Operations for management of esophageal variceal hemorrhage

Many surgical procedures, including four categories of portal-systemic shunts and a variety of nonshunting operations, have been proposed for patients who bleed from esophagogastric varices. As data have accumulated from clinical trials designed to assess these operations, no single procedure has emerged as ideal for all patients. The urgency of surgical operation, status of hepatic hemodynamics and experience of the surgeon appear to be the most important factors to consider in selecting the appropriate operation for a patient. The timing of the operation with respect to the acute bleeding episode remains controversial. As more effective, conservative methods for temporarily controlling hemorrhage have become available, however, most surgeons now prefer elective procedures because they have lower surgical mortality than emergency intervention. Selective portal-systemic shunts (distal splenorenal shunt and left gastric-vena caval shunt) and nonshunting operations are probably the only procedures that preserve hepatic portal perfusion and thus are less frequently complicated by postoperative encephalopathy than completely diverting shunts. Side-to-side portal-systemic shunts, because they decompress hepatic sinusoids and the splanchnic viscera, are the most effective operations for relieving ascites. None of the available procedures have been proved by controlled trials to be superior to others with respect to long-term postoperative survival.