[Portal hypertension and variceal bleeding: shunt in concomitant or general prehepatic block]

Thrombosis of the portal system should be ruled out in all patient with esophagogastric varices. Such patients with no evidence of concomitant liver disease and with a high risk of rebleeding (e.g. gastric varices, low platelet counts, endoscopic criteria) should be referred to decompressive shunt surgery. The type of shunt is dictated by the patent segments of the portal system. Splenectomy should be avoided. The results show a low operative mortality, a zero encephalopathy and a low rebleeding rate. Patients with prehepatic thrombosis and liver cirrhosis represent a more severe problem since the risk and mortality of variceal hemorrhage is high and on the other hand TIPS procedure and liver transplantation may be impossible. In case of a high risk of rebleeding or endoscopic therapy failure we advocate surgical shunting as the risk of encephalopathy appears to be low when portal flow diversion already exists.