Which of the following is the most effective definitive therapy for both prevention of recurrent variceal hemorrhage and control of ascites?

D. Side-to-side portacaval shunt.

DISCUSSION: Shunt operations are the most effective means of preventing recurrent variceal hemorrhage. Rebleeding rates after endoscopic sclerotherapy range from 40% to 60%. Although extensive esophagogastric devascularization has effectively prevented recurrent bleeding in Japanese series, these operations have been followed by rebleeding rates in excess of 25% in most Western series. Although one controlled trial has shown more frequent recurrent hemorrhage following the distal splenorenal shunt than after the portacaval shunt, most series have reported rebleeding rates of less than 10% for both of these operations. Both the liver and the splanchnic viscera are important sites of ascites formation.

Since the distal splenorenal shunt maintains sinusoidal and mesenteric venous hypertension and requires interruption of important retroperitoneal lymphatics, it tends to aggravate rather than relieve ascites. Hepatic sinusoidal pressure may be unchanged or even increased after an end-to-side portacaval shunt. Only side-to-side portal-systemic shunts, such as the side-to-side portacaval shunt, reliably decompress both the liver and splanchnic viscera, thus preventing ascites formation.