Enucleation for Giant Liver Haemangioma

67 quantitative measures of liver function remained good. These data are consistent with our own study comparing DSRS and sclerotherapy which measured quantitative liver function. We showed that patients successfully managed with sclerotherapy, who had no major rebleeding, showed a significant improvement in galactose elimination capacity over the first year1. Lesson: the data in this study show that neither of the randomized therapies significantly accelerate liver failure compared to each other. What of the high mortality and failure to achieve surgical rescue of patients who failed sclerotherapy in this study? This factor is the major difference between this study and our previously published study .I n the Emory study only one patient randomized to scler-otherapy died as a direct result of rebleeding, and 12 were successfully salvaged by surgical management. In contrast, in the present study 8 patients died as a direct result of rebleeding in the sclerotherapy group and only 5 patients had surgical rescue. The authors correctly point out that access was a major problem for their sclerotherapy patients who rebleed, and this highlights one of the shortcomings of sclerotherapy. What are the lessons? In patients in whom sclerotherapy is selected as primary management, a strategy should be in place from the outset to treat rebleeding or consider surgical treatment for persistent high risk varices. Finally, it must be remembered that sclerotherapy and surgical shunt are not the only treatments for variceal bleeding. Liver transplant has dramatically altered the management of patients with end-stage liver disease. But, it is end-stage liver disease and not variceal bleeding per se which is the indication for transplant. However, in any patient who bleeds from varices, full evaluation at the time of the initial bleed is a critical step to help answer the question: is this patient now, or will they in the future be a candidate for liver transplant? The answer to that question will influence treatment choice. We have recently published an approach to the evaluation of such patients'. In addition, the radiologists are back in the fray5. Trans-jugular intrahepatic portal system shunts (TIPS) can provide portal decompression, but lack of randomized trials and good objective data leave the role of TIPS to be defined. In summary, the four prospective randomized trials which have compared DSRS to sclerotherapy all show better control of bleeding with decompressive shunt6. Neither therapy appears to significantly accelerate liver failure. Survival differs in these studies, …