Prospective study of a planned approach to the surgical management of bleeding oesophageal varices.

A policy of joint management of patients with acute variceal bleeding was constructed and applied prospectively to 37 consecutive patients. According to the protocol, every patient underwent an initial joint assessment by a physician and a surgeon soon after admission and resuscitation, which included age, previous history, physical examination and biochemical profile. Pugh's modification of Child's scoring system was used to assess the severity of the underlying hepatic disorder. Patients in groups A and B who were less than 70 years of age were treated by shunt surgery carried out during the same admission. Patients outwith this category were managed conservatively and a blood transfusion limit (10 units) imposed unless the clinical picture subsequently improved or the liver function was good but the patient was not eligible for surgery because of age. Twenty seven patients underwent shunt surgery, the most frequent procedure being a Warren shunt (n = 21). The average hospital stay in the surgically treated group was 18 days. The 30 day operative mortality was 15%. Two further deaths in the shunted group occurred during the follow-up period (mean = 30 months, range = 6-97 months). Seventeen patients in the shunted group remain well but three have required further therapy because of rebleeding episodes (two with sclerotherapy, one by surgery). Two patients who went abroad after recovery from their shunt surgery have been lost to follow up. The survival in the conservatively treated group was short and recurrent bleeding common. This experience indicates that an initial joint assessment using established criteria reliably identifies the poor prognosis group of patients with variceal haemorrhage and allows the rationalisation of the hospital resources.Early and expeditious selective shunt surgery in the good risk category carries an acceptable mortality and is cost effective in the long term.