Editor,—We read with great interest the article by Jalan and colleagues (Gut2000;46:578–81OpenUrlCrossRefPubMedWeb of Science) on the clinical position of transjugular intrahepatic portosystemic stent-shunt (TIPSS). This procedure is a useful method of reducing portal pressure by creating a portosystemic shunt in the liver. They suggested that TIPSS can be a successful treatment for bleeding gastric fundal varices (FV) unresponsive to pharmacological and endoscopic therapy. However, Sanyalet al reported that TIPSS was ineffective for FV associated with a large gastrorenal shunt, even when the hepatic venous pressure gradient falls below the critical bleeding threshold of 12 mm Hg.1

The behaviour of varices at different sites seems to differ.2 Therefore, FV should be treated on the basis of their haemodynamics. FV arise from the dilation of short or posterior gastric veins and are frequently associated with a large gastrorenal shunt that decompresses the portal system.3 Balloon occluded retrograde transvenous obliteration (B-RTO) is a novel radiological treatment for FV that was developed by Kanagawa and colleagues.4 This procedure involves insertion of a balloon catheter into a gastrorenal shunt via the femoral or internal jugular vein. It is similar …

Dr R Jalan.r.jalan{at}ucl.ac.uk