Selective or total shunts for variceal bleeding

Shunt surgery remains an important therapeutic option in the management of variceal bleeding, and both total and selective shunts have a role to play. The distal shunt is associated with a lower long-term encephalopathy rate and may yield better survival in the nonalcoholic patient; it is, therefore, the preferred shunt in the elective situation. The total shunt is technically easier to perform and more widely available; it is, therefore, preferred in the emergency situation. Ordinarily, the side-to-side and end-to-side shunts have similar outcomes; however, in patients with hepatic venous outflow obstruction and patients with intractable ascites, the side-to-side shunt should be used.