[Variceal hemorrhage in portal hypertension: role of surgery in the acute and elective situation].

Abstract

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 first bleeding remains constant between 30 and 50% and depends directly on patient risk (Child C). Surgical intervention during the acute bleeding phase carries a mortality rate of up to 70% and should therefore be avoided. About 90% of patients with acute variceal haemorrhage may satisfactorily be managed with pharmacotherapy and/or endoscopic banding alone. If bleeding persists, 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 interposition graft is preferred, whereas for transplant candidates a TIPS is used. The long-term outcome for surgical shunts is significantly better compared to TIPS. Secondary prophylaxis consists of medical treatment (propanolol) and repeated endoscopic banding. If rebleeding occurs under adequate therapy, surgery (mesocaval shunt/TIPS) should be evaluated. However, liver transplantation is the only curative therapeutic option for this life-threatening disease.