SURGICAL-MANAGEMENT OF ACUTE VARICEAL HEMORRHAGE

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.