Lecture notes for medical students

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2. Portal Hypertension
Surgical Therapy

3. Portal Hypertension
Surgical Therapy
• Can be divided into two categories:
1. Procedures that attack a menifestation of
Portal Hypertension.
2. Procedures aiming to reduce Portal
pressure.

4. Portal Hypertension
Surgical Therapy
I.Control of Menifeststion:
A.Bleeding Varices-
1.Ligation of varices.
a.Transthoracic
b.Transabdominal
2.Transection procedures
a.Gastric
b.Oesophageal(Stapler)
c. Oesophageal with paraoesophageal
devascularization.

5. Portal Hypertension
Surgical Therapy
I.Control of Menifeststion:
A.Bleeding Varices-
3.Resection of varix bearing area-
Oesophagectomy
a.Roux en Y
b.Jejunal interposition
c.Colonic interposition
d.Reversed Gastric tube.

6. Portal Hypertension
Surgical Therapy
I.Control of Menifeststion:
b.Ascites
Peritoneo-venous shunts.

7. Portal Hypertension
Surgical Therapy
II.Control of portal pressure and flow:
1.Splenectomy
2.Shunts

8. VARICEAL BLEEDING
Definitive Therapy

9. VARICEAL BLEEDING
Definitive Therapy
• Rationale: 67% rebleed
• Most rebleed < 6 weeks
• Definitive Tx during initial stay

10. VARICEAL BLEEDING
SURGICAL OPTIONS
• Total Shunt
• Selective Shunt
• Partial Shunt
• Non-Shunt

11. Total Shunts

12. Total Shunts
End to Side Portocaval Side to Side Portocaval
Interposition Shunts Central Splenorenal

13. Total Shunts
• Divert most (all?) portal flow
• Options
Portocaval Shunt
Interposition Shunt
Central Splenorenal Shunt

14. Total Shunt Results
• Prevent rebleed > 90%
• Thrombosis with graft
• Encephalopathy rate 40%

15. Selective Shunts
• Goals:
Prevent variceal bleeding and encephalopathy
• Mechanism:
Decompress Varices
Maintain Portal Perfusion
Maintain Portal Hypertension
• Key:
Decompress only gastrosplenic compartment

16. Distal Splenorenal Shunt

17. DSRS vs Total Shunts
• Six randomized trials in N.A.
• Mean follow-up 39 mos (1-8 yrs)
OP
MORT
LATE
MORT
SHUNT
OCC ENCEPH
DSRS% 10.9 24.2 7.3 19.8
TOTAL% 8.3 34.7 9.0 34.4

18. Partial Shunts
• Ease of portocaval
• Limited portal diversion
• Maintain some liver perfusion
• Short, straight PTFE graft

19. Non-Shunt Operations
• Options
Esophageal transection
Variceal ligation
Devascularize +/- splenectomy
• Very limited role

20. Liver Transplant

21. Liver Transplant
• Indicated for liver failure
Not for variceal bleeding

22. TIPS
Transjugular Intrahepatic Portocaval Shunt

23. TIPS

24. TIPS

25. TIPS
• Technically feasible
• Complications 9 - 50%
Infection Intraperitoneal Bleeding
Congestive Failure Subcapsular Hematoma
Acute Renal Failure Hemobilia
• Mortality (30 day) 3 - 13%
(1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884,
(3) LaBerge Radiology 1993;187:913.

26. Problems With TIPS

27. Problems With TIPS
• Encephalopathy minimum 15%
• Occlusion 33 - 73% @ one year
• Rebleeding
18% @ one year (1)
19% @ 4.7 months (3)
(1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884,
(3) LaBerge Radiology 1993;187:913.

28. The Role For Tips

29. The Role For Tips
• Refractory bleeding
• Bridge to transplant
• Child C
• ??? refractory ascites
• Relative contraindication: Poor f/u

30. Special Cases of
Portal Hypertension

31. Splenic Vein Thrombosis

32. Splenic Vein Thrombosis
• Etiology:
Pancreatitis - Acute or Chronic
Pancreatic Carcinoma
• Hallmark:
Isolated Gastric Varices
• Treatment:
Splenectomy (if bleeding)

33. Portal Vein Thrombosis

34. Portal Vein Thrombosis
Etiology:
Congenital - “Cavernous Transformation”
Hallmark:
Normal Liver Function W/ Varices
Treatment:
Endo Tx OR DSRS

35. Budd-Chiari Syndrome
•

36. Budd-Chiari Syndrome
• Etiology
Hypercoagulable: Estrogens, XRT, Myeloprolif, PNH
IVC Occlusion: RA Myxoma, Pericarditis, Membrane
Liver Mass
High Dose ChemoTx
• Presentation: Classic Triad
Abdominal Pain
Ascites
Hepatomegaly

37. Budd-Chiari Syndrome
• Diagnosis
– U/S, CT, Angio
• Treatment
– NOT a static disease
– If NO necrosis  Symptomatic Tx
– If necrosis  Shunt (PCS or MAS) or Transplant

38. SclTx vs TIPS
Five Randomized Trials - 360 patients
Mean Follow-up 15 mos (1-36)
* p < 0.05 in all but one study
** p < 0.05 in all studies
*** n.s. in all but one study where survival  w/ SclTx
REBLEED* ENCEPH** SURVIV***
SCLTX 37% 8% 88%
TIPS 17% 32% 81%

39. Child’s Classification
A B C
Bilirubin < 2 2 – 3 > 3
Albumin > 3.5 2.8 – 3.5 < 2.8
Ascites None Controlled Uncontrolled
Enceph None Minimal Advanced
Nutrition Excellent Good Poor

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