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  1. 1. EVOLUTION OF SURGERY EVOLUTION OF SURGERY OF PORTAL HYPERTENSION OF PORTAL HYPERTENSION IN Egypt (last century) IN Egypt (last century) Prof. Mohamed Abd Elwahab Prof. Mohamed Abd Elwahab Gastroenterology Surgical Center Gastroenterology Surgical Center Mansoura University Mansoura University
  2. 2. • Hitherto, portal hypertension in Egypt (and allover the world) remains full of mysteries in its pathogenesis, prevention and management. • Eminent bleeding from varices remains the most common problem faced by the medical profession in Egypt. • The “rightfor” and type management of such cases with or without bleeding remains a battle ground between physicians and surgeons.
  3. 3. The Story of Surgery of Portal Hypertension. •Nicolai Eck………. 1877 •Whipple……. 1935-1945 •Linton……………1961 •Warren…………. 1966 •Drapanase……… 1975 •Tips………. 1990-2002
  4. 4. • The story of the surgical treatment of portal hypertension begins in 1877 in Russia. At that time Nicolai Eck described a portocaval shunt for treatment of portal hypertension. (Eck Nv. 1953)
  5. 5. • In 1893 Pavlov and his Co-workers refuted ECK’s conclusion. • Initial success in controlling variceal bleeding was achieved in 1903 when Vidal performed a portocaval anastomosis in cirrhotic patients
  6. 6. • In 1935 Whipple et al. Studied the natural history of portal hypertensive bleeding in patients with cirrhosis, his initial success published in 1945 triggered an explosion of enthusiasm for portocaval shunt and its variants • Controlled prophylactic and therapeutic trials over the following 15 years however confirmed the infectiveness of total shunt in prolonged survival
  7. 7. • In an attempt to obviate or reduce the late morbidity and improve survival following portacaval shunt, several investigators looked for a procedure that would achieve variceal decompression without depriving the liver of its portal blood supply. • Linton et al for example advocated splenectomy and central splenorenal shunt as a method which could meet these criteria, however with time, the shunt failed, either enlarged sufficiently or thrombosed.
  8. 8. • After central splenorenal Drapanas popularized the mescoval interposition shunt and calaimed that this procedure succeeded in achieving variceal decompression. This type of shunt proved later on to be not effective in management of variceal bleeding due to high incidence of hepatic cell failure, encephalopathy and shunt thrombosis.
  9. 9. Distal Spleno Renal 1967 Shunt (Rational) • Selective decompression of gastro-esophageal varices. • This shunt leaves the spleen. • Portal hypertension maintained for perfusion the liver. • Improvement of gastrointestinal congestion and absorption.
  10. 10. I N EG YP T Ancient History
  11. 11. The Nile Valley was Inhabited at Least as Early as 20,000 Years Age • Written document did not appear until the early dynastic period 3500-3000 B.C. • Schistosomasis in Egypt discovered 3000 years ago as a written documents in the walls of the temple in upper Egypt. • They discovered the way of transmission, protection and the treatment.
  12. 12. Two Ancient Egyptian Farmers wearing penile sheath
  13. 13. Circumcision , operation , Ankh . ma Hor’s tomb. Saqqara The operator rubs the organ by a stone (Right ) then cuts by a shaped flint (left)
  14. 14. Abdominal distension and umbilical hernia in boatman ptah-Hetep’s tomb , Saqqara.
  15. 15. Hearst papyrus, case 83 which antimony (inset) is mentioned for first time to treat schistosomiasis.
  16. 16. In recent history. Dr. Theodor Bilharz. in Cairo, in 1851 discovered human schistosomasis.
  17. 17. In last century
  18. 18. • Bleeding esophageal varices as a complication of portal hypertension is the most common causes of upper gastrointestinal hemorrhage in Egypt. The economic impact of this disease is compounded by the fact that it affect individuals at the peak of their productive life.
  19. 19. IN EGYPT PORTAL HYPERTENSION Evoluted in different ways 1-Aetiopathology 2- Haemodynamic 3- Managment
  20. 20. Aetiopathology •In 1928 sorour followed by Hashem 1947 laid down the foundation of the pathological pattern of liver periportal fibrosis as a cause of portal hypertension. • The pathology of liver cirrhosis changed in the late 70s and early 80s duo to appearance of type B. hepatitis, C-hepatitis and mixed pathology.
  21. 21. • During the first half of the last century, hepatic schistosomiasis represent the cause of portal hypertension replaced by hepatic cirrhosis due to hepatitis B and C viruses as a causes of portal hypertension in the last two decades.
  22. 22. Changes in liver pathology, last 20 years (1500 patients) 300 250 200 150 100 50 0 80-85 85-90 90-95 95-2000 Bil. Mixed Nonbil.
  23. 23. Homodynamic • Intraoperative portal pressure (occluded and free) was measured for the first time by Khairy in 1960 • Study of splenic pulp in vivo by Badan • Transplenic spleno portography • Selective superior mesenteric angiography
  24. 24. Surgery has Evolved Widely During the Last Century DUE TO 1. Change of liver pathology 2. Development of new surgical techniques 3. Appearance of wide variety of alternative to the patient and phyciation (pharmacological endoscopic, interventional radiology)
  25. 25. Managment 1- Splenectom 1908 2- Total shunt 1950 3- Non shunt 1957 4- Mesocaval shunt 1974 5- Selective shunt 1978 6- Injection sclerotherapy 1980 7- Present status
  26. 26. Surgery for portal hypertension started early in this century by splenectomy fot the first time in 1908. (Aly pasha Ibrahim 1908)
  27. 27. However though splenectomy lowered portal pressure (75-40%) this proved to be at most temporary. (Musa 1962-E-Sherif 1904)
  28. 28. In the Forties • Total port-systemic shunts were introduced in the west (Whipple 1945-Blackkemone 1947). • In Egypt shunt surgery was practiced in late fifties
  29. 29. Total Shunts • In the 1950 portocaval shunts were applied to schistosomal patients in Egypt. Up to 1970 this type of surgery was criticized by many surgeons. However because of the high incidence of mortality and morbidity this procedure was abandoned in this patients.
  30. 30. Non Shunts • In the 1960 Hassab popularized splenectomy and extensive devascualarization as a new surgical aaproach for schistosomal portal hypertension. • In the same period Khairy 1964 introdced the operation of splenectomy and vasoligation of the oesophagus and stomach • Many modification tried after those two operation in theforme of • Suprediaphaogmatic devascualarization • Trans gastric ligation • Esophageal transection
  31. 31. Non shunt • Lack of satisfaction of splenectomy in thatment of O.V. Lack of satisfaction of splenectomy in thatment of O.V. has led to the development of porto-azygos has led to the development of porto-azygos disconnection in it’s different forms including Hassabs disconnection in it’s different forms including Hassabs operation (1959) Which is still practiced till now. operation (1959) Which is still practiced till now. • Rational of Hassabs operation .. Rational of Hassabs operation 1.Decongestion of variceal bearing area. 1.Decongestion of variceal bearing area. 2. Reduction of portal hypervolaemia. 2. Reduction of portal hypervolaemia. 3. Improvement of all blood elements. 3. Improvement of all blood elements. 4. Improvement of liver function 4. Improvement of liver function
  32. 32. Hassab’s operation • Has the advantage of low operative mortality low encephalopathy. • However it faild to achieve its goal, with high rebleeding rates.
  33. 33. Mesocaval Graft In EGYPT (1976) 1- Mortality 43% 2- Encephalopathy 30% 3- Hepatic failure 30%
  34. 34. Distal Spleno-Renal Shunts: DSRS (Selective Shunt) • In the early 1970, with the era of the selective shunt. DSRS became popular in Egypt around 1972 and it was adopted by many Egyptian surgeons and still is Over two decades later this type shunt was practiced allover Egypt.
  35. 35. Selective Shunts •Science 1990 this type of shunt started to die out – Change of pathology – Loss of selectivity – Sclerotherapy
  36. 36. • However with the passage of time However with the passage of time collateralization occurred turning it into collateralization occurred turning it into potentially total shunt with higher potentially total incidence of encephalopathy incidence encephalopathy
  37. 37. Selective Shunt Corono-renal Shunt • An alternative to selective shunt • Not used due to high incidence of thrombosis
  38. 38. Injection Sclerotherapy • In Egypt injection sclerotherapy started around 1975, was done by surgeons and still in many center using solid then flex scopes. Gradually it was taken over by endoscopists, and became the first and sometime the only line of treatment of bleeding varices.
  39. 39. Transjuglar intra hepatic porto- systemic shunts (TIPS) 1- To bridge to transplancation II- Last resort in acute bleeding in child C
  40. 40. Present status Sclerotherapy or band therapy are the treatment of choice.. Is there is any place for surgey. Is there is any place for surgey. • Failure of sclerotherapy Failure of sclerotherapy •Gastric varices Gastric varices • Duodenal varices Duodenal varices • Young patients with good liver Young patients with good liver • Segmental portal hypertension Segmental portal hypertension
  41. 41. • Failures of sclorotherapy Failures of sclorotherapy – Failure to clear the esophagus. Failure to clear the esophagus. – Recurrent massive bleeding during treatment Recurrent massive bleeding during treatment – Development of gastro-duodenal varices. Development of gastro-duodenal varices. – Congestive gastropathy. Congestive gastropathy.
  42. 42. Gastric Varices • Bleeding gastric varices are usually massive Bleeding gastric varices are usually massive difficult to diagnose and to control. difficult to diagnose and to control. • They are best controlled by surgery. They are best controlled by surgery. • Shunt surgery is more superior than non-shunt. Shunt surgery is more superior than non-shunt.
  43. 43. From 1975-2002 13377 patients With bleeding varices managed in gastroenterology center Mansoura University EYYPT
  44. 44. Management of bleeding varices in gastroenterolgy center mansoura University • Surgery 1915 • Injection sclerotherpy 11467
  45. 45. Type of Treatment by Period 75-80 80-85 85-90 90-95 95-2000 Surgrey 108 374 454 468 387 Injection 0 560 1250 4500 5157
  46. 46. Type of Operation No % Slective shunt Distal splenorenal 606 32 Coronorenal 40 2 Total shunt Mesocaval 33 1.7 Small diameter 20 1 Central lieno- renal 26 1.3 Non shunt Hassab 811 42.4 Splenectomy vasohigation vasohigation 335 17.5 Stapler Stapler 39 2
  47. 47. Hospital Mortality No. % DSRS 606 (19) 3% Non shunt 1185 (23) 2% Total shunt 79 (7) 9%
  48. 48. Rebleeding No % Selective shunt (606) 36 6% Non shunt (1185) 272 23% Total shunt (79) 6 8%
  49. 49. Hepatic pathology as prognostic factor (after DSRS) Bilharz. Non Mixed Mortality late 8% 17% 22% H.C.F. 4% 12% 16% Portal perfusion 94% 75% 50% Encephalopathy 4% 22% 26%
  50. 50. Schistosomal patients have • A better survival rate with low incidence of encepahalopathy after DSRS. Compared with the cirrhatics and mixed population (Annals of surgery 89)
  51. 51. Encephalopathy No % Selective shunt (606) 72 12% Non shunt (1185) 35 3% Total shunt (79) 79 40%
  52. 52. Late Mortality F.U./y No % Selective shunt (606) 15 88 14% Non shunt (1185) 14 142 12% Total shunt (79) 10 63 80%
  53. 53. conclusion • The history of portal hypertension started in Egypt more than 5000 y ago • Evolution happened to many changes as etiopathology- surgery and intervention radiology • The present situation - Pathology N - Sclerotherapy is the first choice O - Selective shunt or non shunt W (according to many factors)
  54. 54. Thank YOU