The role of portosystemic shunting in the management of portal hypertension.

In this chapter, we have tried to indicate the role of the portosystemic shunt in the treatment of portal hypertension. The conclusions are evident: in the last 10 years it has lost its role as leader in the treatment of portal hyper-tension. However, some firm statements can be made. The selective shunt is an operation that provides both good variceal decompression and satisfactory maintenance of liver function. Its results in great part depend on the skill of the surgeon. Only a patient with good liver function (Child's classes A and B) is a candidate for shunt surgery, with, very occasionally, a patient with severe disease (class C). In an emergency, the operation is used only after failure of sclerotherapy, but it must be used at the right time before the patient's condition has deteriorated. In the prevention of variceal rebleeding, the selective shunt or sclerotherapy can be routine measures. The choice between the two treatments depends on the patient's willingness and the ability of the institution to perform both procedures successfully. If sclerotherapy is chosen, the institution must be able to rapidly rescue a sclerotherapy failure by shunt surgery. Liver transplantation is probably the treatment of the future, but it is at present impossible to suggest that the procedure is feasible for all patients with variceal bleeding and severe liver disease.