The Role of the Distal Splenorenal Shunt in the Sclerotherapy Era?

65 Clearly it is essential to have an organized, experienced team in place. One needs an energetic endo-scopist, an aggressive surgeon; a capable anesthesio-logist and the rest of the supporting cast to undertake prompt diagnostic procedures, perform major surgery quickly, to provide nutritional support and to carry the patient through the post-operative period and a long term follow-up. Despite all this praise, Orloffis not perfect. He makes the point that he is using the Child-Turcotte-Campbell system of grading the severity of cirrhosis7, but he is not. In the Campbell modification it is necessary to determine whether the ascites is "easily controlled" or "difficult to control", decisions that require multiple observations. In Orloff's series ascites is graded on its preserved absence and volume immediately after a discussion. Furthermore, there are better methods of treating active bleeding than by infusing vasopressin. One aspect of these data must be taken into serious consideration, i.e. "The Wizard Phenomenon". A wizard is defined as "one endowed with exceptional skill...and able to achieve something held to be im-possible''9. Orloff's reported feats with EPCS surgery easily satisfy this definition. One must worry whether subsequent surgeons can equal Orloff's achievements, but this lis the way of the world. In all fields of human endeavor progress is made by incremental breakthroughs. On October 18, 1968, for example Bob Be-amon made a prodigious longjump at the Olympics is Mexico City (8.90 m), almost 22 inches, longer than the existing world record, which had changed less than 8 inches in 33 years. In 1991, this new record, too, was broken o. Starzl et al., performed the first liver transplant in a human in 1963 a unique occurrence thought then to be of little practical value, and now, thirty years later, this procedure is performed as standard therapy at hundreds of hospitals. EPCS has been performed by many surgeons for many years, perhaps, not so successfully as Orloff, but I predict that using a different time frame, surgeons will be able to perform this procedure as rapidly and effectively as the Wizard of San Diego. After considering all these data I think that EPCS may be the one true treatment of actively bleeding varices and that Orloff is its prophet. between mercaptans and ammonia or fatty acids in the production of coma: a possible role for mercaptans in the pathogenesis of hepatic coma.systemic encephalopathy and portacaval anastomosis: a prospective controlled investigation. (1973) …