50 YEARS OF SURGERY FOR PORTAL-HYPERTENSION AT THE CLEVELAND-CLINIC-FOUNDATION - LESSONS AND PROSPECTS

Objective The 50-year experience with surgery for the treatment of por tal hypertension and bleeding varices at the Cleveland Clinic is revie wed. Summary Background Data A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transe sophageal ligation of varices or devascularization of the esophagus an d stomach with splenectomy; portal-systemic (total) shunts; distal spl enorenal (selective) shunts; endoscopic sclerotherapy; transjugular in trahepatic portal-systemic shunts; and liver transplantation. Methods Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994. Results O ur use of these procedures has changed as experience and new technique s for managing portal hypertension have evolved. Most ligation-devascu larization-splenectomy procedures were performed before 1980; they pro vide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is reble eding. Total shunts were performed most frequently before 1980; with p atient selection, operative mortality was reduced to 8%, control of bl eeding was achieved in more than 90%, but the incidence of encephalopa thy was high (30%). Selective shunts provide almost equal protection f rom rebleeding with less post-shunt encephalopathy. We currently use s elective shunts for patients with good liver function. Liver transplan tation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patient s. Conclusions The selection of patients for these procedures is the k ey to the successful management of portal hypertension.