Surgical Options for the Management of Portal Hypertension

Abstract

In the current age of endoscopic and interventional radiologic management of bleeding varices, the paradigm of surgical management for portal hypertension has radically shifted. There remains, however, a less common but important role for the well-trained surgeon who understands and is capable of managing portal hypertension. Patients who may benefit from surgical intervention are those with early cirrhosis or non-cirrhotic portal hypertension and suffer from variceal bleeding due to the consequences of portal, mesenteric, or splenic vein thrombosis. In addition, good surgical candidates who have limited access to care, may not be capable of close follow-up, or who have had failed prior therapy can benefit from more definitive surgical shunting. Liver transplantation has also changed the landscape in managing portal hypertension as the ultimate treatment for patients with advanced cirrhosis. Limited indications and fewer surgeons having been exposed to shunting procedures for portal hypertension have resulted in fewer shunts being performed, though they remain indicated under special circumstances. It is critical that we discern the role of various treatment options in different clinical scenarios and appreciate that under certain circumstances, a surgical intervention is indicated. This article reviews the history and progression of surgery for portal hypertension and highlights the current role of the surgeon in the era of multidisciplinary intervention. Furthermore, an algorithm for current management of variceal bleeding is presented.