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Portal Hypertension: A Multidisciplinary Approach to Current Clinical Management.
1. P C HAYES

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Portal Hypertension: A Multidisciplinary Approach to Current Clinical Management. Edited by Knechtle SJ. (Pp 298; illustrated; $150.00/£93.75.) Futura Publishing Company, 1998. ISBN 0-87993-414-X. I am sure most academics, from time to time, have considered writing a monograph about their favourite subject. Enthusiasm soon wanes however with the realisation of the amount of work and when publishers introduce market related factors such as cost (around £50), authorship (ideally international), usefulness to trainees, etc. The authors of this book however went ahead to write a 300 page monograph on portal hypertension costing$150 and written exclusively by American authors, half of whom are from the same institution.

The first thing that strikes me about this book is that it is surgically orientated, which is perhaps not surprising given the authors, but what is surprising is its concentration on transjugular intrahepatic portosystemic stent shunts (TIPSS). Most of the 11 chapters are 20−30 pages long, whereas the one on TIPSS is well over 100 pages. Although for TIPSS enthusiasts this must be very interesting and is indeed well written but it does make the book seem unbalanced. Some of the other chapters definitely err on the brief side, particularly that on natural history, which is just five pages—too brief, especially considering that one and a half of these pages concerns treatment. The chapter on medical management of portal hypertension is also somewhat superficial. Some trials are discussed but not in a particularly systematic way and there is some repetition and contradiction of other chapters. The authors of the trials and meta-analyses looking at propranolol for the primary prophylaxis of variceal haemorrhage will be disappointed at the lukewarm recommendation given in the chapter on medical management. The temperature cools further in the last chapter (by the editor) that suggests that no therapy can be justified in this situation (primary prophylaxis) with the possible exception of betablockers with or without nitrates.

The thought that immediately struck me on reading this book is, who is it written for? It is unlikely that a monograph, particularly in an area that is moving rapidly and dates quickly, will be bought and read by trainees, even wealthy ones, and specialists in the area already have good evidence-based texts that are up to date in the form ofCurrent Opinion in Gastroenterology andClinics in Gastroenterology. With the emphasis placed on TIPSS it may be that the interventional radiologists would find it useful but most of the other chapters are clearly written for clinicians.

Unlike books written by an international panel of experts, texts such as this, that are principally from one institution, do offer the opportunity of looking at the results from one multidisciplinary team with an interest and expertise in the area. There are occasions in this book where this has been done well, such as in the chapter on TIPSS and liver transplantation but generally there is a tendency just to mention the authors’ opinion and the selected results from few other centres. There is an air of optimism throughout the book particularly about the impact of TIPSS. Although in some areas such as acute variceal bleeding I think this may be justified, the repeated suggestion that TIPSS should be used in ascites, is over-stated and the references used are not particularly up to date.

Another area of optimism in the book is the repeated suggestion that surgical results are getting better because of better selection of patients. Although this may have a beneficial effect on surgeons and surgical results, the patients who are excluded, which may be the majority, may not be quite so impressed. To reserve surgery for patients with good liver function who are likely to do well and unlikely to die from their bleed and keep TIPSS for the poorest patients may be reasonable, as long as when comparisons are made it is clear what has been studied. My own feeling is that endoscopic treatment is underplayed throughout the book and that surgery is proposed in situations when endoscopic treatment may be equally as effective.

Overall, therefore, I think this is an enthusiastic attempt to write what is now a relatively unusual entity—that is, a monograph on a specialist subject. The book, I suspect, will have difficulty surviving in the world of systematic reviews, meta-analyses and consensus conferences.

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