Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Long-term results of emergency shunt in 94 patients with bleeding varices

Randomized trials of endoscopic therapy and transjugular intrahepatic portosystemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis

IMPORTANCE

Bleeding esophageal varices has been studied extensively, but bleeding gastric varices (BGV) has received much less investigation. However, BGV has been reported in ≤ 30% of patients with acute variceal bleeding. In our studies of 1,836 bleeding cirrhotics, 12.7% were bleeding from gastric varices. BGV mortality rate of 45-55% has been reported. The BGV literature has mainly involved retrospective case reports, often with short-term follow-up.

OBJECTIVE

We sought to describe the results of a prospective, randomized, controlled trial (RCT) in unselected, consecutive patients with BGV comparing endoscopic therapy (ET) with portacaval shunt (PCS; n = 518), and later comparing emergency transjugular intrahepatic portosystemic shunt (TIPS) with emergency portacaval shunt (EPCS; n = 70).

DESIGN, SETTING, AND PARTICIPANTS

Initially, our RCT involved 518 patients with BGV comparing ET with direct PCS regarding control of bleeding, mortality rate, and disability. When entry of patients ended, the RCT was expanded to compare emergency TIPS with EPCS (n = 70). This RCT of BGV was separate from our other RCTs of bleeding esophageal varices.

INTERVENTIONS

Initially, ET was compared with PCS. In the second part of our RCT, emergency TIPS was compared with emergency PCS (EPCS).

MAIN OUTCOME MEASURES

Outcomes were survival, control of bleeding, portal-systemic encephalopathy (PSE), quality of life, and direct costs of care. In the RCT of ET versus PCS, 28 and 30%, respectively, were in Child class C. In the expanded RCT of TIPS versus EPCS, 40 and 41%, respectively, were in Child class C. Permanent control of BGV was achieved in 97-100% of patients treated by emergency or elective PCS, compared with 27-29% by ET. TIPS was even less effective, achieving long-term control of BGV in only 6%. Survival rates after PCS were greater at all time intervals and in all Child classes (P < .001). Repeated episodes of PSE occurred in 50% of TIPS patients, 16-17% treated by ET, and 8-11% treated by PCS. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0-2% of PCS patients.

CONCLUSION

These results support the conclusion that PCS is uniformly effective, whereas ET and TIPS are not very effective.

Randomized controlled trial of emergency transjugular intrahepatic portosystemic shunt versus emergency portacaval shunt treatment of acute bleeding esophageal varices in cirrhosis

BACKGROUND

Emergency treatment of bleeding esophageal varices (BEV) in cirrhosis is of paramount importance because of the resultant high mortality rate. Emergency therapy today consists mainly of endoscopic and pharmacologic measures, with use of transjugular intrahepatic portosystemic shunt (TIPS) when bleeding is not controlled. Surgical portosystemic shunt has been relegated to last resort salvage when all other measures fail. Regrettably, no randomized controlled trials have been reported in which TIPS and surgical portosystemic shunt were compared in unselected patients with acute BEV, with long-term follow-up. This is a report of a long-term prospective randomized controlled trial (RCT) that compared TIPS with emergency portacaval shunt (EPCS) in patients with cirrhosis and acute BEV.

STUDY DESIGN

A total of 154 unselected, consecutive cirrhotic patients ("all comers") with acute BEV were randomized to TIPS (n = 78) or EPCS (n = 76), and the two treatments were compared with regard to effect on survival, control of bleeding, portal-systemic encephalopathy (PSE), and disability. Diagnostic workup was completed within 6 h and TIPS or EPCS was initiated within 24 h. Regular follow-up was accomplished in 100 % of patients and lasted for 5 to 10 years in 85 % and 3 to 4.5 years in the remainder. This report focuses on control of bleeding and survival.

RESULTS

The clinical characteristics of the two groups were similar, and the distribution of Child classes A, B, and C was almost identical. TIPS was successful in controlling BEV for 30 days in 80 % of patients but achieved long-term control of BEV in only 22 %. In contrast, EPCS controlled BEV immediately in all patients and permanently in 97 % (p < 0.001). TIPS patients required almost twice as many units of blood transfusion as EPCS patients. Survival rate at all time intervals and in all Child classes was significantly greater following EPCS than after TIPS (p < 0.001). Median survival was over 10 years following EPCS, compared to 1.99 years following TIPS. Stenosis or occlusion of TIPS was demonstrated in 84 % of patients who survived 21 days, 63 % of whom underwent TIPS revision, which failed in 80 %. In contrast, EPCS remained permanently patent in 97 % of patients. Recurrent PSE was threefold more frequent following TIPS than after EPCS (61 versus 21 %).

CONCLUSIONS

EPCS was uniformly effective in the treatment of BEV, while TIPS was disappointing. EPCS accomplished long-term survival while TIPS resulted in a survival rate that was less than one fifth that of EPCS. The results of this RCT in unselected, consecutive patients justify the use of EPCS as a first-line emergency treatment of BEV in cirrhosis (clinicaltrials.gov #NCT00734227).

Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis

BACKGROUND

The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage.

STUDY DESIGN

A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death.

RESULTS

The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01).

CONCLUSIONS

EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).

Colorectal surgery in cirrhotic patients: assessment of operative morbidity and mortality

PURPOSE

The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery.

METHODS

From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality.

RESULTS

Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P < 0.05), postoperative complications (P < 0.04), postoperative infections (P < 0.01), and total colectomy procedures (P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P < 0.04).

CONCLUSIONS

Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.

Beneficial Effect of Partial Portal Decompression Using the Inferior Mesenteric Vein for Intractable Gastroesophageal Variceal Bleeding in Patients With Liver Cirrhosis

BACKGROUND

Use of the inferior mesenteric vein (IMV) for partial portal decompression has not been recommended as a first-line option for intractable gastroesophageal variceal bleeding because of the thin diameter of the vein. Although these indications remain relevant, few reports have compared partial portal decompression using the IMV with other therapies. We propose that partial portal decompression using the IMV is a useful alternative treatment for intractable variceal bleeding.

METHODS

We performed partial portal decompression using the IMV in eight patients with intractable variceal bleeding that had been uncontrolled using medical and endoscopic therapies. All patients were classified into Child's class B or C. The surgical data, morbidity, and mortality were assessed.

RESULTS

Mean portal venous pressure significantly decreased from 26.9 +/- 2.0 mmHg before the surgery to 19.8 +/- 3.9 mmHg after the surgery. The operative mortality rate was 0%. The mean duration of hospital stay was 25.5 +/- 13.3 days. Although one patient experienced recurrent bleeding, shunt patency was well maintained in all patients during the follow-up period (mean 28.9 +/- 14.1 months). Six patients are still alive and well without ascites or hepatic encephalopathy. Two of the Child's class C patients who underwent emergency shunt died owing to hepatic decompensation.

CONCLUSION

Partial portal decompression using the IMV can be a safe, effective way to treat intractable variceal bleeding in patients with liver cirrhosis. However, use of the shunt procedure may have the most survival benefits for cirrhotic patients with preserved liver function.

Current state of portosystemic shunt surgery

BACKGROUND

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective, and durable procedures to treat variceal bleeding in patients with low operative risk and good liver function.

DISCUSSION

In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) and a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or transjugular intrahepatic portosystemic shunt insertion fails to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) should be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

Trauma in Cirrhotics: Survival and Hospital Sequelae in Patients Requiring Abdominal Exploration

Hepatic cirrhosis significantly increases the mortality and morbidity of elective surgery; therefore we hypothesized that cirrhosis would adversely impact outcome after abdominal trauma. We used the trauma registry to identify 17 patients with cirrhosis who sustained trauma injuries requiring emergent exploratory laparotomy. Patients were characterized with respect to age, sex, hospital days, intensive care unit days, and trauma scores. A control group (n = 73) was constructed from the registry by matching age, sex, Injury Severity Score (ISS) and Abbreviated Injury score. Mortality rates were compared by Fisher's exact test and age, ISS, Revised Trauma Score 2, and hospital and intensive care unit days were compared by Student's t test. Despite similar ISS between cirrhotic patients and controls, patients with cirrhosis had a fourfold increase in mortality (mortality odds ratio = 7.2; 95% confidence interval = 2.2–24.0). Cirrhotic trauma patients had a complication rate of 71 per cent and a mortality of 44 per cent. We conclude that cirrhosis is a major independent risk factor for mortality in trauma patients with injuries that require emergent abdominal surgery.

Management of portal hypertension-related bleeding

Although endoscopic sclerotherapy and TIPS remain the primary therapeutic tools in management of acute variceal bleeding, surgical shunts must be considered for low-risk patients with bleeding. OLTx is the only definitive treatment for patients with end-stage liver disease and vascular decompensation. Furthermore, the current prospective multicenter randomized study, funded by the National Institutes of Health and Human Services, will help determine the role of DSRS versus TIPS in cirrhotic patients with good hepatic reserve. This is a necessity in a time in which organ shortages are ever-increasing because of a growing disparity between the number of patients listed for transplantation each year versus the number of suitable organ donors. The various surgical techniques should be applied in different situations based on patients' clinical status at the time of the bleed and whether they are considered candidates for liver transplantation.

Transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding in portal hypertension: comparison of emergency and elective interventions

Nonsurgical reduction of portal hypertension by transjugular intrahepatic portosystemic shunt (TIPS) is widely used for prevention of variceal rebleeding (elective TIPS). Information is limited about the value of emergency TIPS for acute variceal bleeding unresponsive to endoscopic and drug therapy. The aim of the present study was therefore to determine whether the effects and complications differ between emergency and elective TIPS in patients with cirrhosis of the liver. TIPS was performed in 11 patients with acute variceal bleeding unresponsive to endoscopic treatment and 22 patients in stable condition after an episode of variceal bleeding. Clinical examination, blood sampling, Doppler sonography of TIPS flow, and upper gastrointestinal endoscopy were performed at days 1, 7, and 30 and at three-month intervals after TIPS. Mean follow-up was 549 (1-987) days. Bleeding was controlled by emergency TIPS in 10/11 patients. Probability of survival was not different after emergency and elective TIPS (0.73 vs 0.84 at one year). Early rebleeding (< or =2 weeks) occurred more often after emergency TIPS (3/11 vs 0/22 patients; P = 0.03), but there was no significant difference in late rebleeding. Occlusion of TIPS was more frequent after emergency TIPS. Occurrence of TIPS stenoses was identical in both groups (4/11 vs 8/22). De novo or deterioration of preexisting hepatic encephalopathy was similar (18% vs 24%; NS). It is concluded that TIPS is effective for control of acute variceal bleeding unresponsive to endoscopic and drug treatment. Early rebleeding and stent occlusion occurred more often after emergency TIPS. Late rebleeding, complications, and long-term survival did not differ from elective TIPS.

Abdominal operations in patients with cirrhosis: still a major surgical challenge

BACKGROUND

Hepatic transplantation and portasystemic shunts can be safely performed in patients with advanced liver disease, whereas other abdominal procedures appear to have a much higher mortality rate. This study reviews the outcomes of patients with cirrhosis after the full spectrum of abdominal operations.

METHODS

In a 12-year period, 92 patients diagnosed with cirrhosis required either an emergent or elective abdominal operation. There were four categories of operations: cholecystectomy in 17 patients, hernia in 9, gastrointestinal tract in 54, and other procedures in 12. Fifty-five clinical, laboratory, and operative variables were analyzed to identify factors predictive of poor outcome.

RESULTS

Coagulopathy developed in 24 patients (27%) and sepsis in 15 (16%). The mortality rate after emergent operations was 50%, compared to 18% for elective cases (p = 0.001). Other factors that predicted mortality included the presence of ascites (p = 0.006), encephalopathy (p = 0.002), and elevated prothrombin time (p = 0.021). The mortality in Child's class A patients was 10%, compared to 30% in class B and 82% in class C patients.

CONCLUSIONS

Patients with cirrhosis undergoing elective or emergent operations are at a significant risk of developing postoperative complications leading to death. The most accurate predictor of outcome is the patient's preoperative Child's class.

Portal vein thrombosis in cirrhosis with variceal hemorrhage

Organized thrombus in the main trunk of the portal vein was encountered in 85 (6.5%) of 1300 patients with cirrhosis and variceal hemorrhage who underwent direct portacaval shunt (PCS). The thrombus was successfully removed with restoration of portal blood flow in all patients by phlebothrombectomy and balloon catheter extraction. Of the 85 patients, 65 were among 400 unselected patients who underwent emergency PCS (16%), and 20 were among 900 selected patients who underwent elective PCS (2%). All patients were closely followed for at least 5 years. Patients with portal vein thrombosis (PVT) had more advanced liver disease than those without PVT, reflected preoperatively in significantly higher (P < 0.01) incidences of ascites (75%), severe muscle wasting (52%), varices of very large size (94%), the hyperdynamic state (94%), severe hypersplenism with a platelet count of less than 50,000/mm3 (92%), and placement in Child's class C (52%). Side-to-side PCS reduced the portal vein-inferior vena cava pressure gradient to a mean of 23 mm saline solution in patients with PVT, similar to the marked pressure reduction obtained in patients without PVT. PCS promptly stopped variceal bleeding in all patients in the emergency PCS group. Permanent prevention of recurrent variceal bleeding was successful in 95% of patients with PVT and more than 99% of patients without PVT. Survival rates were similar in patients with and without PVT. In patients with PVT, survival rates at 30 days and 1, 5, 10, and 15 years following emergency PCS were 69%, 66%, 65%, 55%, and 51%, respectively, and following elective PCS were 95%, 90%, 70%, 65%, and 60%, respectively. Quality of life was similar in patients with and without PVT. Long-term PCS patency was demonstrated yearly in 93% of patients in the group with PVT and in 99.7% of patients without PVT. Other similarities after 5 years between patients with and without PVT, respectively, were the incidences of recurrent encephalopathy (9% vs. 8%), alcohol abstinence (61% vs. 64%), improved liver function (68% vs. 62% to 75%), and return to work (52% vs. 56% to 64%). It was concluded that in patients with cirrhosis and variceal hemorrhage it is almost always possible to remove portal vein thrombus by means of phlebothrombectomy and then perform a direct PCS with results similar to those achieved in the absence of PVT.

Is the role of transjugular intrahepatic portosystemic shunts limited in the management of patients with end-stage liver disease?

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) are an established method for the treatment of the complications of portal hypertension. Recent reports have suggested that TIPS require frequent follow-up and may interfere with orthotopic liver transplantation (OLT).

METHODS

Retrospective chart review was performed of ultrasound studies, angiographic studies, and complications of the first 100 patients treated consecutively with TIPS from February 1992 through October 1995.

RESULTS

Ninety-seven patients had functional TIPS. Thirty-one percent of patients treated emergently survived, significantly less than the 96% survival of elective patients. Fifty percent of the shunts were found to require angioplasty by 5 months. Seventeen patients treated with OLT did well, without intraoperative bleeding problems, and are alive.

CONCLUSIONS

The TIPS method treats successfully the complications of portal hypertension but requires careful follow-up. The technique may be used prior to OLT. For non-OLT candidates, the cost effectiveness of TIPS versus surgical shunting remains in question.

Current management of oesophageal varices

Patients with chronic liver disease and large varices with endoscopic features which put them at high risk of bleeding, especially if they have a HVPG of more than 12 mmHg, should be treated with beta-blockers at a dose which lowers their pulse by 25%, as prophylaxis against future bleeding. Once a patient bleeds from oesophageal varices, emergency treatment with octreotide should be commenced until endoscopic sclero- or ligation therapy is performed. If these treatments are not readily available, or if bleeding continues in spite of treatment, balloon tamponade is employed to arrest bleeding. In the event of recurrent bleeding, further sclero- or ligation therapy should be attempted, but continued bleeding would dictate surgical therapy or insertion of a TIPS. What operation is performed would depend on the local expertise. In a suitable candidate, liver transplantation would be considered. If bleeding is controlled by sclero- or ligation therapy, chronic sclerotherapy should be continued until the varices are obliterated, and beta-blockers commenced. Regular follow-up should be arranged to encourage abstinence from alcohol if appropriate, and to decide the most opportune time for transplantation if indicated.

Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation. Lessons and prospects

OBJECTIVE

The 50-year experience with surgery for the treatment of portal hypertension and bleeding varices at the Cleveland Clinic is reviewed.

SUMMARY BACKGROUND DATA

A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transesophageal ligation of varices or devascularization of the esophagus and stomach with splenectomy; portal-systemic (total) shunts; distal splenorenal (selective) shunts; endoscopic sclerotherapy; transjugular intrahepatic portal-systemic shunts; and liver transplantation.

METHODS

Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994.

RESULTS

Our use of these procedures has changed as experience and new techniques for managing portal hypertension have evolved. Most ligation--devascularization--splenectomy procedures were performed before 1980; they provide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is rebleeding. Total shunts were performed most frequently before 1980; with patient selection, operative mortality was reduced to 8%, control of bleeding was achieved in more than 90%, but the incidence of encephalopathy was high (30%). Selective shunts provide almost equal protection from rebleeding with less post-shunt encephalopathy. We currently use selective shunts for patients with good liver function. Liver transplantation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patients.

CONCLUSIONS

The selection of patients for these procedures is the key to the successful management of portal hypertension.

Hepatic disorders. Features and appropriate management

The spectrum of liver disease is extremely wide, with many of the underlying disorders having acute and chronic presentations. Most of the underlying pathogenetic mechanisms are accounted for by autoimmune disease, viral infection and toxic insult. The management strategy of any liver disease is a combination of treating the symptoms and complications that arise, as well as drug therapies relevant to the specific underlying diagnosis. Encephalopathy, ascites, spontaneous bacterial peritonitis, variceal bleeding and pruritus are the main complications at which drug therapy is directed, although in some cases it represents only 1 aspect of the overall management. Drug therapy per se is largely ineffective in acute liver failure with the possible exception of acetylcysteine, but many drugs are used in the management of the constituent components of this complex medical emergency. Treatments for specific liver conditions are expanding, especially in the areas of autoimmune and viral disease. The increasing availability and success of liver transplantation has tended to change the emphasis of management, and it is often not appropriate to exhaust the treatment options before referring the patient for transplantation. A comprehensive review of all liver disease is beyond the scope of this article, but hopefully the important principles of management and commonly occurring clinical decisions are discussed.

Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices

A prospective randomized trial was conducted in unselected, consecutive patients with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamponade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received identical supportive therapy initially. All patients were followed up for at least 10 yr. The protocol contained no escape or cross-over provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p < 0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p < 0.001). Mean requirement for blood transfusion was 7.1 +/- 2.6 units in the shunt group and 21.4 +/- 2.6 units in the medical group (p < 0.001). Eighty-one percent of the patients in the shunt group were discharged alive compared with 45% in the medical group (p = 0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p < 0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.

Emergency transjugular intrahepatic portasystemic stent shunting as salvage treatment for uncontrolled variceal bleeding

Creation of a transjugular intrahepatic portasystemic stent shunt (TIPSS) was used as a rescue treatment for patients with variceal bleeding refractory to standard medical and endoscopic treatment. Over a 2-year period 242 episodes of variceal bleeding were treated and emergency shunting was performed on 20 patients with uncontrolled bleeding (Pugh grade A, one; B, seven; C, 12). The procedure was technically successful and controlled bleeding in all patients. Six patients had early rebleeding within 5 days, and further shunting was required in two. Two had late rebleeding related to shunt occlusion and had a further TIPSS procedure followed by portacaval shunting. Twelve patients died within 40 days from liver failure and sepsis, and there were two late deaths after 2 and 6 months, unrelated to bleeding. TIPSS insertion is an effective therapeutic option in patients with acute variceal bleeding refractory to medical and endoscopic treatment. However, despite control of bleeding in this group, the hospital mortality rate was high, reflecting the severity of the underlying liver disease.

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.

Surgical management of acute variceal hemorrhage

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.

Portal hypertension management

Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric devascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic porto-systemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.