Romanian surgeons made several important contributions to the history of portal hypertension surgery in the 20th century. Prof. Dr. Dumitru Burlui performed over 500 operations for portal hypertension between 1960-1980 and described various surgical techniques in his publications, including splenectomy, spleno-renal shunts, porto-caval anastomoses, and omento-esophagodiaphragmatic fixation to create shunts. He modified existing techniques and also developed new ones such as anterior gastric transection with variceal ligation. Burlui's work established him as a leading figure in the surgical treatment of portal hypertension.

1. Authors: Dr. Sinziana Ionescu
Prof. Dr. E. Bratucu
Bucharest Oncology Institute
Bucharest, Romania
ROMANIAN
CONTRIBUTIONS TO THE
HISTORY OF THE
SURGERY OF PORTAL
HYPERTENSION

2. Let us begin our time travel experiment!

3. The definition of portal
hypertension
• The portal vein carries
approximately 1500 mL/min of
blood from the small and large
bowel, the spleen, and the
stomach to the liver Obstruction
of portal venous flow, whatever
the etiology, results in a rise in
portal venous pressure.
• Normal portal pressure is
generally considered to be
between 5 and 10 mm Hg. Once
the portal pressure rises to 12
mm Hg or greater, complications
can arise

4. MAIN OPTIONS IN THE SURGERY OF PORTAL HYPERTENSION

5. National and international historical context for
the surgery of portal hypertension
1877 Eck s fistula the first porto-caval
anastomosis described experimentally in
dogs, resulting sometimes in “Eck’s meat
intoxication’’
1907 Jianu – the anastomosis of the superior
mesenteric vein to the vena cava –
experimental surgery
1913 Bogoras performs the operation above
in humans
1953 Voinea Marinescu performs the first
mesenterico caval derivation
1955 P Constantinescu performs a troncular
porto-caval anastomosis
1957 Juvara spleno-renal anastomosis

6. Prof.Dr. Dumitru Burlui (1920-1983)
• He wrote and collaborated in 9 surgical
monographies
• Corresponding member of the Academy of
Medical Sciences 1969
• President of the Romanian Surgical Society 1979
• Member of the leading committee of
International Society of Vascular Surgery 1973
• Member of the International College of Digestive
Surgery Rome
• 500 cases of portal hypertension operated with a
global mortality of 25%

7. Prof. dr. D. Burlui –Monographies-
• 1.Diagnosis and surgical treatment of broncho-pulmonary cancer,
Moscow 1955
• 2.How to treat portal hypertension, Medical Publishing House,
Bucharest, 1967
• 3.Ombilical vein in the porto-hepatic-biliary surgery, Medical
Publishing House, Bucharest 1970
• 4.Surgery of the hepatic hydatid cyst, Medical Publishing House,
1976
• 5.Surgery of portal hypertension, Medical Publishing House , 1980

8. Portal hypertension - operative indications -
as described in Prof.Dr. Burlui’ s book “Surgery of portal hypertension”,
Medical Publishing House 1980 Bucharest
1.SPLENECTOMY
2.SPLENO- RENAL SHUNT WITH
OR WITHOUT SPLENECTOMY
3. SIDE TO SIDE PORTO-CAVAL
ANASTOMOSIS
4.LEFT PORTO RENAL
ANASTOMOSIS OR RENO
PORTAL
5.SIDE TO SIDE PORTO-CAVAL
ANASTOMOSIS
B. Extrahepatic block
1. SPLENECTOMY not so efficient , better
is 2. MESENTERICO-CAVAL SHUNT
A. Intrahepatic block

9. Surgical techniques described and put into
practice by prof. dr. D.Burlui
1) ANTERIOR GASTRIC TRANSECTION
ASSOCIATED WITH CONTINUOUS
SUTURE OF GASTRIC VARICES AND
VASCULAR LIGATION
He modified the techniques of Torres
Degni (1963) and Tanner (1950) which
both involved inter-azygo-portal
disconnections
The operation was of not so much de-
compressive value but it was efficient in
haemorrhagy accidents

10. 2) OMENTOESOMEDIASTINOPEXY

11. OMENTOESOMEDIASTINOPEXY- theoretical context
• The procedure performs collateral shunting between the portal and cava
system
• It is associated with splenectomy to suppress the clinical and lab picture
of hypersplenism and with ligation and chemical phlebosclerosis to
abolish the esophageal and or gastric varices
• Prevents the reappearance of esophageal varices
• The left half of the greater omentum is mobilized cephalad up to the
esophageal muscular opening where it is fixed by stay sutures
• As a result of the operation, a close contact of the greater omentum with
the esophagus will produce a connective vascular junction in which the
surrounding mediastinal tissue also participates, resulting a newly formed
capillary and arteriolar network, therefore omentoesomediastinopexy
gives a local esomediastinal portal systemic shunt the blood of the
mediastinal vessels being drained through the azygos veins into the
general systemic circulation

12. Advantages over Bourgeon s operation:
(spleen mobilisation with intrapulmonary
anastomosis)
 Mobilization of the spleen is not necessary
 Minimal blood losses which is good in the
prevention of shock
 All the accidents and complications of the
mobilization of the spleen are avoided
3)SUBDIAPHRAGMATIC INTRASPLENIC
PNEUMOSPLENOPEXY
• The inferior left pulmonary lobe was mobilized into the
abdominal cavity, a wedge being cut in the superior pole
of the spleen into which the tip of the inferior pulmonary
lobe was introduced and fixed in this position by suturing
the circumference of the splenic wedge adhering to the
diaphragm, by interrupted sutures
• It is without much derivative power , as interventions
which did not diminish the portal hypertension by
minimum 10, do not protect the patient from
haemorrhagic shock

13. 4)OMPHALOCAVAL ANASTOMOSIS SIDE TO SIDE VARIANT
• The condition required to perform this operation is to have a particular situation:
an ombilical vein which was spontaneously re-canalized
• LEGER did this operation end to side , Burlui performed it side to side because the
vein was elongated and curved and- in the first particular case- there was
thrombosis of the portal and superior mesenteric

14. 5.CORONARY CAVAL ANASTOMOSIS SIDE TO SIDE
Intraoperative omphaloportography revealed
a narrow portal vein insufficient for an
anastomosis ; on the other hand,the gastric
coronary vein was sinous and dilated forming
varicose like dilatations.In the lesser
omentum the vein formed a loop that bulged
through the pars flaccida coming close to the
inferior vena cava
This anastomosis, as are others, is kept open
by the flux passing through them and, if after
the derivation the flux decreases too much
the anastomosis might close

15. 6.EXTRAPERITONISATION OF THE RIGHT LOBE OF THE LIVER (1959)
• Belli covered the liver in a plastic bag in order to perform a treatment of
ascitis
• In 1964 this technique was published in Presse Medicale;
• Included in the New French Treaty Of Surgery under L. Leger (1975)
• It decollates the diaphragmatic and inferior visceral peritoneum and
removes them from the liver , therefore the liver enters in direct contact
with the diaphragm and the liver lymphatics drain into the diaphragmatic
lymph vessels –this in dogs was seen directly and obviated histologically
• This procedure is easier to perform on atrophic livers in order to have more
room to do the sectioning-because atrophic livers are small

16. 7.EXTENDED MALLET -GUY PROCEDURE (1947)
• Extension of the sympathectomy from the trunk of the common
hepatic artery to that of the proper hepatic artery it has the value
of a neurectomy with consequent vasodilation
• The procedure ensures better irrigation of the cirrhotic liver

18. Nervous plexus from the abdominal viscera

19. PERIHEPATIC SYMPATHECTOMY (EXTENDED MALLET GUY PROCEDURE) ---
OPERATIVE STAGES

24. Thank you very much for accompanying me in
this trip with the time machine!