The use of portal-systemic shunt procedures for the treatment of acutely bleeding oesophageal varices is now reserved for the 5-10% of patients who fail to respond to pharmacotherapy or sclerotherapy.
Portal-systemic shunts have a high intraoperative mortality and a poor 5 year survival, particularly in patients with significant hepatic decompensation. The most common problem is chronic hepatic encephalopathy.
There are two types of portal-systemic shunt procedures:
- non-selective procedures:
- the whole portal system is decompressed
- include the end-to-side and the side-to-side porta-caval shunts
- carry a high risk of hepatic encephalopathy
- selective procedures:
- only decompress the oesophagogastric venous network
- have a lower risk of encephalopathy
- include the spleno-renal and the left-gastric -inferior venal cava shunts
Transjugular intrahepatic portal-systemic shunting (TIPSS) is a new procedure which is particularly useful in the treatment of acutely bleeding oesophageal varices if liver transplantation is being considered.