[Atypical portocaval anastomosis for hemorrhage in portal hypertension]

The success of endoscopy in treating esophageal varices and the later introduction of liver transplantation into the algorithm of therapy for liver failure shifted surgery of portal hypertension out of sight of hepatologists and surgeons. This decline from surgical treatment was further confirmed by introduction of TIPS into clinical practice. It is completely out of question that only liver transplantation is the causal solution of decompensated liver disease and a series of reliable and less invasive methods may be selected for acute treatment of bleeding from varices. However, even at the present time the portal-systemic shunt may be used in its own indication in repeatedly bleeding patients with a good liver capacity, where it can play a role by bridging the time to liver transplantation in a way similar to TIPS or even to provide a final solution, which makes it possible to live the life expectancy in adequate comfort without the risk of bleeding complications. However, it is not always possible to place a surgical shunt on some of the main branches of the portal vein. In such cases, devascularization is often successfully applied. Atypical shunts represent an exceptional alternative, because side feeder veins of the portal vein are rarely of sufficient caliber for placing a hemodynamically significant shunt. The authors describe two cases, in which stubborn anemia-causing bleeding events in portal hypertension were treated with left-side epiploic-renal shunt or anastomosis between the mesenteric and left-side iliac vein.