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 porto
systemic shunting (TIPS) is likely to have a further impact. When acut
e or chronic sclerotherapy fails or when bleeding is secondary to gast
ric varices or portal hypertensive gastropathy, emergency surgery may
be life-saving and should be done promptly before worsening hepatic fu
nctional decompensation develops. Child's class C liver disease is not
a contraindication to emergency surgery; many patients who fail nonop
erative attempts at control of bleeding are of this risk status. The m
ost commonly utilized emergency procedures are portacaval and interpos
ition mesocaval shunts, both of which are effective, and esophageal tr
ansection, which is associated with a higher incidence of late rebleed
ing. An emergency distal splenorenal shunt is appropriate for selected
patients who are not actively bleeding at the time of surgery. TIPS i
s the preferred alternative for acute or chronic endoscopic sclerother
apy failures who are candidates for liver transplantation within the s
ucceeding 6 to 12 months.