Which of the following is the most effective definitive therapy for both prevention of recurrent variceal hemorrhage and control of ascites?

Shunt operations are the most effective means of preventing recurrent variceal hemorrhage. Rebleeding rates after endoscopic sclerotherapy range from 40% to 60%. Although extensive esophagogastric devascularization has effectively prevented recurrent bleeding in Japanese series, these operations have been followed by rebleeding rates in excess of 25% in most Western series. Although one controlled trial has shown more frequent recurrent hemorrhage following the distal splenorenal shunt than after the poacaval shunt, most series have repoed rebleeding rates of less than 10% for both of these operations. Both the liver and the splanchnic viscera are impoant sites of ascites formation. Since the distal splenorenal shunt maintains sinusoidal and mesenteric venous hypeension and requires interruption of impoant retroperitoneal lymphatics, it tends to aggravate rather than relieve ascites. Hepatic sinusoidal pressure may be unchanged or even increased after an end- to-side poacaval shunt. Only side-to-side poal-systemic shunts, such as the side-to-side poacaval shunt, reliably decompress both the liver and splanchnic viscera, thus preventing ascites formation.