The changing spectrum of treatment for XXXX .

@entity1 @entity101 @entity548 @entity75 @entity5273 @entity409 @entity49 @entity1578 @entity35952
OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and @entity5273 ( @entity5273 ) on @entity1 selection and outcome of surgical treatment for this complication of @entity101 , as reflected in a single surgeon's 18-year experience with operations for @entity548 . SUMMARY BACKGROUND DATA: Definitive treatment of @entity1 who bleed from @entity101 has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and @entity5273 have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive @entity1 who were surgically treated for portal @entity101 @entity548 between 1978 and 1996 were reviewed retrospectively. Four @entity35952 separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and @entity5273 (January 1993) became available in our institution were analyzed. Throughout all four @entity35952 , a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and @entity49 , respectively. Most other @entity1 received a DSRS. RESULTS: The risk status ( @entity1 's class) of @entity1 undergoing surgery progressively improved (p = 0.001) throughout the 4 @entity35952 , whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute @entity548 episodes (sclerotherapy, @entity5273 ) and advanced @entity409 complicated by ascites (liver transplantation, @entity5273 ) became available (p = 0.009). In all @entity35952 , the operative mortality rate was directly related to @entity1 's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk @entity1 underwent operations for @entity548 , the incidence of postoperative @entity75 decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage @entity1 who developed @entity1578 after a prior surgical procedure. There were no differences between @entity35952 with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and @entity5273 has resulted in better selection and improved results with respect to quality and length of survival for @entity1 treated surgically for @entity548 . Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected @entity1 with @entity548 secondary to @entity101 .
