ROLE OF ELECTIVE OPERATION IN THE TREATMENT OF PORTAL-HYPERTENSION

Variceal bleeding is associated with a high rate of rebleeding and dea th if left untreated. Operative therapy is an important modality for m anaging portal hypertension in patients unsuitable for, or who fail, s clerotherapy. Review of 41 patients undergoing 42 surgical procedures for portal hypertension since 1988 revealed 22 elective procedures wit h a 4.5 per cent operative mortality. Ten emergent procedures were und ertaken for patients actively bleeding, resulting in a 40 per cent mor tality rate. Minor rebleeding not related to portal hypertension occur red in 2 of the 35 patients who survived long term, and long-term shun t patency was 97 per cent. These 41 patients were compared with 35 pat ients undergoing transjugular intrahepatic portosystemic shunt (TIPS) at Vanderbilt University Medical Center, whom we have previously repor ted. Five patients underwent shunt procedures after TIPS failure. Atte mpts to decompress portal hypertension using TIPS placement have met w ith limited success because of early thrombosis (12%), stenosis (41%), and a high rebleeding rate. Our data suggest that elective operative shunting procedures for the treatment of portal hypertension in Child' s class A or B patients are associated with low rates of mortality, en cephalopathy, and rebleeding. Moreover, the encephalopathy rate that o ccurred after TIPS or operative total shunt was higher than that obser ved in patients undergoing selective distal splenorenal shunt. Therefo re, we advocate elective operation rather than TIPS in the management of portal hypertension in patients with good liver reserve. TIPS is be tter suited for the patient with active bleeding, poor liver reserve, transplant candidates, or in patients with prohibitive operative risk.