Direct portacaval anastomoses are safe and effective in patients with previous abdominal operations

Variceal rebleeding after portosystemic shunting. Strategies and solutions to a vexing problem

The purpose of this review was to discuss an approach to the treatment of recurrent bleeding from esophageal or gastric varices after portosystemic shunt. From our own clinical experience, as well as that of others, it appears that re-establishment of portal decompression should offer the best chance at long-term survival. Luckily, innovations in angiographic technique have allowed attainment of this goal without the inordinate risk of an operative procedure. However, not all patients' situations will be amenable to such treatment. For some of them, operative decompression of the portal venous system can be carried out in an anatomic area previously untouched. For those patients in whom no decompression is possible, direct endoscopic treatment of the varices will offer an alternative, albeit temporizing, approach.

The portacaval shunt. Is it still indicated?

This article has attempted to question whether the more recently introduced methods of treating the patient with variceal hemorrhage have resulted in higher salvage rates and a better quality of life. Data concerning other types of central shunts, selective shunting, nonshunt operations, hepatic transplantation, sclerotherapy, and pharmacologic manipulation have all been critically reviewed. It seems clear that, although some of these modalities are roughly equivalent to portacaval shunting, others are inappropriate. This is especially so in the majority of patients with portal hypertension in the United States whose cirrhotic etiology is based on alcohol addiction. Additionally, a large, one-institution series of side-to-side portacaval shunts has been presented that yielded good results. It is hoped that this presentation has succeeded, at a minimum, in causing the reader to question the basis of treatment for variceal hemorrhage and, at a maximum, in convincing him or her to retain the portacaval shunt as a mainstay in treating the hemorrhagic complications of portal hypertension.