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This paper reports the clinical results of a retrospective study comparing endoscopic injection sclerotherapy (EIS) and back-up surgical treatment after EIS in the management of acute variceal bleeding. The 74 patients included in the study were divided into 2 groups. Group I consisted of 41 patients who received EIS over a mean period of 2.2 sessions and Group II consisted of 33 patients who underwent EIS and subsequent surgical intervention, in the form of 19 distal splenorenal shunts and 14 nonshunting procedures. The overall percentage of patients in whom initial control of variceal bleeding was achieved was 91.8 per cent. Four of the Group II patients were saved by emergency nonshunting operations. Rebleeding was experienced by 4 (28.6 per cent) of the 14 patients who underwent nonshunting surgery but by only 1 (5.3 per cent) of the 19 patients who underwent selective shunt surgery. The cumulative survival in Group II was significantly superior to that in Group I with 2 year survival being achieved in 66.7 per cent of the Group II patients but in only 23 per cent of Group I patients. Thus, the combination of initial EIS and back-up surgical intervention may be more beneficial than sclerotherapy alone for patients with acute variceal bleeding, while, the distal splenorenal shunt may be a more suitable surgical technique for patients having previously EIS.

A prospective randomized trial of selective distal splenorenal shunt (DSRS) versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a so-called pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished.

A 27 year old cirrhotic male underwent stenosis of the distal splenorenal shunt to treat bleeding of esophageal varices. Percutaneous transluminal angioplasty was performed first by catheterization of the right femoral vein, but without success. Therefore, a direct puncture of the splenic vein through the spleen was made, under sonographic guidance, followed by balloon dilatation of the stenotic anastomosis. The pressure of the splenic vein before and after PTA was 35 and 29 cm H2O, respectively. Both the follow-up barium esophagogram and esophagoscopy showed marked regression of the esophageal varices.