Variceal haemorrhage in portal hypertension: role of surgery in the acute and elective situation

The role of surgery in portal hypertension has changed over time. The past decade has seen significant advances in pharmacotherapy (acute and elective ), endoscopy and interventional radiology. However, mortality from the firs t bleeding remains constant between 30 and 50% and depends directly on pati ent risk (Child C). Surgical intervention during the acute bleeding phase c arries a mortality rate of up to 70% and should therefore be avoided. About 90% of patients with acute variceal haemorrhage may satisfactorily be mana ged with pharmacotherapy and/or endoscopic banding alone. If bleeding persi sts, balloon tamponade (Linton) is indicated. In case of recurrent bleeding under maximal therapy (problem bleeder), delayed shunting may be indicated . In patients with Child A/B cirrhosis surgical mesocaval shunt with an int erposition graft is preferred, whereas for transplant candidates a TIPS is used. The long-term outcome for surgical shunts is significantly better com pared to TIPS. Secondary prophylaxis consists of medical treatment (propano lol) and repeated endoscopic banding. If rebleeding occurs under adequate t herapy, surgery (mesocaval shunt/TIPS) should be evaluated. However, liver transplantation is the only curative therapeutic option for this life-treat ening disease.