Seventy consecutive cirrhotic patients with persistent or recurrent variceal
bleeding were included in a clinical trial to compare the efficacy and safety of
portacaval shunt (PCS) and stapler transection (ST) in patients with low surgical risk, and of stapler transection and endoscopic
sclerotherapy (ES) in patients with high surgical risk. To classify the patients into low- and high-risk groups a new scoring system was used, based on an analysis of factors influencing operative mortality in an earlier series of emergency
portacaval shunt. Thirty-eight low-risk patients were randomly allocated for treatment with
portacaval shunt (19 patients) or stapler transection (19 patients), and 32 high-risk patients for stapler transection (17 patients) or ES (15 patients). The operative mortality of patients treated by PCS was close to that expected according to retrospective data, this indicating that the proposed scoring system is highly discriminant. In low-risk patients,
portacaval shunt evidenced greater haemostatic efficacy and fewer complications than stapler transection. However,
hepatic encephalopathy during follow-up was more frequent in the
portacaval shunt group and there were no significant differences in operative mortality and long-term survival between the two groups. In high-risk patients, stapler transection and
sclerotherapy had a similar haemostatic efficacy, operative mortality and long-term survival. However,
sclerotherapy occasioned fewer complications than stapler transection. Our results motivate us to recommend stapler transection for low-risk patients and to consider
sclerotherapy as an alternative for high-risk patients in the
emergency treatment of uncontrolled variceal
bleeding.