role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice

1. Role of devascularization in
management of portal
hypertension
Presented by
Dr Quiyum
Phase B
Hepatobiliary,pancreatic and liver Transplant surgery

2. Introduction
 Gastroesophageal varices are major source of morbidity and mortality among
patients with portal hypertension.
 The reported 6-week mortality following each episode of variceal bleeding
remains in the range of 15-20%.

4.  Devascularization being a variceal-directed ablative surgery
 aims at obliteration of varices or disconnection of the esophagogastric veins from
the hypertensive portal tributaries.
 The goal of the esophagogastric devascularization is to disconnect the esophagus
esophagus and stomach from this collateral system while maintaining a
portosystemic shunt in place via the adventitial plexus surrounding the esophagus

5. Relevant anatomy
 portal hypertension develops<<diversion of portal venous blood away << join the low-
pressure systemic circulation via collateral pathways— natural portosystemic shunts
(esophagogastric region is the main site of shunting.)
 The coronary vein and gastric veins are connected with the superior vena cava by
collateral channels in the submucosa of the esophagus(mainly)
between the two muscular layers,
and in the periesophageal area (adventitial plexus).
 increased blood flow and resistance in the muscularis layer << increase in venous
pressure<<formation of dilated and tortuous varices.
 in the esophageal wall ,
The intrinsic veins include the submucosal, subepithelial,
and the intraepithelial veins
the extrinsic vein - Periesophageal veins
.

6. In portal hypertension, the increased venous pressure can produce
varices throughout the length of the esophagus and down into the
upper stomach; however, the bleeding from esophageal varices usually
occurs in the lowest 5 cm of the esophagus.
In the stomach, although varices are seen more often on the lesser
curve, it is the less common fundal varices that are more dangerous
and likely to lead to exsanguinating hemorrhage (Mathur et al, 1990).
Therefore a technique targeting this vulnerable area would help in
controlling or preventing bleeding from esophageal varices.
An ideal technique would be the permanent obliteration or
interruption of varices in the lower periesophageal vessels and
intraepithelial dilated vessels

7. Indication
 patients with underlying chronic liver disease
1. Acute VH when other method have failed
2.not candidates for transplantation and need varices-directed surgery or have symptomatic
hypersplenism needing splenectomy,
3. bridge to liver transplantation when TIPPS unavailable.
4. a shunt is indicated but unshuntable vein in patients with
extensive mesenteric venous thrombosis, including portal, splenic, and superior
mesenteric vein thrombosis or
an inadequate vein size to permit a shunt
Not recommended if LT available,
Not recommended in chronic or prophylactic setting

8.  patients with healthy liver,
 extrahepatic portal vein obstruction (EHPVO) and noncirrhotic portal fibrosis
(NCPF
 portal biliopathy in the absence of a shuntable vein (Varma et al, 2014)
 and chronic pancreatitis with portal hypertension
#good results in children with massive splenomegaly with hypersplenism secondary to EHPVO (Rao et al, 2004; Subhasis et al, 2007).
Goyal and coworkers (2007
##isolated splenectomy as a means of secondary prophylaxis for variceal bleeding has a 30% to 50% failure rate and hence is not
advocated (Coelho et al, 2014; Raia et al, 1984), except in the instance of left-sided portal hypertension.

9. contraindication
 CTP –C
 When LT indicated
 Prophylactic or chronic VH

10. Type of devascularization procedure
 HASSAB DEVASCULARIZATION PROCEDURE (1960-
1970)
 SUGIURA AND FUTAGAWA DEVASCULARIZATION
PROCEDURE(1970-1980)
 MODIFIED SUGIURA DEVASCULARIZATION PROCEDURE
(later)
 Other modification
 Laparoscopic devascularization

11. Hassab’s procedure 1957
Dr. Mohammed Aboul-Fotouh Hassab, a professor of surgery at Alexandria University in Egypt.
 abdominal incision.
 Splenic artery ligation followed by splenectomy is performed.
 ligation of short gastric veins is followed by ligation of the vessels
ascending through the hiatus and the diaphragm.
 The gastrohepatic ligament is incised, the left gastric vessel is
divided between ligatures.
 abdominal esophagus is circumferentially dissected and looped
with umbilical tape,ligation of vessels around the abdominal
esophagus; this includes devascularization of 3 to 4 inches (7 to 10
cm) of lower esophagus and proximal stomach
 with sacrificing of vagus nerve and ligation of left gastric vessels
The abdomen is closed after placement of a drain in the region.
 An important aspect of the Hassab procedure is the
absence of esophageal transection and pyloroplasty

12. Result
 In Hassab’s series (1967),
 174 patients operated during or after a bleed, with 39 patients operated under emergency
conditions at the time of bleeding, and in 151 patients, devascularization was performed
prophylactically (total 364 pt)
 an in-hospital mortality of 9% for elective cases, an emergency setting, the mortality was 38.4%
 there was only one late rebleeding event during follow-up.
 varices disappeared completely or improved in 91% of patients.
 But the intramural connections, combination with sclerotherapy is necessary further.

13. literature
 modified gastroesophageal decongestion and splenectomy GEDS (Hassab) was performed on
patients who need immediate surgical intervention for variceal bleeding.
 safe, simple and less time-consuming No esophageal transection was performed in this
procedure; therefore no esophageal fistula,
 The rebleeding rate was 23%

14. Sugiura and fataura procedure
 transthoracic and an abdominal procedure
performed through two separate incisions.(lt
lateral thoracotomy and upper midline)
 The thoracic procedure involves extensive
paraesophageal devascularization (30-50)up to the
inferior pulmonary vein and esophageal
transection.
 The abdominal procedure includes splenectomy,
devascularization of the abdominal esophagus
and cardia, and selective vagotomy and
pyloroplasty

15.  Sugiura and Futagawa (1973) reported
 the disappearance of varices (97%).
 The overall operative mortality was 4.6%, and postoperative hemorrhage occurred in two patients.,
 patients who underwent the procedure, 203 (30%) had prophylactic, 363 (54%) had elective, and 105
(16%) had an emergency procedure.

 Portal hypertension etiology was cirrhotic in 495 cases, EHPVO in 39 cases, and from other causes in
remainder.
 Operative mortality was 4.9% overall, with 13.3% mortality in emergency cases and 3% in elective
In patients with cirrhosis, ChildPugh status–based mortality was 0% for 244 Child-Pugh class A patients,
2% for 251 class B patients, and 16% for 176 class C patients.
 Late deaths were due to hepatic failure and hepatocellular carcinoma and not due to variceal bleeding.
the Sugiura procedure was believed to be technically complex and time consuming and
was largely ignored or abandoned.

16. Modified Sugiura procedure
 Only abdominal approach
with variations being
 inclusion or exclusion of esophageal transection
 splenectomy,
 vagal preservation,
 and anti reflux surgery
 The main vagal trunk is preserved; highly selective
vagotomy is performed, and therefore no drainage
procedure is necessary. Fundoplication is not
performed. Esophageal transaction is performed by
using an EEA stapler

17.  When the esophagus is inflamed
because of multiple sessions of
sclerotherapy, especially in the acute
setting, the stapling is done just below
the gastroesophageal junction
(Chaudhary & Aranya, 1991).
Occasionally, fundic resection is needed
for bleeding from large fundic varices
 the Sengstaken-Blakemore tube is
used for temporary control of bleeding,
we first perform the esophagogastric
devascularization and splenic artery
ligation without deflating the tube and
later proceed to splenectomy
 Placement of a feeding jejunostomy
in patients with esophageal
transection or stapling permits early
institution of enteral nutrition
postoperatively. A gastrograffin
swallow is done around the seventh
postoperative day, after which oral
alimentation is resumed.

18. Laparoscopic devascularization

20.  the Hassab operation devascularizes only the extramural vessels; intramural vessels are not
treated.
 Only one study in the Chinese literature compared the Hassab and Sugiura procedures and found
the Sugiura procedure to be more effective in terms of reduction of rebleeding and eradication of
varices, with comparable operating time and morbidity (Wen et al, 2008
 Studies comparing devascularization alone with devascularization with esophageal
transection have shown comparable rebleeding rates. The esophageal transection group has a
higher incidence of esophageal stricturing (Johnson et al, 2006; Zhang et al, 2014)
 comparing splenectomy with no splenectomy groups, both were comparable in rebleeding,
operative time, and morbidity. The preservation of the spleen was associated with decreased
perioperative blood transfusion requirement and the portal vein thrombosis rate.
 another modification included splenic artery ligation instead of performing a splenectomy.

21. Efficacy
 ability to control bleeding without the attendant liver dysfunction, as occurs with a shunt procedure.
 Overall, devascularization procedures have a rebleeding rate of 5% to 16% and mortality rate of 1%
to 7%, without risk of encephalopathy
 Immediate control of bleeding is achieved in almost all cases: 95% to 100%
 The 5 year survival rate with the Hassab operation ranges from 73% to 85%, seemingly better than other devascularization
procedures.
 The 5 year survival rate of the Sugiura and modified Sugiura operations is approximately 70% and dramatically decreases
to approximately 30% in the emergency setting.
 Outcomes are much better in noncirrhotic portal hypertension. Approximately 10% to 15% of patients with EHPVO have
no shuntable vein or a thrombosed splenoportal and mesentericoportal axis.

22. Shunt or devascularization ???
 RCT showed ,
devascularization was found to have superior survival and less incidence of encephalopathy rate
Rebleeding was less with shunting in another RCT
A meta-analysis (2013(1716 patients, of which 770 underwent devascularization, and in 946, a shunt ).
 Although there was no significant difference in the mortality rate and overall survival,
 the recurrent bleeding rate was significantly higher in the devascularization group than shunt group;
 the rate of encephalopathy was lower in the devascularization group.
 Ascites control was better in the shunt group.

23. Complication
 Rebleeding
 Esophagial leak /stricture
 OPSI
 Post splenectomy sepsis

25. Summery :
16 cases were undertaken the splenectomy and esophagogastric devascularization.
During the follow-up of 6-72 months, no esophageal and gastric varices were found.

26.  The surgical treatment of 18 patients with PVCT was studied retrospectively. Eight
patients underwent mesocaval shunt with artificial grafts, two patients had splenectomy
and disconnection, three patients had a central splenorenal shunt, and six patients had a
distal splenorenal shunt.
There were no deaths or hepatic encephalopathy after operation.
Bleeding recurred in two patients (disconnection in one, mesocaval shunt in one).
The individualized choice of shunt is ideal for treating PVCT, and the combined procedures
of shunt and disconnection are useful. The Rex shunt will be the focus of PVCT surgery in
the future.

27.  Surgical procedure selection was based on overall consideration of several factors, according to
the severity of vascular dilation, the PC location, and the extent of liver dysfunction.
 Splenectomy was performed for 21 cases with apparent splenomegaly, but without obvious
lumpy, tortuous dilation of the lower esophagus and gastric fundus veins.
 Surgical vascular disconnection in the gastric fundus and lower esophagus in combination with
splenectomy was performed in 36 cases with severe tortuous dilation in the lower esophagus
and gastric fundic mucosa.
 Among them, surgical thrombus removal and end-to-end anastomosis of the PV were
performed in 8 cases with the main PV trunk occlusion
 In three children tortuous dilation of the intrahepatic portal vein, with severe damaged liver
function, was detected. Living-donor liver transplantation was selected for these patients.

28.  Five patients were symptomatic. Three patients had intermittent bleeding from esophageal and gastric varices, and
all 5 had relative degrees of hypersplenism with enlarged spleens and thrombocytopenia (11,000 to 77,000)
 Postoperative complications included ascites in 2 patients that resolved within 1 month. There were no early shunt
thromboses.
 Gastrointestinal bleeding did not recur in any patient, and ascites resolved in all. Spleen size decreased significantly
(P <.01) from 9.4 ± 4.0 cm to 5.0 ± 3.7 cm below the left costal margin. Mean platelet count and white blood cell
count rose after shunting from 79 ± 42 to 176 ± 73 (P <.02) and 5.4 ± 2.3 to 7.5 ± 3.9 (P =.06), respectively. All
shunts were studied at 1 and 7 days, and 3 and 6 months after the procedure. Shunt patency was documented in all
cases. Subsequently, shunt blockage occurred in 2 patients.
 Conclusions: The Rex shunt has proven to be an effective method of resolving portal hypertension caused by EPVT
including thrombosis after living donor transplantation. This shunt is preferable to other surgical procedures because
it eliminates portal hypertension and its sequelae by restoring normal portal flow to the liver

30.  30 children with symptomatic CTPV that were treated by a Rex shunt between 2008 and 2015.
 All children were evaluated based on symptoms, complete blood count, portal system color-flow Doppler ultrasound or
computed tomography angiography portography and gastroscopy for gastroesophageal varices pre- and postoperatively.
Children were also evaluated during follow-up. Intraoperative evaluations included liver biopsy, portography and portal
pressure.
 Rex was successful in 28 patients (93.3%). The portal pressure immediately decreased significantly after placing of the
< 0.01).
 During the clinical follow-up period within 2-82 months, transaminase levels were maintained in the normal range. Blood
flow velocity and diameter of the left portal vein significantly increased after surgery (P < 0.01).
 In addition, leukocyte and platelet counts increased postoperatively and anemia improved significantly (P < 0.01).
Gastroscopy results indicated that the degree of gastroesophageal varices significantly alleviated postoperatively within 3
months and 1 year (P < 0.01). In 2 patients who demonstrated nodular cirrhosis and chronic active hepatitis, success of the
Rex shunt was not achieved after operation. We found that for Rex effectiveness hepatic pathology and patient age were
major determinants.
 Conclusion: Rex shunt is an effective approach for the treatment of children suffering from CTPV at an early stage that do
not show additional liver lesions.

31. Operative vedio

32. Our patient
Problem:
 Oesophagial varices
 Hypersplenism
 PVCT
 Cholelithiasis
 choledocholithiasis
Proposed :
 Modified Sugiura plus
cholecystectomy
,choledocholithotomy +_
rex shunt if expertise
available

34. Thank you