Not Every Patient With Variceal Bleeding Needs a Liver Transplant" might be an alternative title for the article by van Hoek et al1 published in the July issue of the Archives. This is an important article because it shows that satisfactory outcome can be achieved in appropriately selected patients by a decompressive shunt. Issues of patient selection, organ shortage, and cost dictate the need to explore "lesser" therapies than transplantation to manage the complications of cirrhosis. Certainly, liver transplantion is an effective therapy to relieve portal hypertension and stop variceal bleeding while at the same time addressing the basic abnormality. But, it is end-stage liver disease, not variceal bleeding, that is the indication for liver transplantation.
This report presents 57 patients receiving a shunt because they were not candidates for transplantation. Is this emphasis correct? The opposite approach could be advocated of evaluating for a decompressive shunt: only consider