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  • 1. Options in the Treatment of Portal Hypertension Portal Hypertension, itself, is not an indication for treatment Only the complications of Portal Hypertension need treatment
  • 2. The Complications of Portal Hypertension
    • UPPER DIGESTIVE BLEEDING
    • ASCITIS
  • 3. UPPER DIGESTIVE BLEEDING
    • The most common and severe complication of portal hypertension
      • Causes – esophagian varices, gastric varices, portal gastropathy
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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%
  • 8. 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.
  • 9. Operative Devascularisation
    • Reduce blood flow to varices
    • Interrupt bleeding source
    • Eliminate the complications of splenomegaly (hypersplenism)
  • 10. Types of operative procedures(1)
    • Hassab operation
      • Splenectomy
      • Devascularization of the upper stomach
  • 11. 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.
  • 12.
    • 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)
  • 13. 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
  • 14. 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
  • 15. Disadvantages of portasystemic shunts
    • Technically more difficult
    • Because of reducing of portal blood flow two severe complication can occur:
      • Impaired Liver Function
      • Hepatic Encephalopathy
  • 16. PORTACAVAL SHUNTS
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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.
  • 22. SPLENORENAL SHUNTS
  • 23. 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
  • 24. SPLENORENAL CENTRAL SHUNT splenic vein left renal vein vein Proximal end to side anastomosis Spleen
  • 25. 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.
  • 26. 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
  • 27. 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
  • 28. SPLENORENAL DISTAL SHUNT
  • 29. 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.
  • 30. 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
  • 31. 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
  • 32.
      • The aims of the treatment of portal hypertension:
      • Prevent Bleeding
      • Stop the Bleeding
      • Prevent Recurrent Variceal Bleeding
  • 33. 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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. Surgical treatment according of portal hypertension (PH) type PRESINUSOIDAL SINUSOIDAL POSTSINUSOIDAL
  • 38. PRESINUSOIDAL EXTRAHEPATIC INTRAHEPATIC
  • 39. 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
  • 40. 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
  • 41. Sinusoidal PH (Cirrhosis)
    • Surgical treatment have to preserve portal blood flow
    • Most of this patients are candidates for liver transplant
  • 42.
    • 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
  • 43. 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
  • 44. Postsinusoidal PH with caval vein obstruction
    • Mesoatrial shunt
    Postsinusoidal PH with liver failure Liver transplant
  • 45. 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
  • 46. Mortality (1)
    • Operative devascularisation 18 patients from163 (10,7%)
    • Causes:
      • Peritonitis: gastric wall necrosis ( 3 )
      • Hepatic failure ( 15 ) Child B,C
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. Conclusions (3)
    • Impaired liver function:
      • LIVER TRANSPLANT