Bleeding due to portal hypertension: the role of surgery

Several therapeutic options are available to stop acute variceal bleeding or prevent its recurrence. Sclerotherapy has emerged as the optimal method for stopping acute bleeding, and as primary therapy for preventing recurrence. Surgery is required for the 30% to 40% in whom sclerotherapy fails. Selective variceal decompression has emerged as the best surgical option to balance bleeding control and maintenance of liver function. Survival is significantly improved at five years in nonalcoholic (75%) compared with alcoholic (45%) cirrhotic patients. Recent advances have modified the operative technique to better maintain portal perfusion. Total shunts stop bleeding, and may be used in emergencies. Devascularization procedures have a 20% to 40% rebleeding rate, but do not accelerate liver failure. Liver transplantation, which is increasingly indicated for patients with end-stage liver disease and variceal bleeding, is dictated by the degree of hepatic failure. To provide optimal patient care, a center should be able to offer all of the treatment methods.