Surgery and sclerotherapy for treatment of portal hypertension and oesophageal varices.

Surgery and sclerotherapy are both used for the prevention of rebleeding from varices and for primary prevention. Prophylactic shunt surgery has been shown to be harmful, but devascularisation procedures are in use in Japan. Shunt surgery is the most effective therapy for the prevention of rebleeding and does not decrease survival rates in patients, compared with those not receiving therapy. However, the risk of encephalopathy, which may be severe, is increased. Sclerotherapy reduces the number of patients rebleeding by only a small proportion, but greatly diminishes the number of episodes of rebleeding. However, the value of emergency sclerotherapy in preventing rebleeding throughout the long term studies, as opposed to the solely elective component, has not been evaluated. The non-injection arm received neither emergency nor elective injection. Randomised studies comparing sclerotherapy and shunt surgery show surgery to be more effective and to have similar survival rates to sclerotherapy, with the exception of 1 study. Devascularisation, as practised by Sugiura, results in bleed-free rates equivalent to those achieved with shunts. These results have not been reproduced in the West. Since liver transplantation is a reality today, shunt surgery involving the portal vein and devascularisation should be avoided.