRS) combines good control (greater than 90%) and maintenance of hepatic function. Survival after DSRS is significantly better in nonalcoholic, 75% at 5 years, compared to alcoholic cirrhotics, 45% at 5 years: this difference is associated with improved maintenance of portal flow in the former. Loss of portal flow in 60% of alcoholics has led to modification of DSRS with total disconnection of the splenic vein from the pancreas, resulting in improved portal flow maintenance. Patients with bleeding secondary to portal vein thrombosis and schistosomiasis are excellent candidates for DSRS. Total shunts will stop bleeding, and may be required emergently for uncontrolled hemorrhage. Portacaval H-graft is easily performed, but loss of portal flow accelerates liver failure. Devascularization procedures have a 20-40% rebleeding rate, but do not accelerate liver failure. Liver transplantation is increasingly indicated for patients with end-stage liver disease and variceal bleeding. However, it is the degree of hepatic failure, rather than the variceal bleeding per se, which dictates the need for this therapy. Optimal patient care requires that a center should be able to offer all such therapies.