surgical management of portal hypertension

1. SURGICAL MANAGEMENT OF PORTAL
HYPERTENSION-CIRRHOTIC AND NON-
CIRRHOTIC CAUSES
By-
Dr. ATUL KHARE

2. PORTAL HYPERTENSION
• PORTAL HYPERTENSION IS DEFINED BY A PORTAL PRESSURE
HIGHER THAN 5 MM HG.
• •PATHOPHYSIOLOGY-
• •ALL FORMS OF CIRRHOSIS LEAD TO PORTAL HYPERTENSION
• .•PRIMARY EVENT IS OBSTRUCTION TO PORTAL BLOOD FLOW DUE TO
NODULESWHICH COMPRESS HEPATIC VENOUS RADICLES.
• •TREATMENT OF PORTAL HYPERTENSION IS AIMED TO DECREASE
PORTAL PRESSURES AND PREVENTION OF COMPLICATIONS SUCH AS
ASCITIS, VARICES, HEMORRHOIDS, SPLENOMEGALY ETC.

3. Management of portal hypertension In cirrhosis
SURGICAL
MANAGEMENT
• Decompressive
Shunt Surgeries
• Devascularisation
Surgeries
• Liver
Transplantation.
NON-SURGICAL MANAGEMENT
• Medical Management ( Beta-Blockers,
Somatostatins analogues)
• Balloon Tamponade.
• Endoscopic Therapy--Banding /Sclerotherapy
/Gluing with tissue adhesives/ Thrombin –
Adrenaline Injection into the varices.
• TIPS (Transjugular Intrahepatic Porto Systemic
Stenting)

4. AIMS OF SURGICAL INTERVENTION IN PORTAL
HYPERTENSION WITH CIRRHOSIS
•CONTROL OF ACUTE BLEEDING VARICES.
•TREATMENT OF REFRACTORY ASCITIS.
•DECOMPRESSION OF PORTAL SYSTEM.
•MAINTAIN HEPATIC AND PORTAL BLOOD FLOW.
•TRY TO REDUCE OR NOT COMPLICATE HEPATIC ENCEPHALOPATHY.

5. DECOMPRESSIVE SHUNTS
• DECOMPRESSION IS CONSIDERED SECOND-LINE TREATMENT.
• RESERVED FOR PATIENTS WHO REBLEED THROUGH PHARMACOLOGIC
THERAPY AND ENDOSCOPIC BANDING OR WHOSE VARICES REMAIN “HIGH
RISK.”
• SURGICAL SHUNTS :
1. NON-SELECTIVE  Completely decompress portal system.
2. SELECTIVE  Compartmentalize Portal system.
3. PARTIAL SHUNTS  Partially decompress portal system.
an Ideal shunt -
1) reduce portal venous
pressure.
2) maintain hepatic and
portal blood flow.
3) reduce or not
complicate hepatic
encephalopathy.

6. Types of shunts
NON-SELECTIVE SHUNTS
• END TO SIDE PORTA CAVAL
SHUNT (ECK FISTULA)
• SIDE TO SIDE PORTA CAVAL
SHUNT
• MESENTERICO CAVAL SHUNT
• MESENTERICO CAVAL SHUNT
WITH GRAFT
• PROXIMAL SPLENORENAL
SHUNT—LINTON’S SHUNT
SELECTIVE SHUNTS
•DISTAL SPLENO RENAL SHUNT—WARREN’S
SHUNT
•INOKUCHI SHUNT BETWEEN LEFT GASTRIC
VEIN AND IVC THROUGH A GRAFT.
PARTIAL SHUNTS•Small-diameter
interposition portacaval shunt using a PTFE
graft, combined with ligation of the
coronary vein and other collateral vessels

7. PORTA CAVAL SHUNTs
•Portal vein is divided close to the hilus of the liver
and the splanchnic end anastomosed to the side of
the vena cava.
•It does not relieve ascites but will control variceal
bleeding.
•Complications : portosystemic encephalopathy and
accelerated hepatic failure.
•Portal Vein anastomosed to vena cava in side to side
fashion.
•In addition to controlling variceal bleeding, these
shunts also control ascites.
•Complications : portosystemic encephalopathyand
accelerated hepatic failure.

8. MESENTERICO CAVAL SHUNT
•Intact upper end of the portal vein serves as a decompressive outflow from the high pressure
obstructed liver sinusoids.
•In addition to controlling variceal bleeding, these shunts also control ascites.
•Complications : portosystemic encephalopathy,accelerated hepatic failure and shunt thrombosis.

9. SPLENORENAL SHUNT
•Anastomosis of the proximal splenic vein to the renal
vein.
•Splenectomy is performed.
•Complications : shunt thrombosis
•Only indication for a total portal systemic shunt at
present is for patients with acute Budd Chiari syndrome
•End of splenic vein is shunted to the side of the left
renal vein.
•Splenic vein should be > 10 mm in size (diameter).
•It selectively decompresses the portal bed near
oesophago-gastric area.
•Liver is also perfused adequately and so possibility of
encephalopathy is less.

10. PARTIAL SHUNTS
1) Partial shunts are side-to-
side shunts whose
diameter is reduced to 8
mm.
2) Polytetrafluoroethylene
(PTFE) graft is
approximately 2–3 cm
long, and beveled at each
end to give a larger
anastomosis.
3) 90% control of variceal
bleeding
4) Complications-shunt
thrombosis.

11. Indications of Shunt surgery in portal
hypertension due to cirrhosis
• Patients who have MELD scores of <15, who are not candidates for
hepatic transplantation.
• Patient have limited access to TIPS therapy and the necessary follow-
up.
• Patients having reCurrent bleeding vaarices.
• Patients having refractory ascitis.

12. Complications of shunt surgeries
• Shunt thrombosis
• portosystemic encephalopathy
• accelerated hepatic failure.
• Subsequent hepatic transplantation can be made more difficult.
• After the age of 40, survival is reduced and encephalopathy is twice as common

13. Outcomes of various shunt surgeries
• Distal splenorenal shunt is best available shunt, as It selectively
decompresses the portal bed near oesophago-gastric area and Liver is
also perfused adequately and so possibility of encephalopathy is less.
• mortality rate in good - risk patients is about 5%.
• mortality rate For poor - risk patients is About50%.
• Bleeding from gastro - oesophageal varices is prevented or greatly
reduced, rebleeding rates are aBout ( 5 to 10%)
• Variceal size decreases and varices may disappear within 6 months to 1
year.
• Hepatic encephalopathy may be transient. Chronic changes develop in 20
– 40% and personality deterioration in about one - third

14. DEVASCULARISATION SURGERIES
• OESOPHAGEAL STAPLER TRANSECTION OF JOHNSTON
• BOEREMA—CRILE OPERATION—THORACIC APPROACH
• MILNES—WALKER THORACIC OESOPHAGEAL TRANSECTION
• TANNER’S ABDOMINAL OESOPHAGO GASTRIC TRANSECTION
• HASSAB OPERATION—. distal esophagus and proximal gastric devascularization +
vagotomy and pyloroplasty+ splenectomy
• SUGIURA—FUTAGAWA OPERATION—distal esophagus and proximal gastric
devascularization + esophageal transection and re-anastomosis +splenectomy
• MODIFIED SUGIURA OPERATION.
-Mathur procedure -- distal esophagus and proximal gastric devascularization +
esophageal transection and re-anastomosis+ nissen fundoplication +/- splenectomy

15. INDICATIONS OF DE-VASCULARISATION SURGERIES
• Done when TIPS or surgical shunt Is not possible or unsuccessful in
controlling bleeding.
• Control of acute variceal bleed
• indicated in Child Turcotte Pugh- A or B patients as an alternative to
sclerotherapy or endoscopic ligation
• Devascularization surgeries are palliate procedures., they do nothing
to lower portal pressure
• Unfavorable anatomy for a shunt =portal vein – smv- splenic vein
thrombosis
• expertise not available for shunting

16. SUGIURA—FUTAGAWA OPERATION
• THESE OPERATIONS APPROACH THE PROBLEM OF VARICEAL
BLEEDING BY INTERRUPTING INFLOW TO THE VARICES.
• Separate abdominal and thoracic approaches were utilized in
one operation or in two separately staged operations.
• THE COMPONENTS ARE 
SPLENECTOMY
GASTRIC AND ESOPHAGEAL DEVASCULARIZATION
OESOPHAGEAL TRANSACTION
PYLOROPLASTY.

17. HASSAB OPERATION
• 1960 Hassab popularized
splenectomy and extensive
devascularization for
Schistosomal Portal
hypertension
• Components=
• distal esophagus and
proximal gastric
devascularization
• vagotomy and pyloroplasty
• splenectomy

18. MODIFIED SUGUIRA’S PROCEEDURE
• MODIFICATION DONE BY DR. S. K. MATHUR
• Outside the japan porto-systemic shunts Have been favored as the
surgical procedure of choice for the management of portal hypertension
of noncirrhotic etiology.
• transabdominal extensive esophagogastric devascularization with
esophageal or gastric stapled transection
• Devascularization procedures have resulted in high rebleed rates
probably owing to a limited extent of devascularization
• The modified Sugiura's procedure is safe and effective for long-term
control of variceal bleeding especially in the emergency setting and in
patients with anatomy unsuitable for shunt surgery or if surgical expertise
for a shunt operation is not available.

19. COMPLICATIONS OF DEVASCULARISATION SURGERIES
• dysphagia related to a localized stricture at the anastomosis
• esophageal reflux.
• esophageal leaks at the anastomotic site.
• Ectopic varices formation.
• Varices can recur because portal pressure remain high
• 0esophagogastric devascularization ,without oesophageal stapled
transection ,is a safe and effective procedure because both have
similar results and lesser morbidity
• >20% patient have variceal re-bleeding rates

20. Outcomes of devascularisation surgeries
• Rebleeding rates are higher than surgical shunts ( 11 to 17%).
• the rate of hepatic encephalopathy in the devascularization
surgeries is significantly less.

21. ADVANTAGES AND DISADVANTAGES
ADVANTAGES-
1.Emergency control of variceal bleeding in EHPVO mainly using devascularization
2.Less chances of encephalopathy, glomerulopathy and myelopathy
DISADVANTAGES→
• there is no decompression of the portal venous system.
• portal pressures remain high with the attendant risk of worsening portal
biliopathy, portal hypertensive gastropathy.
• additional risk of development of ectopic varices
• rebleeding rates of de-vascularization ( 11 to 17%) are higher as compared to
shunts ( 5 to 10%).
HENCE, SHUNTS ARE PREFFERED OVER DEVASCURAISATION

22. Shunt surgeries v/s De-vascularization
surgeries
PROPERTY SHUNT DEVASCULARIZATION
1. REBLEED RISK + +++
2.PORTAL PRESSURE LOW REMAIN HIGH
3.DECOMPRESSION OF PORTAL
VENOUS SYSTEM
YES NO
4.MAINLY USED EHPVO
5.BLEED CONTROL + +++
6.ENCEPHALOPATHY +++ -

23. SPLENECTOMY
• Earliest non –shunting procedure (in proximal lienorenal shunt splenectomy
done)
• Portal hypertension secondary to splenic vein thrombosis is potentially curable
with splenectomy.
• Splenectomy is not indicated for hypersplenism per se in patients with portal
hypertension.
• INDICATIONS-
• bilharzial hepatic fibrosis
• releive pain due to perisplenitis and enlarged spleen
• ascitis
• massive splenomegally-ncph
• isolated spleenic vein thrombosis

24. SPLENECTOMY
• Complications of splenectomy-
1) Left lung- Atelectasis/pneumonia/ effusion.
2) Hemorrhage, intraabdominal abscess, DVT etc.
3) Overwhelming post splenectomy infections
.4) Portal vein thrombosis
5) Ascitis

25. ASCITIS
• almost 10% of patient with cirrhosis and ascitis develop intractable ascitis
• when large volume paracentesis fail to releive ascitis patient submitted for
surgical option –
1)Portosystemic shunting- indicated for- intractable ascitis
good liver function test
all other treatment option fail
2)Peritoneo-venous shunting- laveen and denver shunt
3)Liver transplant- done in severely compromised liver

26. LAVEEN AND DENVER SHUNT
• Provide definitive relief of ascitis
• Mortality remain high in patient with
severe liver failure, spontaneous
bacterial peritonitis or variceal
bleeding

27. THANKYOU