50 YEARS OF SURGERY FOR PORTAL-HYPERTENSION AT THE CLEVELAND-CLINIC-FOUNDATION - LESSONS AND PROSPECTS

Objective The 50-year experience with surgery for the treatment of portal hypertension and bleeding varices at the Cleveland Clinic is reviewed. Summary Background Data A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transesophageal ligation of varices or devascularization of the esophagus and stomach with splenectomy; portal-systemic (total) shunts; distal splenorenal (selective) shunts; endoscopic sclerotherapy; transjugular intrahepatic portal-systemic shunts; and liver transplantation. Methods Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994. Results Our use of these procedures has changed as experience and new techniques for managing portal hypertension have evolved. Most ligation-devascularization-splenectomy procedures were performed before 1980; they provide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is rebleeding. Total shunts were performed most frequently before 1980; with patient selection, operative mortality was reduced to 8%, control of bleeding was achieved in more than 90%, but the incidence of encephalopathy was high (30%). Selective shunts provide almost equal protection from rebleeding with less post-shunt encephalopathy. We currently use selective shunts for patients with good liver function. Liver transplantation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patients. Conclusions The selection of patients for these procedures is the key to the successful management of portal hypertension.