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Controversy remains about the best treatment for patients with esophagogastric variceal bleeding. In spite of different therapeutic alternatives and recent progress, such as liver transplantation of TIPS, many patients will finally be treated by standard surgery. With the aim to know the results of surgery in shunting vs non-shunting procedures, we have analyzed a recent and consecutive series of 68 cirrhotics patients operated on for variceal hemorrhage. According to the surgical technique there were three groups: I) 30 patients underwent a total portacaval shunt; II) 18 cases with an azygosportal disconnection; III) 20 patients with a partial portacaval shunt (8-10 mm H-portacaval PTFE graft). All groups were homogeneous considering age, sex etiology, Child-Pugh grade and timing of surgery (elective vs urgent). The complications and mortality rates were similar for the three groups. The overall operative mortality was 10%, and 5% in selected cases (Child-Pugh A-B, non urgent cases). With a follow-up for I, II and III group of 47, 44 and 27 months respectively, chronic encephalopathy have been seen in 61%, 15% and 15% respectively (p < .05). No patient in group I has rebled, and only one case in the II and III groups had a recurrence of hemorrhage. The actuarial three years survival was 76%, 86% and 85% (p NS), and the five year survival was 41% vs 86% for the groups I and II respectively (p < .05). In conclusion, in selected cases, surgery gives excellent immediate and long term results. In patients with variceal bleeding and failure of first line treatments, such as sclerosis or pharmacology, the partial H-portacaval shunt and non-shunting procedures are good alternatives, with low incidence of rebleeding and chronic encephalopathy.

The severe complications of portal hypertension have not been solved yet, except the majority of cirrhotic livers suffering of hemorrhagic varices which are expected to be managed by a liver transplant. When we started to study post operatively our patients operated on with the porta azygous disconnection in whom we ligate the splenic artery and the short vessels with the technique we described in 1981, we found that the patients subject to this procedure have no alterations in their splenic circulation. An anatomic research study determined that the spleen is also irrigated by the left gastroepiploic artery which it has not been described before. This finding simplifies our surgical disconnection procedure because now it is not necessary the ligation of the splenic artery.

The partial or complete obstruction of portal vein and or one of its branches is the most frequent cause of portal hypertension in children. A patient with extrahepatic portal hypertension and progressive course is presented, with great development of esophagogastric varices and multiple episodes of upper gastrointestinal hemorrhage. At the age of 9 years he was submitted to an azygos-portal disconnection by abdominal route, with manual transection of the esophagus, covered and protected by a gastric fundoplication. Postoperative endoscopic control demonstrated significant reduction in the size of esophageal varices and disappearance of gastric varices. Eleven months after surgery the patient was asymptomatic and a new endoscopic control showed no recurrence of varices.

One of the main drawbacks attributed to azygoportal disconnection operations in the surgical treatment of bleeding esophageal varices is recurrence of hemorrhage. The present paper reviews the results obtained as regards hemorrhage recurrence in 4,975 patients who underwent azygoportal disconnection in 41 series published in the western literature in recent years. An analysis is also made of the factors that, according to different authors, could be related to the failure of these procedures to prevent eventual variceal hemorrhage.

Many procedures are described to solve the problem of the massive hemorrhages due to esophageal varices in children with Portal Hypertension in which it's not possible to do a porto-systemic shunt by cause of the age. It's possible to treat them by sclerotherapy but in case of massive hemorrhages in which the patient life is at risk we have used the azygo-portal disconnection following the SUGIURA technique making the esophageal transection with autosuture instrument. We believe that this technical simplification account for more instances in which it's indicated. And it could be preferred to other procedures used with the same objective. We have done it in two male patients which came to our Center in several occasions due to massive hemorrhages. In both cases the Portal Hypertension is of extrahepatic cause. Follow up it is been satisfactory in both cases. Being one of them more than 3 1/2 years without hemorrhagic episodes, remaining under clinical and endoscopic controls. We have used in this cases the Proximate ILS of 21 mm. of Ethicon.