Portal hypertension: surgical management in the 1990s.
BACKGROUND
Although liver transplantation offers definitive treatment for portal hypertension with end-stage liver failure, surgical portosystemic shunts avoid the risks of transplantation and immunosuppressive therapy, and transjugular intrahepatic portosystemic shunt (TIPS) creates a portosystemic shunt with minimal operative risk. The appropriate applications of these modalities are discussed.


METHODS
All adults undergoing primary liver transplantation alone (PLT, n = 265), PLT after 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 survival. 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 be surgical candidates.


CONCLUSIONS
TIPS, surgical shunts, and liver transplantation each have a logical role in management of portal hypertension. Surgical candidates with Child's B or C liver failure should be treated with liver transplantation, and TIPS offers effective treatment for nonsurgical candidates. Surgical shunts can be performed with excellent results in patients with Child's A liver disease. Portal vein occlusion with normal liver function can be successfully treated with surgical shunts.
Knechtle
S J
SJ
Department of Surgery, University of Wisconsin Medical School, Madison.
Kalayoglu
M
M
D'Alessandro
A M
AM
Pirsch
J D
JD
Armbrust
M J
MJ
Sproat
I A
IA
Wojtowycz
M M
MM
McDermott
J C
JC
Crummy
A B
AB
Belzer
F O
FO
D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D006975:Hypertension, Portal / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011170:Portasystemic Shunt, Surgical