The role of elective operation in the treatment of portal hypertension.

Variceal bleeding is associated with a high rate of rebleeding and death if left untreated. Operative therapy is an important modality for managing portal hypertension in patients unsuitable for, or who fail, sclerotherapy. Review of 41 patients undergoing 42 surgical procedures for portal hypertension since 1988 revealed 22 elective procedures with a 4.5 per cent operative mortality. Ten emergent procedures were undertaken for patients actively bleeding, resulting in a 40 per cent mortality rate. Minor rebleeding not related to portal hypertension occurred in 2 of the 35 patients who survived long term, and long-term shunt patency was 97 per cent. These 41 patients were compared with 35 patients undergoing transjugular intrahepatic portosystemic shunts (TIPS) at Vanderbilt University Medical Center, whom we have previously reported. Five patients underwent shunt procedures after TIPS failure. Attempts to decompress portal hypertension using TIPS placement have met with limited success because of early thrombosis (12%), stenosis (41%), and a high rebleeding rate. Our data suggest that elective operative shunting procedures for the treatment of portal hypertension in Child's class A or B patients are associated with low rates of mortality, encephalopathy, and rebleeding. Moreover, the encephalopathy rate that occurred after TIPS or operative total shunt was higher than that observed in patients undergoing selective distal splenorenal shunt. Therefore, we advocate the elective operation rather than TIPS in the management of portal hypertension in patients with good liver reserve. TIPS is better suited for the patient with active bleeding, poor liver reserve, transplant candidates, or in patients with prohibitive operative risk.