The management of esophageal variceal
hemorrhage ranges from conservative to surgical modalities. Before introduction of
liver transplantation as a potentially curative
therapy of the underlying etiology, decompressive
portosystemic shunt operations have been the mainstay of mostly palliative procedures. Our own experience with surgery for advanced hepatic disease and
portal hypertension over 20 years includes 803
liver transplantations and 201
portosystemic shunts, emphasizing our primary objective of treatment. The results after shunt surgery were favorable in Child class A candidates when performed electively and with selective
decompression. After liver replacement the clinical status of the patient, including hepatic function and extrahepatic complications, had a strong influence on postoperative outcome, with the chance of excellent long-term survival. The additional risk of previous shunt surgery for subsequent
transplantation could be reduced over time. Based on this experience and reports from others there are enough reasonable arguments for shunt and
transplantation. Instead of the choice being controversial, the two forms of
therapy should supplement each other and be available in the same center that specializes in the treatment of patients with diseases that eventually lead to
liver failure and
portal hypertension. Selection of either approach must depend on etiology, stage of the disease, and proper timing. Shunt procedures may be indicated in stable patients with the risk of
bleeding after
sclerotherapy failure, in those with
contraindications to
transplantation, or as a bridge to
transplantation. The role of
liver transplantation has been clearly established in patients with progressive or endstage (otherwise intractable)
hepatobiliary disease.