This ppt enumerates the role of Surgery in Portal Hypertension. Earlier, dealing with Portal Hypertension was purely a surgical endeavour but nowadays due to advent of better endoscopic procedures, managing Portal Hypertension is now primarily a Physician's work.

1. ROLE OF SURGERY IN PORTAL
HYPERTENSION
PRESENTER : DR SARANG P
BOMBATKAR
GUIDE: DR S FULARE SIR

2. OVERVIEW
1. Introduction
2. Portal Vein
3. Portocaval anastomosis
4. Portal Hypertension
5. Management of Variceal Bleeding
6. Role of Surgery in Management of
Variceal Bleeding
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3. INTRODUCTION
There are 2 venous drainage systems that
drain the abdominal structures:
• The Portal venous system
• The Systemic Venous system
Portal Vein provides 75% of hepatic blood
flow and 50% of the oxygen delivery.
• Its trunk is 4.8 to 8.8 cm long with an
average length of 6.4 cm and o.6 to 1.2 cm
wide with an average width of 0.9 cm.
• It is formed behind the neck of the
pancreas at the level of the second lumbar
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4. 20XX
IMAGE COURTESY: ATLAS OF HUMAN ANATOMY ; FRANK NETTER; 6TH EDITION
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5. PORTOCAVAL
ANASTOMOSIS
• A porto caval anastomosis is a connection
between the veins of the portal venous
system, and the veins of the systemic venous
system.
• In portal hypertension, blood may be re-
directed through the porto-systemic
anastomoses (as these are now under a
lower pressure). If a large volume of blood
passes through these anastomoses over a
long period of time, the veins around the
anastomosis can become abnormally dilated
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1. Lower end of esophagus : Left
Gastric and Short gastric veins
with Azygos vein : esophageal
varices
2. Umbilicus : between paraumbilical
vein and anterior abdominal vein
leading to caput medusae
3. Lower end of rectum : Between
Superior Haemorrhoidal vein and
inferior, Middle haemorrhoidal
vein.
4. Retroperitoneal collaterals: Vein
of Retzius

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8. PORTAL HYPERTENSION
• Portal hypertension is defined by a portal pressure
gradient (the difference in pressure between the portal
vein and the hepatic veins) greater than 5 mm Hg.
• Portal Hypertension is the sustained elevation of Portal
venous Blood pressure more than 10 mm Hg.
• The best method to estimate this gradient is by
transfemoral-hepatic vein catheterization with a balloon
tip catheter.
• Portal hypertension per se produces no symptoms and is
generally diagnosed following presentation with
decompensated chronic liver disease causing encephalopathy,
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9. Portal hypertension
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• Normal pressure in PV : 5 to 7 mm Hg
• Portal HTN: > 10 mm Hg
• Esophageal varices occur at >12 mm Hg.
• At > 20 mm Hg, very high mortality due to
Variceal Bleed.

10. CAUSES OF PORTAL HYPERTENSION
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11. PORTAL
HYPERTENSION
• The collateral network through the coronary and short gastric
veins to the azygos vein is clinically the most important
because it results in the formation of esophagogastric varices.
• The most common cause of prehepatic portal hypertension is
portal vein thrombosis. This accounts for approximately 50% of
cases of portal hypertension in children.
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12. History of Surgical Management of
Portal HTN
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Shunt Surgeries
1. 1867: Eck’s Fistula: End to side Portocaval
shunt
2. 1945: Whipple’s Portocaval Shunt
3. 1947: Linton’s Proximal Splenorenal Shunt
4. 1967: Warren’s Distal Splenorenal Shunt
5. 1970: Inokuchi’s Left gastric caval shunt
6. 1984: Sarfeh’s and Rypins Small Diameter H
Graft Portocaval shunt

13. History of Surgical Management of
Portal HTN
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Non Shunt Surgeries
1. 1928: McIndoe’s Left gastric vein Ligation
2. 1947: Phemeister & Humphreys Gastrectomy,
esophagectomy
3. 1949: Grey & Whitesell’s Devascularisation
4. 1949: Boerema’s Button: Transabdominal
Esophageal resection anastomosis
5. 1950: Boerema & Crile’s Transthoracic suture
ligation of varices
6. 1967: Hassab: Transabdominal Gastroesophageal
Devascularisation with splenectomy with
esophageal transection

14. History of Surgical Management of
Portal HTN
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Non Shunt Surgeries
• 1973: Sugiura & Futugawa : 2 stage complete
Thoracic and abdominal devascularisation with
esophageal transection splenectomy and pyloroplasty
• 1982: Peracchia et al : Transabdominal
Devascularisation with esophageal transection
• 1986: Dr Mathur: Modified Sugiura procedure:
Transabdominal Extensive Esophagogastric
devascularisation with gastroesophageal stapling
without Splenectomy.

15. VARICEAL HEMORRHAGE
• Bleeding from esophagogastric varices is the single most
life threatening complication of portal hypertension. It
is responsible for approximately one third of all deaths
in patients with cirrhosis.
• Approximately 50% of these deaths are caused by
uncontrolled bleeding. The risk for death from bleeding is
mainly related to the underlying hepatic functional
reserve. Patients with extrahepatic portal venous
obstruction and normal hepatic function rarely die of
bleeding varices, whereas those with decompensated
cirrhosis (e.g., Child-Pugh class C) may face a mortality
rate in excess of 50%.
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16. MANAGEMENT OF VARICEAL HEMORRHAGE
• In a patient with upper gastrointestinal bleeding,
general measures are instituted that include securing the
airway, ensuring adequate iv access ,fluid infusion, type
and crossmatch of blood, and judicious blood and products
transfusion.
• For acutely bleeding patients with portal hypertension,
nonoperative treatments are generally used as a first-
line approach as these patients are high operative risks
because of decompensated hepatic function.
• Endoscopic treatment (e.g., sclerosis or ligation) has
become the mainstay of nonoperative treatment of acute
hemorrhage because bleeding can be controlled in more
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18. BALLOON TAMPONADE
• Balloon tamponade is effective for
massive or refractory variceal bleeding
but is only recommended as a ‘bridge’
to definitive treatment. If the rate of
blood loss prohibits endoscopic
evaluation, a Sengstaken–Blakemore tube
or a Minnesota tube can be inserted to
provide temporary hemostasis.
• Once inserted, the gastric balloon is
inflated with 300 mL of air and
retracted to the gastric fundus and the
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19. SELF EXPANDING METAL
STENTS
• Self-expanding covered metal oesophageal stents
have also been employed for the emergency treatment
of oesophageal varices and results are equivalent
to balloon tamponade unless the bleeding site is
intragastric.
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20. ENDOSCOPIC VARICEAL
LIGATION
• The combination of
variceal ligation and
pharmacotherapy with
nonselective beta
blockade is more
effective than variceal
ligation alone.
• The Varix is drawn into
the ligator by suction
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21. APPROACH TO VARICEAL
BLEED
Once Acute bleeding is controlled, a patient of
Variceal bleeding can be managed by 2 approaches:
1.Interventional Approach
2.Operative Approach
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22. TRANSJUGULAR INTRAHEPATIC PORTO
SYSTEMIC SHUNT
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INTERVENTIONAL APPROACH

23. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC
SHUNT
INDICATIONS
1.Indicated in patients in whom
Pharmacological and endoscopic
approach to control Variceal
bleeding has failed.
2. Can be done before Liver
transplant when patients are on
waitlist.
3.Refractory ascites in a
Cirrhotic pt.
CONTRAINDICATIONS
1.Long standing complete
portal vein Obstruction
2.Right IJV Obstruction
3.Pre existing Septicemia
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24. APPROACH TO A PATIENT WITH SUSPECTED
VARICEAL BLEEDING
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25. Surgical Intervention for Portal
HTN
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• Emergency Surgery for Control of Acute
Variceal Bleeding
• Elective Surgery as primary therapeutic
modality
• Elective surgery as rescue therapy after
failure of endoscopic therapy.

26. Indications of Emergency Surgery
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1. Continued or recurrent bleeding despite 2
sessions of endoscopic variceal ligation.
2. Significant rebleeding within 48 hrs.
• Procedure of choice: Modified Sugiura
procedure.

27. Elective Surgery as primary
therapeutic modality
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1. Sinistral PHTN (Left sided Portal HTN) : seen
in patients with isolated splenic vein
thrombosis. Splenectomy is curative in these
patients.
2. Symptomatic Hypersplenism
3. Symptomatic massive splenomegaly affecting
quality of life.

28. SHUNT SURGERIES
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Portosystemic shunts are clearly the most effective means of preventing recurrent
hemorrhage in patients with portal hypertension. These procedures are effective because
they all decompress the portal venous system to varying degrees by shunting portal flow
into the lower pressure systemic venous system.
Shunts are of 3 types :
1. Non selective shunts : They completely divert portal blood flow away from the liver
2. Selective shunts
3. Partial Shunts

29. SHUNTS
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Non selective
Partial Shunt
Selective
Shunt
1. End to side Shunts
2. Side to side shunts
3. Proximal Splenorenal shunts
1. Sarfeh Shunt
1. Distal Splenorenal
shunt
2. Inokuchi shunt (Left
Gastric vein to IVC)

30. FEATURES OF SHUNT SURGERIES
Advantages
• Most effective means of preventing
recurrent hemorrhage in patients with
Portal hypertension.
Disadvantage
s
• Accelerate hepatic failure and lead to frequent
postshunt encephalopathy.
• End to side portacaval shunts cant control
ascites.
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31. END TO SIDE
PORTOCAVAL
ANASTOMOSIS
• Also k/a Eck’s Fistula.
• It diverts all the Portal blood flow away from
liver, hence has high incidence of Hepatic
encephalopathy.
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32. SIDE TO SIDE
SHUNTS
1. Portacaval : Portal vein to IVC
2. Mesocaval: IMV to IVC
3. Mesorenal: IMV to Renal Vein
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33. SIDE TO SIDE PORTACAVAL SHUNT
The liver and intestines are both important
contributors to ascites formation, side-to-side
portosystemic shunts are the most effective shunt
procedures for relieving ascites as well as for
preventing recurrent variceal bleeding. Because they
completely divert portal flow, like the end-to side
portacaval shunt, however, side-to-side shunts also
accelerate hepatic failure and lead to frequent post
shunt encephalopathy.
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34. SPLENORENAL
SHUNT
The conventional splenorenal shunt
consists of anastomosis of the
proximal splenic vein to the renal vein.
Splenectomy is also performed.
Because the smaller proximal rather
than the larger distal end of the
splenic vein is used, shunt thrombosis
is more common after this procedure
than after the distal splenorenal shunt.
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35. Distal Splenorenal Shunt
(Warren Shunt)
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• Divide the splenic vein at its junction with the
superior mesenteric vein, and anastomoses the splenic
vein to the left renal vein.
• This selectively decompresses gastroesophageal
varices.
• Control of bleeding has been at 94%, with good portal
perfusion maintained in 90% of patients initially.
• The overall incidence of encephalopathy has been
around 15% following this operation.
• Spleen is preserved.

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37. DISTAL SPLENORENAL SHUNT WITH SELECTIVE VARICEAL
DECOMPRESSION
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38. SARFEH SHUNT (PARTIAL SHUNT)
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39. Devascularisation Procedure
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• These operations approach the problem of variceal
bleeding by interrupting inflow to the varices.
• The components are splenectomy, gastric and
esophageal devascularization, and possibly esophageal
transection.
• The effectiveness of these procedures appears to
depend on the aggressiveness of the operation.
• The advantage of these procedures is that portal
hypertension is maintained with portal flow to the
cirrhotic liver.
• Devascularization can be useful when patients have
extensive portal and splenic venous thrombosis and there
are no other operative or radiologic options.

40. Sugiura Procedure
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• The Sugiura procedure for oesophageal varices combines splenectomy
with oesophagogastric devascularisation, permanently interrupting
the intraoesophageal portacaval shunt while preserving
perioesophageal varices. The surgery is performed on the stomach
wall and all venous tributaries are divided as for highly
selective vagotomy except on both the lesser and greater curves.
• The upper half of the stomach and 8–10 cm of oesophagus are
cleared (less than originally described but avoiding entering the
chest).
• After devascularisation with careful preservation of the
collateral channels and the vagus, a large oesophageal stapler is
introduced into the lower oesophagus, which is transected just

41. Sugiura Procedure
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1. Transthoracic extensive devascularisation of lower
esophagus from the level of left inferior pulmonary
vein upto diaphragm, ligation and division of all peri
esophageal perforating veins and collaterals.
2. Esophageal transection at level of diaphragm followed
by end to end anastomosis in 2 layers using
interrupted sutures.
3. Transabdominal devascularisation of upper half of
lesser curvature of stomach for a distance of 6 7 cm
below cardia.
4. Splenectomy
5. Vagotomy
6. Pyloroplasty

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43. Liver Transplantation
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• Transplantation in patients who have bled secondary to
portal hypertension is the only therapy that addresses
the underlying liver disease in addition to providing
reliable portal decompression.
• There is evidence that variceal bleeders with well
compensated hepatic functional reserve (Child-Pugh
class A and B+) are initially better served by
nontransplantation strategies. (First line T/t:
Pharmacological + Endoscopic)
• If a nontransplantation procedure (e.g., operative
shunt or TIPS) is performed initially, these patients
should be carefully assessed at regular intervals of 6
to 12 months. Hepatic transplantation should be
considered when other complications of cirrhosis

44. DEFINITIVE TREATMENT OF PORTAL
HYPERTENSION
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46. References
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[1] Bailey’s and Love Short Practice of Surgery ; 27th edition
[2] Sabistan Textbook of Surgery; The Biological basis of Modern
Surgical Practice; 21st edition
[3] Schwartz Principles of Surgery
[4] Sherlock’s Diseases of Liver and Biliary system;12th edition
[5] Recent advances in Surgery-9; Roshan Lall Gupta
[6] Principles and Practice of Surgery; A Davidson Title
[7] Lisa N Leopardi, Matthew S Metcalfe, Guy J Maddern,
Ite Boerema—surgeon and engineer with a double-Dutch legacy to
medical technology,Surgery, Volume 135, Issue 1,2004,
https://doi.org/10.1016/j.surg.2003.08.022.

47. THANK YOU
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