PORTAL-HYPERTENSION - SURGICAL-MANAGEMENT IN THE 1990S

Background. Although liver transplantation offers definitive treatment for portal hypertension with end-stage liver failure, surgical portos ystemic shunts avoid the risks of transplantation and immunosuppressiv e therapy, and transjugular intrahepatic portosystemic shunt (TIPS) cr eates a portosystemic shunt with minimal operative risk. The appropria te applications of these modalities are discussed. Methods. All adults undergoing primary liver transplantation alone (PLT, n = 265), PLT af ter TIPS (n = 34), PLT after surgical shunts (n = 12), surgical shunt alone (n = 13), TIPS alone (n = 35), or surgical shunt after PLT (n = 5) served as the basis of this study. Results. In contrast to surgical shunts before PLT, TIPS before PLT increased the 1-year graft surviva l. Surgical shunts alone were done in 18 patients with normal or near normal liver function with 100% survival. TIPS alone offered effective symptomatic relief to most patients, all of whom were judged not to b e surgical candidates. Conclusions. TIPS, surgical shunts, and liver t ransplantation each have a logical role in management of portal hypert ension. Surgical candidates with Child's B or C liver failure should b e treated with liver transplantation, and TIPS offers effective treatm ent for nonsurgical candidates. Surgical shunts can be performed with excellent results in patients with Child's A liver disease. Portal vei n occlusion with normal liver function can be successfully treated wit h surgical shunts.