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Background/aims: We examined the cost and cost effectiveness of distal splenorenal shunt (DSRS) and transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of variceal rebleeding., Methods: Patients participated in a randomized controlled trial comparing DSRS to TIPS. Quality of life (QOL) was measured using SF-36 preceding randomization and yearly thereafter. Cost utility analysis was performed using TreeAge DATA. Costs for both in- and out-patient events and interventions were obtained for each patient. Costs using coated stents were estimated using different rates of stenosis. Incremental cost effectiveness ratios (ICERs) were determined at 1, 3 and 5 years., Results: The average yearly costs of managing patients after TIPS and DSRS over 5 years were similar, $16,363 and $13,492, respectively. Cost of TIPS for surviving patients exceeded the cost of DSRS at years 3 and 5 but not significantly. ICERs per life saved favored TIPS at year 5 ($61,000). If coated rather than bare stents were used the cost effectiveness of TIPS increased slightly., Conclusions: TIPS is as effective as DSRS in preventing variceal rebleeding and may be more cost effective. TIPS, in all aspects, is equal to DSRS in the prevention of variceal rebleeding in patients who are medical failures.

Background & Aims: Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding., Methods: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 +/- 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated., Results: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different., Conclusions: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.

Recent trends in the clinical management of bleeding esophageal varices include a shift away from endoscopic variceal sclerotherapy toward endoscopic variceal ligation. The excellent efficacy of the latter and its lower complication rate favor its increased use. Similarly, the minimally invasive nature of the TIPS procedure and its successful implementation by invasive radiologists have further reduced the need for surgical shunts in general, as well as when endoscopic intervention has failed. A multidisciplinary approach toward evaluation and treatment of variceal hemorrhage can be expected to improve the outcomes of these patients. More selective application of each of the therapies, either alone or in combination with other modalities, leads to improved results, as recently demonstrated by a series comparing outcomes of surgical shunts when used alone or as a preface to liver transplantation.

Objective: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage., Summary Background Data: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures., Methods: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS., Results: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization., Conclusions: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.

Objective: The indications for and the results of portosystemic shunts done in the authors' institution since initiation of a liver transplant program 10 years ago were reviewed., Summary Background Data: With the widespread availability of liver transplantation as definitive treatment of chronic liver disease, the role of shunts in the overall management of variceal bleeding needs to be redefined., Methods: Seventy-one variceal bleeders with cirrhosis who received a shunt (82% distal splenorenal shunts) because of sclerotherapy failure or because endoscopic treatment was not indicated were reviewed retrospectively. In 44 patients with well-preserved hepatic reserve, the shunt was used as a long-term bridge to transplantation (shunt group 1). The remaining 27 patients with shunts were not transplant candidates mainly because of uncontrolled alcoholism or advanced age (shunt group 2). Survival of both shunt groups was compared to that of 180 adult patients with a history of variceal bleeding who underwent transplantation soon after referral., Results: Because of their more advanced liver disease, the liver transplant group had a higher operative mortality rate (19%) than did either of the shunt groups (5% and 7%, respectively) (p < 0.02). Kaplan-Meier survival analysis showed better survival in shunt group 1 (seven patients thus far transplanted) than in either the liver transplant group or shunt group 2 during the early years and superior survival of shunt group 1 and the liver transplant group as compared to shunt group 2 during the later years of the analysis. Only two patients from shunt group 1 have died of late postoperative hepatic failure without benefit of liver transplantation., Conclusions: A shunt may serve as an excellent long-term bridge to liver transplantation in patients with well-preserved hepatic reserve. Shunt surgery still plays an important role in treatment of selected patients with variceal bleeding who are not present or future transplant candidates.

Background: During the past 18 years we have used a selective operative approach for variceal bleeders in whom endoscopic sclerotherapy failed or sclerotherapy was not indicated. Esophagogastric devascularization with splenectomy has been reserved for unshuntable patients and for those in whom a shunt was deemed inadvisable. The purposes of this study are to describe the surgical procedure technique and indications for esophagogastric devascularization and to report its long-term results., Methods: Thirty-two patients who underwent either a limited (n = 9) or extensive (n = 23) esophagogastric devascularization procedure without esophageal transection for variceal bleeding were retrospectively reviewed. Common indications were thrombosis of all splanchnic veins (n = 12), distal splenorenal shunt thrombosis (n = 7), generalized portal hypertension with isolated splenic vein thrombosis (n = 5), and symptomatic splenomegaly or severe hypersplenism (n = 6). Eighteen patients (56%) had cirrhosis, eleven (34%) received an emergency operation, and eighteen (56%) bled from gastric varices., Results: Three patients with Child's class C disease undergoing emergency surgery died during the early postoperative interval. Rebleeding occurred in nine surviving patients (31%) and was the cause of death in three. Rebleeding rates for the limited and extensive devascularization procedures were 50% and 24%, respectively. Only one of 11 patients with diffuse splanchnic venous thrombosis without liver disease has died. The 5-year survival rate of patients with liver disease was 51%. Only two patients experienced postoperative encephalopathy., Conclusions: When used in selected patients, esophagogastric devascularization without esophageal transection is a reasonably effective alternative to shunt surgery.

Objective: To evaluate the results of selective and nonselective emergency portosystemic shunts in patients with acute variceal hemorrhage., Design: Retrospective review., Setting: University medical center and Veterans Affairs medical center., Patients: Forty-two consecutive patients who underwent emergency portosystemic shunts from 1978 through 1994. All patients had chronic liver disease (29 [69%] had alcoholic cirrhosis) and half had Child's class C disease. Sixteen patients were actively bleeding at the time of surgery, and 26 had bled within 48 hours. Twenty-two patients underwent a nonselective shunt and 20 underwent a distal splenorenal shunt. The percentages of patients with Child's class C disease and with active bleeding at the time of surgery were significantly higher in the nonselective shunt group., Main Outcome Measures: Operative mortality; early postoperative rebleeding, shunt patency, encephalopathy, and ascites; and long-term survival., Results: Operative mortality rates were higher in patients with Child's class C disease (43% [9/21]) than in patients with Child's class A or B disease (9% [2/21]) and were higher in patients with active bleeding (all of whom underwent nonselective shunt) (44% [7/16]) than in patients who underwent distal splenorenal shunt (10% [2/20]). All shunts were patent after surgery, and no patient had rebleeding during the early postoperative interval. Early postoperative ascites and encephalopathy rates were similar after nonselective shunt and distal splenorenal shunt. Long-term survival was superior in the lower-risk distal splenorenal shunt group., Conclusions: Even though more effective nonoperative treatments are now available, emergency portosystemic shunt remains an important option for selected patients with acute variceal hemorrhage. When bleeding can be temporarily controlled by nonoperative means, distal splenorenal shunt is an effective and safe emergency procedure. The mortality rate remains high for patients with Child's class C disease undergoing protal decompression.

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.

Surgical options for management of variceal hemorrhage include portosystemic shunts (nonselective and selective), nonshunting operations, and hepatic transplantation. In most centers, operations that preserve hepatic portal perfusion (selective shunt and nonshunting operations) have replaced nonselective shunts as the most commonly performed surgical procedures. The results of multiple controlled trials suggest that the frequency of postshunt encephalopathy is less after the distal splenorenal shunt than after the nonselective shunts. Hepatic transplantation should be considered as initial therapy for nonalcoholic cirrhotics and abstinent alcoholic cirrhotics with variceal hemorrhage or advanced liver disease and without contraindications.

Between September 1982 and April 1988, 60 cirrhotic patients with prior variceal hemorrhage were randomized to undergo the placement of an elective shunt (distal splenorenal: 26; nonselective: 4) or long-term endoscopic sclerotherapy (n = 30). Eighty-six percent of patients had alcoholic cirrhosis, and 33% were classified as Child's class C. After a mean follow-up of 87 months, 60% of patients undergoing sclerotherapy and 17% of shunt patients experienced rebleeding (p < 0.001). Shunt patients have survived longer than those who had sclerotherapy (6-year survival rates of 53% and 26%, respectively; p < 0.05). In part because of the wide geographic distribution of patients, only 4 of 13 patients in whom sclerotherapy failed (31%) could undergo salvage by shunt surgery. Although hepatic portal perfusion was better maintained after sclerotherapy, there were no major differences between the groups in terms of post-therapy hepatic or psychoneurologic function. In a predominantly alcoholic cirrhotic patient population (half non-urban), the results of elective shunt surgery were superior to those of chronic endoscopic sclerotherapy with respect to the prevention of recurrent variceal hemorrhage and survival.

Meta-analysis was used to evaluate 4 clinical trials comparing distal spleno-renal shunt (DSRS) with endoscopic sclerotherapy (EVS) in the prevention of variceal rebleeding: the interval between bleeding and therapy ranges from < 14 days to > 100 days. A questionnaire was sent to each author of the published trials concerning methods, definitions and results of the trials in order to obtain more detailed and up-to-date information. The selected end-points for the meta-analysis were: rebleeding, mortality and chronic encephalopathy. Analysis of the results in the questionnaires was made using the method proposed by Collins. The pooled relative risk (i.e. the combined Odds ratio of each trial as an estimate of overall efficacy) of rebleeding was statistically reduced by DSRS (0.16; 95% confidence interval 0.10-0.27). Despite this, the overall risk of death following DSRS was only marginally decreased (0.78; 95% confidence interval 0.47-1.29); the lack of homogeneity in the results does not permit any significant conclusions on this end-point. However, in non-alcoholic patients, the decrease in risk of death was greater, and this without heterogeneity, following DSRS than EVS (0.59; 95% confidence interval 0.23-1.50). The overall risk of chronic encephalopathy was slightly increased after DSRS (1.86; 95% confidence interval 0.90-3.86). In conclusion, DSRS significantly reduced the risk of rebleeding compared to EVS without increasing the risk of chronic hepatic encephalopathy. However, DSRS did not significantly affect the overall death risk. Only in non-alcoholic disease did it seem to show an advantage over EVS.

Since its introduction into clinical practice in 1967, selective variceal decompression by means of a distal splenorenal shunt (DSRS) has become one of the more commonly performed portal-systemic shunting procedures in the treatment of variceal hemorrhage throughout the world. In addition to selective decompression of gastroesophageal varices, the DSRS provides the advantages of preservation of portal perfusion of the liver and maintenance of intestinal venous hypertension. Many large, uncontrolled series and the majority of controlled randomized studies have demonstrated a lower incidence of encephalopathy after the DSRS than after nonselective shunt procedures. A secondary advantage of the DSRS is that the hepatic hilum is avoided, thus making subsequent liver transplantation a less formidable procedure. None of the studies have shown an advantage to this shunt with respect to long-term survival in patients with alcoholic cirrhosis. However, some of the large, uncontrolled series have shown that survival is significantly improved in patients with non-alcoholic cirrhosis compared to nonselective shunt procedures in the same population. Controlled trials comparing the DSRS to endoscopic sclerotherapy have shown that chronic endoscopic variceal sclerosis is an appropriate initial therapy for most patients as long as shunt surgery is readily available if sclerotherapy fails.

None of the portasystemic shunts are ideal for all patients with recurrent variceal hemorrhage. Hemodynamic and clinical status should determine the type of shunt selected. Patients with a compatible anatomy, hepatopetal protal flow and controlled ascites are best served by a distal splenorenal shunt. Patients with variceal hemorrhage and medically resistant ascites are candidates for a side-to-side shunt, with consideration being given to an operation that avoids dissection of the porta hepatis. The end-to-side portacaval shunt should be used only in the emergency situation when other options are not available. However, due to the effectiveness of other therapies, such as sclerotherapy, in controlling bleeding, emergency shunts are rarely required. On the basis of the controlled trials of distal splenorenal shunt versus sclerotherapy, the latter is the initial treatment of choice with distal splenorenal shunt used promptly when sclerotherapy fails. Patients who live in remote areas, and noncompliant individuals may be best served with a distal splenorenal shunt as initial therapy.

Definitive therapy for variceal hemorrhage has evolved during the past half century. Only completely decompressing shunts (nonselective shunts) were available before 1967. Additional options now include selective shunts, devascularization procedures, endoscopic sclerotherapy, pharmacotherapy, and hepatic transplantation. Although drug treatment is experimental at the present time, the remaining therapeutic options are applicable to various subgroups of patients and in certain clinical settings. At the University of Nebraska, patients with variceal bleeding are first grouped based on their candidacy for transplantation. Transplantation candidates with advanced (Child's class C) or symptomatic liver disease undergo transplantation as soon as possible. Future transplantation candidates with stable, asymptomatic liver disease undergo either long-term sclerotherapy or a distal splenorenal shunt if sclerotherapy fails or if they have poor access to tertiary medical care. These patients are carefully monitored so that they can undergo transplantation before they become high-operative risks. Patients who are not candidates for transplantation receive chronic variceal sclerotherapy as initial therapy so long as shunt surgery is readily available if sclerotherapy fails. When surgery is indicated, the distal splenorenal shunt is preferred to nonselective shunts because several controlled and uncontrolled series have demonstrated a lower frequency of encephalopathy after selective variceal decompression.

The nonoperative management of acute variceal hemorrhage can control acute hemorrhage and allow stabilization of the patient prior to definitive therapy to prevent further bleeding episodes. Balloon tamponade, endoscopic sclerotherapy, and pharmacotherapy can stop acute variceal bleeding. Endoscopic sclerotherapy has the highest reported success rate, decreases the incidence of early rebleeding, and is the recommended first method to control bleeding.

At the present time, liver transplantation must be considered among the treatment options for patients with variceal hemorrhage. For a significant percentage of variceal bleeders throughout the world, however, transplantation is not a viable option either because the patient is not an appropriate transplant candidate or because of the etiology of the patient's portal hypertension. Sclerotherapy and portosystemic shunts remain the mainstay of therapy for these patients. The survival rates with liver transplantation are superior to those reported for other therapies for variceal hemorrhage in patients who have moderate or severe liver disease in addition to variceal hemorrhage. Child's C patients whose variceal hemorrhage is controlled medically should be evaluated for transplantation and receive chronic sclerotherapy while they wait on the transplant list. If the variceal hemorrhage cannot be controlled medically in a transplant candidate, then the patient should undergo an emergency shunt procedure. The shunt of choice is a large-bore H-graft mesocaval or mesorenal shunt. This shunt effectively controls the acute hemorrhage, is relatively simple to perform, does not adversely impact on the subsequent liver transplant, and can simply be ligated after the transplant is completed. Patients who experience variceal hemorrhage as the only manifestation of their liver disease should be treated initially with endoscopic sclerotherapy. For that small group of patients who are either not candidates for sclerotherapy or who rebleed despite sclerotherapy, the choice of shunt or transplantation is presently a difficult one, because both therapies provide excellent results in this group of patients. The choice of therapy should be made on an individual basis and only after consultation with both transplant and shunt surgeons. If a shunt is chosen, we prefer the DSRS because it maintains hepatic portal perfusion in many patients and does not require dissection of the porta hepatis. The management of patients with a prior portosystemic shunt at the time of transplantation depends on the type of shunt and the duration of time between the shunt and the transplant. Shunts not involving the hepatic hilum have little adverse impact on the performance of the transplant. There are insufficient data to assess accurately the effect of a prior portacaval shunt on the transplant. However, our clinical experience and that of other transplant groups indicate that the transplantation of these patients is technically more difficult than that of patients with shunts not involving the hilum. With the availability of other shunting procedures that do not involve extensive dissection of the hepatic hilum, there is little role for either end-to-side or side-to-side portacaval shunts in patients who are potential liver transplant candidates.(ABSTRACT TRUNCATED AT 400 WORDS)

No single treatment for bleeding esophageal varices is appropriate for all patients and situations. An algorithm for management of the patient with acute bleeding is presented in this article. The options for long-term, definitive therapy and the criteria for selection of each are discussed.

Hypersplenism frequently accompanies cirrhosis with portal hypertension. In this series of 76 patients, 36 percent had thrombocytopenia, 41 percent had leukopenia, and 25 percent had both thrombocytopenia and leukopenia. However, hypersplenism was severe enough to necessitate splenectomy in only two patients (3 percent). Nonalcoholic cirrhotic patients exhibit hypersplenism more frequently and to a greater magnitude than do alcoholic cirrhotic patients. Fourteen and 44 percent of alcoholic and nonalcoholic cirrhotics, respectively, had both thrombocytopenia and leukopenia. Distal splenorenal shunts and nonselective shunts are equally effective in relieving preoperative hypersplenism. Approximately two thirds of the patients were relieved of thrombocytopenia or leukopenia after either of these procedures. Splenectomy invariably corrects hypersplenism associated with cirrhosis and should be included as part of the operative procedure in patients requiring surgery for control of variceal hemorrhage.

Since 1978, the operation chosen for patients with variceal hemorrhage has been based on preoperative hemodynamic and clinical factors. One hundred sixteen consecutive patients were managed with the following operations: distal splenorenal shunt (75 patients), nonselective shunts (33 patients), and nonshunting operation (8 patients). Emergency surgery was required in 19 percent of patients. The selection criteria used resulted in the majority of high risk patients receiving nonselective shunts. This selective operative approach resulted in an overall operative mortality of 12 percent, a median survival of 3 years, and postoperative encephalopathy, ascites, and recurrent variceal hemorrhage in 20, 23, and 11 percent of patients, respectively. Operative mortality for the total group was closely related to Child's class. Whereas encephalopathy was most frequent after nonselective shunts, ascites was more common after the distal splenorenal shunt. Recurrent hemorrhage rarely occurred after a shunting procedure, but was a frequent complication of nonshunting operations. Neither the type of procedure selected nor the cause of liver disease influenced long-term survival.

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.

In 1971 a prospective, randomized trial was initiated to determine efficacy of the distal splenorenal shunt in the management of cirrhotic patients who had previously bled from esophageal varices. When entry into the trial was terminated in 1976, 26 patients had received the distal splenorenal shunt (selective) and 29 had undergone a nonselective shunting procedure (18 interposition mesorenal, six interposition mesocaval, and five other nonselective shunts). Three operative deaths occurred in each group. Early postoperative angiography revealed preservation of hepatic portal perfusion in 14 of 16 selective patients (88%), but in only one of 20 nonselective patients (5%; p < .001). Quantitative measures of hepatic function (maximal rate of urea synthesis or MRUS and Child's score) were similar to preoperative values in the selective group but were significantly decreased in nonselective patients on the first postoperative evaluation (p < .001 for MRUS; p < .05 for Child's score). Eighty-seven per cent of selective and 81% of nonselective patients have now been followed for three to six years since surgery. Late postoperative evaluation of 29 survivors (12 selective, 17 nonselective) still shows an advantage to the selective group with respect to MRUS, Child's score, and incidence of hepatopetal portal blood flow, but differences are no longer statistically significant. However, if the seven patients with portal flow (five selective; two nonselective) are compared to the 20 with absent portal flow (seven selective; 13 nonselective), the former group has significantly higher values for MRUS (p < .05) and Child's score (p < .025). No patient with continuing portal perfusion has developed encephalopathy as compared to a 45% incidence of this complication in individuals without portal flow (p < .05). No significant differences between selective and nonselective groups have appeared with respect to total cumulative mortality (ten selective; 38%; eight nonselective, 28%), shunt occlusion (two selective, 10%; five nonselective, 18%), or recurrent variceal hemorrhage (one selective, 4%; two nonselective, 8%). Overall, significantly fewer selective patients have developed postoperative encephalopathy (three selective, 12%; 15 nonselective, 52%; p < .001). Therefore, we conclude that the distal splenorenal shunt, especially when its objective of maintaining hepatic portal perfusion is achieved, results in significantly less morbidity than nonselective shunting procedures.

Figure 2 is the algorithm followed in our institution for management of acute variceal hemorrhage. A small percentage of patients who present with active variceal hemorrhage will stop bleeding after gastric lavage alone. However, most patients require an intravenous vasopressin infusion at a dose of 0.4 units per minute, preferably combined with intravenous administration of nitroglycerin. Although glypressin and somatostatin may be associated with fewer side effects than vasopressin, the superiority of these drugs remains to be determined. Whether pharmacologic therapy succeeds or fails, most patients then proceed to endoscopic sclerotherapy. Sclerotherapy may be used as a temporizing measure in preparation for elective surgery or as a long-term, definitive treatment for prevention of recurrent hemorrhage. Balloon tamponade is reserved for patients who are bleeding too rapidly for effective sclerotherapy and for sclerotherapy failures in preparation for emergency surgery. Because recurrent hemorrhage frequently occurs after balloon deflation, a more definitive treatment (surgery or endoscopic sclerotherapy) should be planned for all patients who undergo balloon tamponade. Because operative risk is unacceptably high for patients with hepatic functional decompensation secondary to variceal hemorrhage, we believe that a policy of routine emergency surgery is unwise. Rather, emergency surgical intervention is reserved for the relatively small number of patients (15 to 25 per cent) who continue to bleed after nonoperative options have failed. Shunt surgery should be considered early in the course of patients with bleeding secondary to gastric varices and portal hypertensive gastropathy, both of which respond poorly to nonoperative measures.