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    33 33 Presentation Transcript

    • Options in the Treatment of Portal Hypertension Portal Hypertension, itself, is not an indication for treatment Only the complications of Portal Hypertension need treatment
    • The Complications of Portal Hypertension
      • UPPER DIGESTIVE BLEEDING
      • ASCITIS
    • UPPER DIGESTIVE BLEEDING
      • The most common and severe complication of portal hypertension
        • Causes – esophagian varices, gastric varices, portal gastropathy
    • ASCITES
        • Surgical treatment needed in cases with poor respond to medical treatment
        • There are only few forms of portal hypertension associated with ascitis, which have a benefit after surgical treatment
          • Budd - Chiari syndrome
    • SPLENOMEGALY
      • Splenectomy is indicated as singular procedure in few instances:
        • Segmentary portal hypertension (splenic vein thrombosis, chronic pancreatitis, arterio-venous fistula)
        • Giant splenomegaly which interfere with a normal growing
        • Severe hypersplenism in the absence of esophageal varices
    • Surgical procedures used in portal hypertension treatment
      • Direct control of bleeding
        • Suture of esophageal varices (esophageal transection)
        • Eso-gastric resection
        • Devascularization procedures
      • Indirect control of bleeding: porto-sistemic shunts
        • Porto-caval shunts
        • Mezenterico-caval shunts
        • Spleno-renal shunts
    • Transgastric suture (esophageal transection) of esophageal varices
      • Easy to performe, practicable in every surgical department
      • Must be performed as the last choice of treatment after all medical or endoscopic procedures
      • As singular procedure in emergency
      • Bleeding is controlled in 70% cases
      • Recurrent variceal bleeding in the first year- 35%
      • Mortality (cirrhosis) - 50%
    • The eso-gastric resection
      • Ablation of esophageal and gastric vari ces
      • A z y go-portal dis junction
      • Usually performed as a polar superior esogastric resection
      • Post operat ive m ortalit y is too high comparative with the benefits ( 50-70%)
      • Is still indicated in bleeding from gastric varices, if we have no other possibility of surgical treatment.
    • Operative Devascularisation
      • Reduce blood flow to varices
      • Interrupt bleeding source
      • Eliminate the complications of splenomegaly (hypersplenism)
    • Types of operative procedures(1)
      • Hassab operation
        • Splenectomy
        • Devascularization of the upper stomach
    • Types of operative procedures(2)
      • Sugiura procedure
        • Extensive transthoracic paraoesophageal devascularization and esophageal transection combined with splenectomy, devascularization of the upper stomach,
        • Disadvantage: thoracic approach
        • Good results especially in Japan
          • Overall mortality - 5,2 %,
          • Mortality distribution: 4,3% (Child A, B), 17%(Child C)
          • Recurrent variceal bleeding rate < 5 %
      Sugiura M, Futagawa S. Esophageal transection with paraesophagogastric devascularization in the treatment of esophageal varices. World J Surg 1984;8:673.
      • Only abdominal approach
        • Same results as Sugiura procedures
      • Procedure
        • Ligation of paraesofageal veins (left and right), devascularization of the stomach with preserving of right gastroepiploic vein
        • Varices ligation or esophageal transection
        • Splenectomy
      Types of operative procedures(3)
    • Advantages of Devascularization Operations
      • Easy technique
      • Low mortality
      • Low recurrent variceal bleeding rate
      • Postoperative encephalopathy is rare - preserving of portal blood flow -
      • Liver function well preserved
      Idezucki Y, Sanjo K, Bandai Y, Kawasaki S, Ohashi K Current strategy for oesophageal varices in Japan. American Journal of Surgery 1990 160:98–104
    • Portasystemic shunt
      • Portacaval shunts
        • End-to-Side
        • Side-to-Side
        • H-graft shunt
      • Splenorenal Shunts
        • Selective: distal splenorenal shunt
        • Non-selective: central splenorenal shunt
      • Mesocaval Shunt
        • Side-to-Side
        • H-graft shunt
    • Disadvantages of portasystemic shunts
      • Technically more difficult
      • Because of reducing of portal blood flow two severe complication can occur:
        • Impaired Liver Function
        • Hepatic Encephalopathy
    • PORTACAVAL SHUNTS
    • Portacaval Shunt End-to-Side
      • Highly effective in splanchnic blood decompression
      • Relatively easy to perform
      • Produce a sustained fall in portaI pressure and prevent recurrence of hemorrhage
      • Sinusoid vessels are not decompressed and ascitis can appear or exacerbate.
      • A future liver transplant can be impaired
    • Portacaval Shunt Side-to-Side
      • Successful in decompressing the splanchnic system
      • Low risk of recurrent vertical bleeding
      • High risk of hepatic encephalopathy
      • Sinusoid vessels are well decompressed
      • Ascites is diminish or reduced
    • Portacaval Shunt Side-to-Side
      • Technically more difficult:
        • Well dissection and mobilization of portal and inferior caval vein
        • Sometimes dissection can be very difficult because of bleeding from pancreatic collateral branches
        • Hypertrophy caudate lobe in cirrhosis and Budd Chiari syndrome need sometimes partial resections of caudate which complicated the operation
    • Portacaval H-graft shunt
      • Interposing a synthetic graft of various diameters between portal and caval vein
      • Aim – decompress the whole portal venous bed, whilst maintaining a pressure gradient to preserve adequate hepatic portal flow
      • Reduce risk of encephalopathy and liver failure
    • Portacaval H-graft shunt
      • 2 Technical Versions
        • Graft diameter - 16 mm
          • Important portacaval flow
        • Graft diameter - 8mm
          • Reasonable portocaval flow
          • Reduce the portal hipertension enough to avoid risk of bleeding
          • Sometimes increase risk of ascitis which often respond on medical treatment
      • Very important: ligation of coronary,right gastroepiploic veins which can compromise the aim of the operation
      Sarfeh IJ, Rypins EB, Mason GR. A systematic appraisal of portacaval H-graft diameters: clinical and hemodynamic perspectives. Ann Surg 1986;204:356.
    • SPLENORENAL SHUNTS
    • Splenorenal central shunt
      • Technique:
        • Splenectomy,
        • Dissection of splenic vein from posterior surface of the pancreas
        • Dissection of the renal vein
        • Splenorenal anastomosis end to side
      • Low portal encephalopathy risk
      • High risk of thrombosis when splenic vein diameter < 12mm
      • Recurrent variceal bleeding higher than other portosystemic shunts
      • Adequate in splenomegaly associated with severe hypersplenism
    • SPLENORENAL CENTRAL SHUNT splenic vein left renal vein vein Proximal end to side anastomosis Spleen
    • Splenorenal distal shunt ( Warren)
      • Selective shunt – divide portal system:
        • High pressure sector mezenteric and portal veins
        • Low pressure sector, gastric and splenic veins
      Henderson JM, Warren WD, Millikan WJ, Galloway JR, Kawasaki S, Kutner MH. Distal splenorenal shunt with splenopancreatic disconnection: a 4-year assessment. Ann Surg 1989;210:332.
    • Splenorenal distal shunt ( Warren)
      • Technique
      • The gastroepiploic arcade should be interrupted and taken down from the pylorus to the first short gastric vessels.
      • Dissection of the splenic vein from posterior pancreatic surface with isolation, ligation and division of the thin walled tributaries from the pancreas to the splenic vein
    • Splenorenal distal shunt (Warren)
      • Dividing the splenic vein before junction with superior mesenteric vein.
      • End to side spleno-renal anastomosis
      • Ligation of left gastric and right gastroepiploic pedicle
      Henderson JM. Surgical treatment of portal hypertension – Baillieres Best Pract Res Clin Gastroenterol - 01-Dec-2000; 14(6): 911-25
    • SPLENORENAL DISTAL SHUNT
    • Splenorenal distal shunt
      • Advantages
      • Slow but efficient varices decompresion
      • Low risk of portal encephalopathy ( <10%) relative to other shunts (32%-50%)
      • Reccurent variceal bleeding: 7%-13% at 5 years
      Boyer TD, Kokenes DD, Hetzler G, Kutner MH, Henderson JM. Effect of distal splenorenal shunt on survival of patients with primary biliary cirrhosis. Hepatology, 1994, 20(6):1482-1486.
    • Splenorenal distal shunt
      • Disadvantages :
      • Sometimes very difficult technically because of venous pancreatic branches
      • Postoperative complications
        • Acute pancreatitis, pancreatic pseudocyst
      • Avoided in presence of ascitis
      • Mortality between 1%-19% according to situation:
      • elective operation or emergency, liver failure or not
    • Mesocaval Shunt
      • Advantage: useful to patients with splenectomy and to the children (diameter of superior mesenteric vein > diameter of splenic vein)
      • Usually a synthetic graft (8mm) is interposed between mesenteric and cava vein
      • High risk of thrombosis
      • Low varices decompression and small risk of encephalopathy
      Gliedman M L, Margulies M The mesocaval shunt for portal decompression. In: Haimovici H (ed.) Surgical management of vascular diseases. 1984, Lippincott, Philadelphia, p 841
        • The aims of the treatment of portal hypertension:
        • Prevent Bleeding
        • Stop the Bleeding
        • Prevent Recurrent Variceal Bleeding
    • Surgical prevention in portal hypertension
      • The place of surgical prevention is after failure of medical and endoscopic treatment
      • Surgical procedures are choused by:
        • Efficiency
        • Postoperative complications and mortality
        • Type of portal hypertension
        • Possibility in future to continue with an other surgical procedure in case of relapse or failure
    • Surgical treatment of upper digestive bleeding (1)
      • Indicated after endoscopic and medical treatment, Sengstaken-Blakemore tube, TIPSS
      • Surgical treatment depending of severity of bleeding and liver dysfunction
      • For esophageal varices the most indicated treatment is varices ligation or esophageal transection.
      • In cases of portal gastropathy or gastric varices surgical treatment is operative devascularisation or esogastric resection
      Cello J P, Grendell J H, Crass R A, Weber T E, Trunkey D D Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up. New England Journal of Medicine 1987 316:11–15
    • Surgical treatment of upper digestive bleeding (2)
      • Portasystemic shunts
      • Not recommended in emergency because of high mortality
      Mitchell R L, Ignatius J A Distal splenorenal shunt: standard procedure for elective and emergency treatment of bleeding esophageal varices. American Journal of Surgery 1988 156:169–172 Terblanche J, Burroughs A K, Hobbs K E F Controversies in the management of bleeding esophageal varices. New England Journal of Medicine 1989 320:1393–1398, 1469–1475
    • Prevention of recurrent upper digestive bleeding
      • Surgical procedures are indicated after failure of endoscopic treatment
      • Gastric varices
      • Portal gastropathy
      • Depending of portal hypertension type and liver resources
    • Surgical treatment according of portal hypertension (PH) type PRESINUSOIDAL SINUSOIDAL POSTSINUSOIDAL
    • PRESINUSOIDAL EXTRAHEPATIC INTRAHEPATIC
    • Presinusoidal PH
      • Segmentary PH – splenic vein thrombosis or extrinsec compresion (chronic pancreatitis), splenic arteriovenous fistula
        • Splenectomy +/- distal pancreatectomy
      • Portal vein obstacle
        • Mesocaval shunt
        • Devascularisations procedures
      • Splenoportal thrombosis
        • Devascularisations procedures
      Extrahepatic
    • Presinusoidal PH
      • Most of patients with preserved liver function
      • Splenorenal distal shunt (Warren) first choice
      • 8 mm graft portacaval shunt
      • Devascularisation operations
        • !!! Also applied on children with spleen preserving when shunt operations are planned in the future
      Intrahepatic
    • Sinusoidal PH (Cirrhosis)
      • Surgical treatment have to preserve portal blood flow
      • Most of this patients are candidates for liver transplant
      • Liver function not impaired
        • If is planned a liver transplant in future splenorenal distal shunt Warren is the first choice
        • If not, portacaval H graft shunt or devascularisation operations are indicated
      • !!! In case of severe hypersplenism are recommended:
        • Splenorenal central shunt
        • Devascularisation operations
      • Impaired liver function:
        • Liver transplant
        • TIPSS (waiting list)
        • Devascularisation operations if a future liver transplant is not feasible
      Sinusoidal PH
    • Postsinusoidal PH
      • Liver function well preserved
      • Ascitis – the most common finding
      • Side to side portacaval shunt
        • Successful in decompressing the splanchnic system
        • Hypertrophy of caudate lobe needs some time partial resections of caudate which complicated the operation
      • H graft portacaval shunt
      Caval vein not obstructed
    • Postsinusoidal PH with caval vein obstruction
      • Mesoatrial shunt
      Postsinusoidal PH with liver failure Liver transplant
    • Fundeni Clinical institute Department of General Surgery and Liver Transplant
      • 1990 - 2002
      • 163 Operative devascularisation
      • 54 Portasystemic shunts
        • 25 splenorenal central shunts
        • 16 splenorenal proximal shunts
        • 6 portacaval shunts
          • 3 with 8 mm graft
          • 1 end to side
          • 2 side to side
        • 6 mesocaval: 5 with 8mm graft
        • 1 mesoatrial
    • Mortality (1)
      • Operative devascularisation 18 patients from163 (10,7%)
      • Causes:
        • Peritonitis: gastric wall necrosis ( 3 )
        • Hepatic failure ( 15 ) Child B,C
    • Mortality (1)
      • Portasystemic shunts 8 patients from 54 (14,8%)
        • 4 splenorenal central shunts
        • 2 splenorenal distal shunts
        • 2 mesocaval shunt
      • Causes:
        • hepatic failure
          • 6 intraoperative bleeding
    • Conclusions (1)
      • Surgical treatment of PH is not standardized
      • The most common complication of PH treated is BLEEDING
      • Surgical treatment only in case of failure of endoscopic treatment
      • Surgical treatment is very efficient in prevention of recurrent upper digestive bleeding
    • Conclusions (2)
      • Portasystemic shunts are the most efficient treatment in prevention of recurrent bleeding
        • Splenorenal distal shunt (Warren) best choice
          • Liver function well preserved
          • Cirrhosis (Child A)
      • Devascularisation operations
        • Portasistemic shunts not feasible
        • Liver function impaired
    • Conclusions (3)
      • Impaired liver function:
        • LIVER TRANSPLANT