Role of liver transplantation in management of esophageal variceal hemorrhage.

The management of esophageal variceal hemorrhage ranges from conservative to surgical modalities. Before introduction of liver transplantation as a potentially curative therapy of the underlying etiology, decompressive portosystemic shunt operations have been the mainstay of mostly palliative procedures. Our own experience with surgery for advanced hepatic disease and portal hypertension over 20 years includes 803 liver transplantations and 201 portosystemic shunts, emphasizing our primary objective of treatment. The results after shunt surgery were favorable in Child class A candidates when performed electively and with selective decompression. After liver replacement the clinical status of the patient, including hepatic function and extrahepatic complications, had a strong influence on postoperative outcome, with the chance of excellent long-term survival. The additional risk of previous shunt surgery for subsequent transplantation could be reduced over time. Based on this experience and reports from others there are enough reasonable arguments for shunt and transplantation. Instead of the choice being controversial, the two forms of therapy should supplement each other and be available in the same center that specializes in the treatment of patients with diseases that eventually lead to liver failure and portal hypertension. Selection of either approach must depend on etiology, stage of the disease, and proper timing. Shunt procedures may be indicated in stable patients with the risk of bleeding after sclerotherapy failure, in those with contraindications to transplantation, or as a bridge to transplantation. The role of liver transplantation has been clearly established in patients with progressive or endstage (otherwise intractable) hepatobiliary disease.