Portal Hypertension. A Multidisciplinary Approach to Current Clinical Management

PORTAL HYPERTENSION. A MULTIDISCIPLINARY APPROACH TO CURRENT CLINICAL MANAGEMENT. Edited by Stuart J. Knechtle. 298 pp. Illust. Futura Publishing Company, Inc., Armonk, NY. 1998. US$150. ISBN 0-87993-414-X

Before the late 1970s, surgical shunts were the only effective definitive treatment for variceal bleeding and were associated with poor results. Treatments such as transjugular intrahepatic portosystemic shunting (TIPS), endoscopic variceal banding and liver transplantation have since been developed, making the management of patients with portal hypertension more complex and more effective.

The goal of this book is to provide a current update on modern application of the latest therapies for portal hypertension. It also provides clinical multidisciplinary approaches to patient management and their rationale rather than an exhaustive review of the subject. Each of the 11 chapters has been written by experienced surgeons, gastroenterologists or interventional radiologists.

For a better understanding of the results of different treatments, the first chapter covers the natural history of esophageal varices. The pharmacologic management of portal hypertension is well described in the chapter on the use of different drugs, not only in the context of treatment of acute variceal hemorrhage but also in its prophylaxis and prevention of rebleeding. Medical management of ascites is also discussed with regard to diuretics and paracentesis. Finally, pharmacologic management of spontaneous bacterial peritonitis and portal systemic encephalopathy is briefly covered.

Two gastroenterologists discuss endoscopic therapy, including sclerotherapy, balloon tamponade and variceal ligation through an in-depth analysis of clinical trials published to date. They thoroughly review sclerotherapy for the treatment of active bleeding and prevention of rebleeding. They also compare variceal ligation to sclerotherapy with detailed reference to published studies. Finally, the management of gastric varices is well described.

There are 2 chapters on TIPS. The first, an extensive chapter of 117 pages, is written by an interventional radiologist. It covers in detail the history of the development, indications, techniques, complications and evaluation of the results of treatment of portal hypertension. The second chapter looks at the impact of TIPS on liver transplantation, describing the clinical benefits of TIPS to patients awaiting liver transplantation and the technical aspects of liver transplantation in patients who have undergone TIPS. A retrospective study at the University of Wisconsin of liver transplant experience in patients who had undergone TIPS is reported.

The editor has contributed a chapter on surgically inserted shunts, describing the history, patient selection and preoperative evaluation, the types of shunts (nonselective and selective) and the complications. He ends the chapter by reporting the University of Wisconsin experience with portosystemic shunts. He has also written a chapter on liver transplantation, including new surgical techniques such as reduced-size liver transplantation, split-liver transplantation and the piggy-back technique, but he does not cover living-related liver transplantation. Liver transplantation before and after portacaval shunting is discussed briefly. Results from the United States of liver transplantation between 1987 and 1994 give the reader a good overview of this surgical therapy in the management of patients with portal hypertension.

In the chapter on devascularization procedures, the authors describe their small personal experience and the world experience with the Sugiura procedure. Two short chapters provide a clinical update of peritoneovenous shunting and portal hypertension in children, mainly in regard to liver transplantation.

The final chapter emphasizes the need for a multidisciplinary approach to the clinical management of patients with portal hypertension. It focuses on algorithms of clinical decision-making for the management of various complications of the disorder.

This book provides a good overview of each of the current therapies for portal hypertension. It will be appreciated mostly by general surgeons having a special interest in this condition and by interventional radiologists, hepatogastroenterologists and intensive care specialists who deal with this complex disease.