Elective management of the patient who has bled from esophageal varices

Variceal hemorrhage can be controlled by nonsurgical means in over 50% of patients. As a result, their general hepatic status can often be improved by preoperative preparation for the elective procedure. The major problem following elective end-to-side portacaval shunting is encephalopathy; it occurs in up to one half of patients who undergo this shunting procedure. Mesocaval shunting has been proposed as a better operation because of lower frequency of encephalopathy; however, the authors' experience has not confirmed this. Distal splenorenal shunting, as shown by the results of a prospective controlled trial, does have a lower frequency of encephalopathy, but the initial morbidity and mortality are higher and an improvement in the duration of survival is not yet evident.