Portal hypertension

1. Portal Hypertension
management
Dr. Shambhavi Sharma
3rd year Resident
PAHS
Moderator : Dr Shantabir Maharjan

2. Introduction
• Portal hypertension defined as portal vein pressure above 5-8mm Hg
• Hepatic-portal vein pressure gradient(HVPG) more than 5 mm Hg

3. Pathophysiology of portal hypertension
Structural changes
(fibrosis, scarring,
vascular thrombosis
etc)
Increased Hepatic Resistance
Dynamic changes
(vascular smooth muscle and stellate
cell contraction)
PORTAL HYPERTENSION Splanchnic Vasodilation
Increased Portal Blood Inflow
Effective Hypovolemia
Activation Of Endogenous
Vasoactive System
Na Retention
Hypervolemia
Increased Cardiac Index

4. Clinical manifestations of portal hypertension
where surgery is required
Cirrhotic
1. Uncontrolled or recurrent Variceal bleeding
2. Liver failure
3. Refractory ascites
Non cirrhotic
1. Hypersplenism
2. Symptomatic splenomegaly
3. Growth retardation
4. Portal biliopathy
5. Uncontrolled or recurrent Variceal bleeding

5. Surgical approach
• Primary therapy : sinistral portal hypertension (isolated splenic vein
thrombosis)
• Rescue therapy :
1. Emergency
2. Elective

6. At emergency setting

7. Management for acute variceal bleeding
• Resuscitation
• Achievement of hemostasis
• Prevention of complications

8. Achievement of hemostasis

9. If bleeding cannot be controlled or endoscopy
delays
Baloon tamponade
• considered a temporary bridge to more definitive measures of
variceal hemorrhage control
• control refractory bleeding in up to 90% of patients
Contraindications:
• History of esophageal strictures
• Recent gastric or esophageal surgeries

10. Sengstaken Blakemore tube/minesota tube

11. • Potential for complications:
• aspiration
• airway obstruction
• esophageal perforation due to overinflation or pressure necrosis
Use should not exceed 36 hours to avoid tissue necrosis

12. • Sengstaken Blakemore tube
• Minnesota tube
Orthotropic
liver
transplantation
Transjugular intrahepatic
portosystemic shunt

13. Transjugular intrahepatic Porto Systemic
shunt (TIPS)
Involves implantation of a metallic
stent
• between an intrahepatic branch of
the portal vein and a hepatic vein
radicle
• The needle track is dilated until a
portal pressure gradient of ≤12
mmHg is achieved.

14. TIPS (contd.)
• TIPS for control of acute variceal bleeding: 93 - 95 %
• 1-month actuarial probability of rebleeding : 22%
• Operative mortality (30 days) : 28%.- 37%
• Complications : 13%
• massive hemoperitoneum
• cardiorespiratory arrest & cardiac failure
• acute renal failure
• bacteremia
Banares R, Am J Gastroenterol. 1998
Bosch J. J Hepatol 2001

15. Contraindications for TIPS
Right heart failure --most significant --acute death from total heart
failure (Peron et al, 2000)
• Older age of patient
• High MELD or Child ough score
• Cavernous transformation
• Polycystic liver disease
• Active spontaneous bacterial peritonitis (SBP)

16. TIPS
Advantage
• Non-operative approach
• Ideal in short term portal
decompression in patient
requiring liver transplant until
donor is available
• Advanced hepatic functional
decompensation who are
unlikely to survive long enough
for TIPS to malfunction
Disadvantage
Shunt stenosis or shunt thrombosis (
upto 50%) within first year
Recurrent portal hypertensive bleeding
Total shunt occlusion in 10-15% of
patients

17. TIPS vs Endoscopic therapy
• Rebleeding = 19 vs 47%
• Encephalopathy = 34% in TIPS

18. TIPS vs Surgery (Distal splenorenal shunt)
Randomised trial
• 73 DSRS & 67 TIPS (Child Pugh A and B patients)
• Follow-up: 2-8yrs
• DSRS and TIPS similar in efficacy in the control of refractory variceal bleeding
• rebleeding : DSRS, 5.5%; TIPS, 10.5%; P = .29
• Re-intervention: significantly greater for TIPS compared with DSR(DSRS, 11% v/s
TIPS, 82%, p<0.001)
• No difference in need for Liver Transplantation
The choice is dependent on available expertise .
Henderson JM, et al, Gastroenterology, May 2006

19. Devascularization procedures
• Reduce blood flow to varices
• Interrupt bleeding source
• Eliminate the complications of
splenomegaly (hypersplenism)
Advantages :
• Easy technique
• Low mortality
• Low recurrent variceal bleeding
rate
• Postoperative encephalopathy is
rare - preserving of portal blood
flow
• Liver function well preserved

20. SUGIURA procedure
• Disadvantage:
• Thoracic approach
• Abdominal approach
• Mortality distribution:
4,3% (Child A, B),
17%(Child C)
• Recurrent variceal
bleeding rate < 5 %
D.Vagotomy and pyloroplasty
Modified sugiura procedure

21. Hassab operation
• Gastro-esophageal decongestion and
splenectomy
• Perhiatal devascularization of lower
esophagus
• Complete separation of the stomach from
its bed
• Ligation of the left gastric artery at the
lesser curvature, peritonization of greater
curvature and suction drainage of the
splenic bed

22. Elective setting

23. Indication for surgery
Absolute
• Symptomatic hypersplenism (recurrent
bleeding or infection)
• Severe thrombocytopenia (<10000)
• Symptomatic or medically refractory
hepatic encephalopathy
• Hepatopulmonary syndrome
• Portopulmonary syndrome
Relative
• Symptomatic splenomegaly (pain,rupture,
infarction,restricting daily activities )
• Poor health related QOL
• Large varices with poor access to health
care or rare blood groups
• Refractory LGI bleed due to ano-rectal
varices or colopathy
• Portal biliopathy
• Growth failure
• Delay In sexual development

24. Patient preparation
(1) underlying liver disease and its severity (Child pugh score/ MELD
Score )
(2) abdominal venous anatomy (imaging )
(3) overall performance status

25. Therapeutic goal:
to decrease portal pressure thus prevent and treat PH complications
Aims :
• Bypass the portal resistance site by creating portoportal or, more
commonly, portosystemic shunts (PSS);
• When not feasible, direct treatment of complications of NCPH (eg,
ligation of varices)

26. Anatomy

27. Blood flow

28. Surgical procedures
• Devascularization procedures
• Decompression procedures

29. Decompression procedures
Aim
• Reduce portal venous pressure
• Maintain total hepatic and portal blood flow
• Avoid the high incidence of complicating hepatic encephalopathy

30. Non selective shunts (complete porto systemic
decompression )
decompress the entire portal system by diverting all
portal flow
Portocaval End to side or side to side anastomosis
Mesocaval Side to side or with an interposition graft
Mesoatrial Requires interposition PTFE graft
Proximal splenorenal End to side anastomosis of proximal splenic vein to left
renal vein
Requires splenectomy
Partial (incomplete portal system decompression) Non selective shunt with diameter <10mm

31. Portocaval shunt
First described by Eck in 1877,
• either joins the portal vein to the
IVC in an end-to-side fashion and
completely disrupts portal vein
flow to the liver
• or joins it in a side-to-side fashion
and thereby maintains partial
portal venous flow to the liver.

32. Portocaval shunt
• Help to decrease variceal bleeding
• Refractory ascites treatment
• Decompresses the splanchnic venous
circulation and intrahepatic sinusoid network
• Performed when TIPS not available or fails
Disadvantage
• Rebleeding rate upto 70%
• Encephalopathy 20-40%
• Accelerated hepatic failure due to
decrease in hepatic perfusion
• Makes subsequent hepatic transplantation
much more technically difficult

33. Mesocaval shunt
• Uses an 8- or 10-mm PTFE graft
• connect superior mesenteric vein to the IVC
• Technically easier to perform
• Ease hepatic transplantation.
• Smaller caliber of the shunt :
1. avoids the deleterious effects of portal blood flow
deprivation on hepatic function
2. reduce the incidence of encephalopathy
Disadvantage : increased risks of shunt thrombosis
and rebleeding

34. Partial (incomplete portal system decompression)

35. Proximal splenorenal shunt

36. Mesoatrial shunt
portal vein to drain directly into the right atrium
Use : Budd Chiari syndrome inferior venacava
thrombosis can be present

37. Selective (variceal-bearing compartment
decompression)
decompress only the variceal-bearing compartment of
the portal venous system and preserve some portal flow
to the liver
Inokuchi's left gastric venous caval End to side anastomosis of left gastric vein vena cava,
may require an autologous graft
Splenocaval End-to-side anastomosis of distal splenic vein to cava,
may require an interposition PTFE graft
Small‐diameter H‐graft shunt. PTFE reinforced grafts that measure 8 mm in internal
diameter and connects the superior mesenteric vein or
portal vein to inferior vena cava.
Warren's distal splenorenal End-to-side anastomosis of distal splenic vein to left
renal vein, includes ligation of the coronary and
pancreatic veins

38. Distal Spleno-Renal shunt
• Aka Warren Shunt
• Division of GE collaterals
• End-to-side splenic to left renal vein
anastomosis
• allows venous drainage of the stomach and
lower esophagus through the short
gastrosplenic veins into the spleen
• allowing the splenic vein to drain directly
into the left renal vein
• ultimately decompresses the left LUQ.
Interruption of all collateral vessels

39. Selective shunt- DSRS
Advantages :
• SMV continues to perfuse
liver
• lower rate of hepatic
encephalopathy and
decompensation (<10%)
• not interfering with
subsequent liver
transplantation.
• Rate of recurrent bleeding
(7-13%)
Disadvantages:
• Technically more
demanding
• Important lymphatic
pathways transected-
aggravates ascites
• Gradual collateralizes-
loss of portal flow in
50% in 1year
• Complications : acute
pancreatitis, pseudocyst
• Mortality: 1-19%)
Contraindication
• Prior splenectomy
• Splenic vein <7mm
• Intractable ascites

40. Portoportal shunts
Rex shunt Connects superior mesenteric vein or varix to the left
portal system at the recessus of Rex (left portal vein
system)

41. Rex Bypass
• Direct portal revascularization can be
achieved by interposing a vascular graft
between the SMV and the Rex
recessus (left portal vein system)
• very successful physiologic cure of
chronic portal hypertension and
restores the portal flow into and
through the liver graft.
• Primary revascularization of liver grafts
• Managing early acute portal vein
thrombosis episodes.

42. Selection of shunts procedure
• Depends on hepatic functional reserve
• patency of the splenoportal venous axis
• Patient's transplant candidacy
• Available surgical expertise
- Portal blood containing hormones, nutrients and cerebral toxins
diversion cause adverse reactions
- Portosystemic encephalopathy
- Accelerated hepatic failure

43. DSRS

44. Follow up
• Regular 6 monthly follow up to look for spleen size, growth, quality of
life, school performance, development of jaundice, decompensation,
portal biliopathy, hepato-pulmonary syndrome

45. References
• Sabiston textbook of surgery, 20th edition
• Consensus on EHPVO, SK Sarin et al., 2006
• ACG & AASLD Joint Clinical Guideline: Prevention and Management
of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis
Am J Gastroenterol 2007;102:2086–2102
• Non-cirrhotic portal hypertension – Diagnosis and
management.Journal of Hepatology 2014 vol. 60 j 421–441 439

46. Thank you