Portal Hypertension


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portal hypertension is hypertension (high blood pressure) in the portal vein and its tributaries.

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  • Portal Hypertension

    1. 1. Surgery for Portal Hypertension: Is it History? S K Mathur MS,FACS Sr.Consultant Surgeon Surgical Gastroenterology HPB Surgery & Liver Transplantation Wockhardt Hospitals (Associated Hospital of Harvard Medical International) & JR Railway Hospital Mumbai
    2. 2. Evolution of Treatment for Portal Hypertension - Cleveland Clinic Modified from Hermann Ann Surg 1996
    3. 3. Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era. Bismuth H , Adam R , Mathur S , Sherlock D . Am J Surg. 1990 Jul;160(1):105-10. Hepatobiliary Surgery and Liver Transplant Unit, Paul Brousse Hospital, Villejuif, France. <ul><ul><li>We propose that initial bleeding be controlled by endoscopic sclerotherapy, </li></ul></ul><ul><ul><li>Grade A patients appear to be managed best by a reduced-size portacaval shunt (RPS) </li></ul></ul><ul><ul><li>with prospects of good survival and few complications. </li></ul></ul><ul><ul><li>Grade B patients can be managed by either sclerotherapy, RPS, or OLT, depending upon individual circumstances. </li></ul></ul><ul><ul><li>Grade C patients are best managed by liver transplantation </li></ul></ul>
    4. 4. Historical trend in Management of Portal hypertension KEM hospital, Mumbai 1950 1980 1990 2000 Surgery Sclerotherapy 1983 Year
    5. 5. Long term results of chronic endoscopic variceal sclerotherapy <ul><li>SKM World literature </li></ul><ul><li>Variceal obliteration 84% 62 - 95% </li></ul><ul><li>Mean no. EVS sessions 5.1+/-2.2 4 - 6.8 </li></ul><ul><li>Variceal recurrence rate 28% 19 - 62% </li></ul><ul><li>Recurrent variceal bleed </li></ul><ul><li>- Prior to obliteration 35% 22 - 58% </li></ul><ul><li>- Post obliteration 5% 3 - 23% </li></ul><ul><li>30 day mortality 3% 1 - 12% </li></ul>Mathur et.al Gastrointest. Endoscopy 1990
    6. 6. Trials of Long term Sclerotherapy V/s Splenornal shunt No. of patients : 112 60 72 66 10-59% required surgery for failed EVS
    7. 7. Surgery for Portal Hypertension Personal Series:1983 - 2007 EVS 542 Sx 190 n=608 23% Surgery in EVS Gr. 10%Primary Sx Mathur SK
    8. 8. Portal Hypertension In India: Etiology 1983-2007 N=608* 14% 45% *Personal series
    9. 9. Clinical Manifestations <ul><li>Variceal bleeding </li></ul><ul><li>Ascitis Cirrhosis </li></ul><ul><li>Liver cell failure </li></ul><ul><li>Non-Cirrhotic portal hypertension </li></ul><ul><li>Symptomatic Splenomegaly </li></ul><ul><li>Hypersplenism </li></ul><ul><li>Growth retardation EHPVO </li></ul><ul><li>Biliary Obstruction </li></ul><ul><li>Menorrhagia </li></ul>
    10. 10. Surgery for Portal Hypertension Indications for Surgery <ul><li>for variceal Bleed : - Esophageal </li></ul><ul><li>- Gastric fundic </li></ul><ul><li>- Ectopic varices </li></ul><ul><li>Other Indications : </li></ul><ul><li>*Symptomatic Splenomegaly </li></ul><ul><li>*Symptomatic Hypersplenism </li></ul><ul><li>*Growth retardation </li></ul><ul><li>*Portal Biliopathy </li></ul><ul><li>* Menorrhagia </li></ul>
    11. 11. Portal Hypertension Current Surgical Options Indications for Surgery <ul><li>Primary Therapy </li></ul><ul><li>Rescue therapy </li></ul><ul><ul><li>- Emergency Surgery </li></ul></ul><ul><ul><li>- Elective Surgery </li></ul></ul>
    12. 12. Indications for Primary Surgery Sinistral PHT (Left sided) <ul><li>n = 3 </li></ul><ul><li>Isolated Splenic vein thrombosis </li></ul><ul><li>bleed from fundal varices </li></ul>Splenectomy : curative
    13. 13. PHT:Indications for Surgery Primary therapy <ul><li>Ectopic variceal bleed </li></ul><ul><ul><li>Jejunal / Ileal / stomal / Colonic / Rectal </li></ul></ul>n = 1 - Biliary variceal bleed - Ruptured retropeitoneal varices
    14. 14. PHT: Indications for Surgery <ul><li>Bleeding Diffuse Fundal Gastric varices </li></ul>
    15. 15. Classification of Gastric Varices Hosking’s BJS 1988 Mathur’s J Gastroenterol Hepatol 1988 Sarin’s Am J Gastro 1989 GOV1 GOV2 IGV1 IGV2 <ul><li>Gv with OV </li></ul><ul><li>Type1 </li></ul><ul><li>Type2 </li></ul><ul><li>Isolated GV </li></ul><ul><li>Type1 </li></ul><ul><li>Type2 </li></ul>Baveno Consensus’96
    16. 16. ENDOSCOPIC AND RADIOLOGICAL APPRAISAL OF GASTRIC VARICES Mathur SK et al. B.J.S. 1990 <ul><li>FGV Incidence : 25% </li></ul><ul><li>FGV Bleed : 100% </li></ul>
    17. 17. Fundic Gastric Varices Results of Glue Injection <ul><li>Initial Control 87 - 100% </li></ul><ul><li>Early rebleed 12.5 – 27% </li></ul><ul><li>Late rebleed 54% </li></ul><ul><li>Fatal Complications 1 – 3% </li></ul><ul><li>Mortality from bleed 6 – 8.5% </li></ul><ul><li>( Endoscopy 1993, 1994, 2002) </li></ul>
    18. 18. Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience Akahoshi T et al. Surgery. 2002 Jan; 131(1 Suppl): S176-81. <ul><li>n=52 , active bleeding 32 and recent bleeding 20 </li></ul><ul><li>mean Follw-up : 28.1 months </li></ul><ul><li>RESULTS: </li></ul><ul><li>Initial hemostasis was 96.2%. </li></ul><ul><li>(no bleeding occurred for 48 hours after sclerotherapy) </li></ul><ul><li>Cumulative non-bleeding rates at : </li></ul><ul><li>1 5 10 years </li></ul><ul><li>64.7% 52.7% 48.2% </li></ul><ul><li>CONCLUSIONS: </li></ul><ul><li>Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices </li></ul><ul><li>but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding. </li></ul>
    19. 19. FGV: Post Glue Injection Complications
    20. 20. Effect of TIPS on Fundal Gastric Varices & Congestive Gastropathy <ul><li>FGV fails to resolve </li></ul><ul><li>& Rebleed in 20 - 50 % of cases </li></ul><ul><li>Cause : presence of spontaneous splenorenal shunt which competes with TIPS for preferential flow </li></ul><ul><li>Portal gastropathy does not disappear completely </li></ul><ul><li>Sanyal et al Ann Intern Med 1997 </li></ul><ul><li>Murphy et al J Vasc Interven Radial 1995 </li></ul>
    21. 21. TIPS for FGV <ul><li>Rebleed 20% (Mean F-U 36.7months) </li></ul><ul><li>30 day Mortality 15% </li></ul><ul><li>(Tripathi D et al GUT 2002) </li></ul><ul><li>Actuarial rebleed 36% over 12 months </li></ul><ul><li>( Hepatology 1999) </li></ul>
    22. 22. Indications for Primary Surgery <ul><li>Bleeding Fundal gastric varices : n = 71 </li></ul>Post Shunt Rebleed 2%
    23. 23. Bleeding Fundal gastric varices Results of Surgery <ul><li>n=71 </li></ul><ul><li>Procedurs: -Shunts 20 </li></ul><ul><li>-Modified Sugiura 48 </li></ul><ul><li>-Splenectomy 03 </li></ul><ul><li>Rebleed: 2% </li></ul><ul><li>(mean FU 48.4months SD27.3, range 3-124) </li></ul><ul><li>(personal unpublished series) </li></ul>
    24. 24. Portal Hypertension Primary Elective Surgery Spleen related Indications <ul><li>Symptomatic Hypersplenism </li></ul><ul><li>Symptomatic Splenomegaly </li></ul><ul><li>Growth Retardation </li></ul>
    25. 25. Portal Hypertension Indications for Surgery <ul><li>Symptomatic hypersplenism: Incidence : 7% </li></ul><ul><li>- WBC < 2000 </li></ul><ul><li>- Platelets < 50,000 </li></ul><ul><li>Recurrent sepsis </li></ul><ul><li>Spontaneous bleeding </li></ul><ul><li>Anaemia in absence of GI bleeding </li></ul>Hypersplenism : 33% - WBC < 4000/Cu mm. - Platelets <1,00000
    26. 26. Portal Hypertension Indications for Surgery <ul><li>Symptomatic Splenomegaly : 1.5% </li></ul><ul><li>- dragging pain & visible lump </li></ul>
    27. 27. Extra hepatic Portal Hypertension in Children Indications for Surgery <ul><li>Growth retardation in EHPVO : </li></ul><ul><li>Incidence </li></ul><ul><li>* Sarin et.al. 51% </li></ul><ul><li>* Mathur et.al. 5% </li></ul>Surgery For growth retardation : 1%
    28. 28. Extra hepatic Portal Hypertension INDICATIONS FOR PRIMARY ELECTIVE SURGERY <ul><li>Other indicaions </li></ul><ul><li>Portal billiopathy </li></ul><ul><li>Menorrhagia </li></ul><ul><li>Spleen related Indications </li></ul><ul><li>Symptomatic Hypersplenism </li></ul><ul><li>Symptomatic Splenomegaly </li></ul><ul><li>Growth Retardation </li></ul>
    29. 29. EHPVO:Portal Biliopathy Bile duct abnormalities: 85 – 100% Symptomatic: 1% MRCP MR Cholangiogram + Superimposed Portogram ERCP
    30. 30. Portal Biliopathy Cholangitis MRCP Endo Sono O.V. Fundal G.V. Peri dochal Varices CBD obstruction
    31. 31. MRCP+MR ANGIOGRAPHY <ul><li>Large calculi in Rt hep duct, CHD and prox CBD with marked IHBR diln. CBD prominent but N. </li></ul><ul><li>E/o EHPVO with portal cavernoma with hepatopetal and hepatofugal collaterals and splenomegaly. </li></ul>
    32. 32. Portal Biliopathy Therapeutic Options <ul><li>Sphincterotomy with endoscopic stone extraction. </li></ul><ul><li>Biliary stenting </li></ul><ul><li>Shunt Surgery: </li></ul><ul><li>- to relieve biliary obstruction </li></ul><ul><li>- to facilitate subsequent bile duct surgery </li></ul>
    33. 33. Biliary Surgery in presence of Portal Hypertension <ul><li>Bile duct obstruction due to portal biliopathy In EHPVO: </li></ul><ul><li>Direct bile duct surgery is hazardous : </li></ul><ul><li>it can lead to profuse uncontrollable bleeding from collaterals around bile duct </li></ul><ul><li>Can result in to mortality </li></ul><ul><li>Recommendation : </li></ul><ul><li>Porta-systemic shunt </li></ul><ul><li>6week interval </li></ul><ul><li>Biliary Surgery </li></ul>A Chaudhary BJS 1998
    34. 34. Portal Biliopathy in EHPVO Results of Porto Systemic Shunt <ul><li>Personal : n=10 </li></ul><ul><li>( 9 failed prior Endotherapy) </li></ul><ul><li>- Shunt alone Success 7(70%) </li></ul><ul><li>- Subsequent Biliary surgery 3(30%) </li></ul><ul><li>Literature*: n=40 </li></ul><ul><li>- Shunt alone success: 70-80% </li></ul><ul><li>- Subsequent biliary surgery: 20-50% </li></ul>*Vibert E, Azoulay D et al. Ann Surg 2007 *A Chaudhary BJS 1998
    35. 35. Portal Hypertension Indications for Surgery for variceal Bleed <ul><li>Rescue therapy </li></ul><ul><ul><li>- Emergency Intervention </li></ul></ul><ul><ul><li>* Acute Variceal bleed </li></ul></ul><ul><ul><li>- Elective Intervention </li></ul></ul><ul><ul><li>* Recurrent Variceal bleed </li></ul></ul><ul><ul><li>Etiology of PHT: - Cirrhotic </li></ul></ul><ul><ul><li>- Non-cirrhotic </li></ul></ul>
    36. 36. Q. What to do for refractory bleeding ? <ul><li>Incidence : 20%–30% of patients </li></ul>
    37. 37. Case # 5 TIPS TIPS
    38. 38. Distal-spleno-renal shunt Splenic vein Renal vein SHUNT
    39. 39. TIPS Vs Surgery Evidence based Medicine : <ul><li>U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments : </li></ul><ul><li>Level I: Evidence obtained from at least one properly designed randomized controlled trial . </li></ul><ul><li>Level II-1: Evidence obtained from well-designed controlled trials without randomization . </li></ul><ul><li>Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. </li></ul>
    40. 40. TIPS for control of acute variceal bleeding <ul><li>Control of bleeding: 93 - 95 % </li></ul><ul><li>1-month actuarial probability of rebleeding : 22% </li></ul><ul><li>Operative mortality (30 days) : 28%.- 37% </li></ul><ul><li>Complications : 13% </li></ul><ul><li>- massive hemoperitoneum </li></ul><ul><li>- cardiorespiratory arrest & cardiac failure </li></ul><ul><li>- acute renal failure </li></ul><ul><li>- bacteremia </li></ul>Banares R, Am J Gastroenterol. 1998 Bosch J. J Hepatol 2001
    41. 41. Rescue Therapy Emergency TIPS vs Surgery Good risk patients <ul><li>Solitary RCT in good risk patients </li></ul><ul><li>active bleed failing first line Rx n = 70 </li></ul><ul><li>TIPS vs small diameter P-C shunt </li></ul><ul><li>Failure of therapy: </li></ul><ul><li>56% TIPS vs 26% Surgery (P < 0.02) </li></ul>Rosemurgy Ann Surg 1996
    42. 42. <ul><li>Elective Rescue Therapy TIPS </li></ul><ul><li>v/s </li></ul><ul><li>Surgical shunts </li></ul>
    43. 43. Ten years' follow-up of 472 patients following TIPSS insertion at a single centre <ul><li>Procedure-related mortality : 1.2%. </li></ul><ul><li>Rebleed: 13.7% (within 2 years of TIPS) (principally from gastric and ectopic varices) </li></ul><ul><li>Shunt patency rates: need for reinterventions </li></ul><ul><li>- Primary 45.4% & 26.0% at 1 and 2 years </li></ul><ul><li>- Secondary assisted patency rate was 72.2%. </li></ul><ul><li>hepatic encephalopathy: 29.9% (de novo encephalopathy: 11.5%) </li></ul>Tripathi D et al , Edinburgh,UK, Eur J Gastroenterol Hepatol. 2004;16:9-18.
    44. 44. TIPS: PTFE covered V/s Uncoverd Stents long-term results of a randomized multicentre study <ul><li>N = 80 (follow-up for 2 yrs) </li></ul><ul><li>TIPS Stent Covered Uncovered </li></ul><ul><li>Primary patency 76% 36% (P=0.001) </li></ul><ul><li>Rebleed 10% 29% (P<0.05) </li></ul><ul><li>Encephalopathy 33% 49% (P<0.05) </li></ul><ul><li>Probability of survival 58% 45% (NS) (2 years) </li></ul>Bureau C et al Liver Int. 2007 Aug;27:742-7.
    45. 45. DSRS v/s TIPS (Retrospective Case Control Study) Good risk patients n=40 <ul><li>Conclusion : </li></ul><ul><li>TIPS - Significantly higher incidence v/s DSRS </li></ul><ul><li>* Rebleed episodes (p < 0.001) </li></ul><ul><li>* Rehospitalization (p < 0.05) </li></ul><ul><li>* Shunt revision (p < 0.001) </li></ul><ul><li>* More expensive (p<0.005) </li></ul><ul><li>30 day mortality : 20% v/s 0% </li></ul><ul><li>(Helton et al Arch surg 2001) </li></ul>
    46. 46. Distal splenorenal shunt versus TIPS for variceal bleeding : a randomised trial <ul><li>73 DSRS & 67 TIPS (Child Pugh A and B patients) </li></ul><ul><li>Follow-up: 2-8yrs (mean46+/-26 months) </li></ul><ul><li>DSRS and TIPS similar in efficacy in the control of </li></ul><ul><li>refractory variceal bleeding </li></ul><ul><li>(rebleeding DSRS, 5.5%; TIPS, 10.5%; P = .29) </li></ul><ul><li>Re-intervention: </li></ul><ul><li>significantly greater for TIPS compared with DSRS </li></ul><ul><li>(DSRS, 11% v/s TIPS, 82%, p<0.001) </li></ul><ul><li>No difference in need for LT </li></ul><ul><li>The choice is dependent on available expertise . </li></ul>Henderson JM, et al, Gastroenterology, May 2006
    47. 47. <ul><li>N=132 TIPS 66 HGPCS 66 </li></ul><ul><li>Mortality 10(15%) 13(20%) (Post procedure) </li></ul><ul><li>Child-Pugh C 70% 84% </li></ul><ul><li>Rebleed: 20(30%) 5(7.6%) </li></ul><ul><li>Shunt stenosis 32(48.5%) 7(10.6%) </li></ul><ul><li>significantly higher after TIPS (P <0.001) </li></ul><ul><li>Encephalopathy: 30% 10% </li></ul>H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246. H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals . Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246
    48. 48. H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals <ul><li>TIPS (N = 66) HGPCS (N = 66) </li></ul><ul><li>Through 24 months, actual survival was superior after HGPCS v/s TIPS ( P = 0.04). </li></ul><ul><li>Survival at 5 to 10 years was superior after HGPCS compared with TIPS for : </li></ul><ul><li>- Child's class A and B ( P = 0.07) </li></ul><ul><li>- MELD scores less than 13 ( P = 0.04) </li></ul>Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246.
    49. 49. Rescue Therapy in Cirrhotics TIPS v/s Surgical shunt <ul><li>Evidence based Conclusions </li></ul><ul><li>for Child A & B & MELD < 13: </li></ul><ul><li>* Surgical shunt has a role </li></ul><ul><li>- DSRS or HGPCS </li></ul><ul><li>for high risk Child C: TIPS </li></ul>
    50. 50. Portal Hypertension Rescue Therapy TIPS Vs Surgical Shunt <ul><li>According to the Centre for Evidence-Based Medicine: </li></ul><ul><li>&quot;Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” </li></ul>
    51. 51. Surgery for Portal Hypertension Is it History? CONCLUSIONS: No <ul><li>Rescue Therapy: 10-20% </li></ul><ul><li>* Cirrhotics: </li></ul><ul><li>- Good risk patients: </li></ul><ul><li>: Surgical Shunt not TIPS </li></ul><ul><li>- Poor risk patients: TIPS </li></ul><ul><li>* Non-Cirrhotic: Surgical Shunt or Devasc. </li></ul>
    52. 52. Surgery for Portal Hypertension Is it History? CONCLUSIONS: No <ul><li>Surgery is the Therapy of choice: </li></ul><ul><li>*Bleed from: </li></ul><ul><li>- Diffuse Fundal Gastric Varices </li></ul><ul><li>- Ectopic varices </li></ul><ul><li>* Symptomatic Splenomegaly </li></ul><ul><li>* Symptomatic Hypersplenism </li></ul><ul><li>* Growth retardation </li></ul><ul><li>* Billiary obstruction </li></ul><ul><li>* Menorrhagia </li></ul>
    53. 53. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. Orloff MJ J Am Coll Surg. 2009 July <ul><li>BACKGROUND: The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN: A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death. RESULTS: The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS: EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027). </li></ul>
    54. 54. THANK YOU
    55. 55. Natural history in EHPVO Hepatopetal blood flow in portal cavernoma Adequate hepatic portal perfusion Preservation of hepatocyte function Normal life span
    56. 56. Acute Variceal Bleeding Indications for Em. Rescue Therapy <ul><li>Failure to control variceal hemorrhage : </li></ul><ul><li>Continued bleed inspite of : </li></ul><ul><li>Vasoactive drugs + Endotherapy + Tamponade </li></ul><ul><li>Recurrent bleed within 72 hours : </li></ul><ul><li>inspite of 2 attempts at EVS / EVL </li></ul><ul><li>- fresh blood in NG tube, </li></ul><ul><li>- fall in HB> 2gm%, </li></ul><ul><li>- need for more than 6 units of blood in 24 hours </li></ul><ul><li>Life threatening hemorrhage even after one session : Hypotension, Bp < 80 mmHg. </li></ul>
    57. 57. INDICATIONS FOR ELECTIVE SURGERY <ul><li>Failure of chronic EVS </li></ul><ul><li>Rebleed in defaulter of EVS </li></ul><ul><li>Inability to follow up - absence from work - travel expense / distance </li></ul><ul><li>Single life threatening rebleed </li></ul><ul><li>Two significant rebleeds </li></ul><ul><ul><ul><li>- Hb fall > 2 gm% </li></ul></ul></ul><ul><ul><li>- 2 units blood </li></ul></ul><ul><li>Persistence of large varices after 6-10 sessions of EVS </li></ul><ul><li>Development of Fundal varices </li></ul>
    58. 58. Surgery for PHT <ul><li>Emergency n=15 </li></ul><ul><li>-Bleeding Fundal Gastric Varices 11 </li></ul><ul><li>-Bleeding Oesophageal Varices 4 </li></ul><ul><li>Elective n= 51 </li></ul><ul><ul><li>Fundal Gastric Variceal bleed 22 </li></ul></ul><ul><ul><li>Hypersplenism 19 </li></ul></ul><ul><ul><li>Growth retardation 2 </li></ul></ul><ul><ul><li>Inability to follow up 7 </li></ul></ul><ul><ul><li>Biliary Obstruction 3 </li></ul></ul><ul><ul><li>Menorrhagia 2 </li></ul></ul>Indications for Primary surgery
    59. 59. EVS:Indications for Elective Surgery <ul><li>Gastric Varices 37 </li></ul><ul><li>Oesophageal Varices 24 </li></ul><ul><li>( failure of EVS) </li></ul><ul><li>Inability to Follow up 15 </li></ul><ul><li>Hypersplenism 24 </li></ul><ul><li>Splenomegaly 3 </li></ul><ul><li>Growth retardation 5 </li></ul><ul><li>Bile duct obstruction 3 </li></ul><ul><li>Gastropathy bleed 1 </li></ul><ul><li>Ectopic Varices bleed 2 </li></ul>
    60. 60. Surgical Options in PHT <ul><li>Devascularisation ( Modified Sugiura ) 110 </li></ul><ul><li>Emergency 73 </li></ul><ul><li>Elective 37 </li></ul><ul><li>Shunts : ( elective) 80 </li></ul><ul><li>* DSRS 31 </li></ul><ul><li>* Proximal leinorenal 39 </li></ul><ul><li>* Side to side leinorenal 4 </li></ul><ul><li>* Spleno- Adrenal 3 </li></ul><ul><li>* End renal-side splenic 1 </li></ul><ul><li>* Mesocaval (PTFE graft) 1 </li></ul><ul><li>* Modified Spleno-renal shunt 1 </li></ul><ul><li>( ‘Y’ Shunt) </li></ul>
    61. 61. Surgery: Long term results Recurrence Rebleed Stricture Block Rebleed Enceph Overall 6% 6% 12% 8% 6% 5% DEVASCULARISATION 53 SD 34 months (4-143 months) SHUNT SURGERY 25 SD 29 months (4-107months) %
    62. 62. <ul><li>No single surgical procedure is ideal for all patients or all circumstances </li></ul>
    63. 63. Choice of Surgery <ul><li>Timing : Emergency vs elective </li></ul><ul><li>Experience of surgeon with shunt surgery </li></ul><ul><li>Portal venous anatomy </li></ul><ul><li>Indication for surgery </li></ul><ul><li>Site of bleed </li></ul>
    64. 64. Distal-spleno-renal shunt