New trends in surgical treatment for portal hypertension

A number of surgical procedures have been developed to manage esophageal varices. Broadly, these can be classified as shunting and non-shunting procedures. While total shunt effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. The distal splenorenal shunt (DSRS), a selective shunt, was developed by Warren in 1967 to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. The DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection (SPD, i.e. skeletonization of the splenic vein from the pancreas to its bifurcation at the splenic hilum) and gastric transection (GT, i.e. transection and anastomosis of the upper stomach with an autosuture instrument). An alternative to shunting was developed by Sugiura and Futagawa in 1973. Esophageal transection (ET) divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. DSRS was more effective than ET in preventing recurrence of esophageal varices, but was associated with a higher incidence of hyperammonemia. The incidence of hyperammonemia in patients who underwent DSRS with SPD plus GT was significantly lower than that in patients who underwent DSRS alone or those who underwent DSRS with SPD. In conclusion, there are various surgical treatments for esophagogastric varices. Distal splenorenal shunt with SPD plus GT is considered an adequate treatment for patients with esophagogastric varices.     

Repeated Shunt Surgery in a Patient with Portal Hypertension

Summary: A 45-year-old male with chronic active hepatitis and portal hypertension had a mesocaval interposition graft performed because of repeated uncontrolled bleeding from oesophageal varices. Acute hepatocellular failure, manifested by Grade IV encephalopathy and severe coagulopathy, developed early in the post-operative course despite the absence of hepatic necrosis or other precipitating factors. Both encephalopathy and coagulopathy resolved rapidly following ligation of the shunt. Variceal bleeding recurred and nine months later an emergency distal lienorenal shunt was performed. Post-operatively the shunt was shown to be patent and there has been no encephalopathy or recurrence of variceal bleeding. It is concluded that (1) the splanchnic haemodynamic effects of a mesocaval interposition graft can result in severe hepatocellular failure and this can be reverted by shunt ligation and (2) the distal lienorenal shunt, while effectively reducing the risk of haemorrhage from varices, may be less likely to result in post-operative encephalopathy than more conventional forms of portal decompressive surgery.     

Repeated Shunt Surgery in a Patient with Portal Hypertension

Summary: A 45-year-old male with chronic active hepatitis and portal hypertension had a mesocaval interposition graft performed because of repeated uncontrolled bleeding from oesophageal varices. Acute hepatocellular failure, manifested by Grade IV encephalopathy and severe coagulopathy, developed early in the post-operative course despite the absence of hepatic necrosis or other precipitating factors. Both encephalopathy and coagulopathy resolved rapidly following ligation of the shunt. Variceal bleeding recurred and nine months later an emergency distal lienorenal shunt was performed. Post-operatively the shunt was shown to be patent and there has been no encephalopathy or recurrence of variceal bleeding. It is concluded that (1) the splanchnic haemodynamic effects of a mesocaval interposition graft can result in severe hepatocellular failure and this can be reverted by shunt ligation and (2) the distal lienorenal shunt, while effectively reducing the risk of haemorrhage from varices, may be less likely to result in post-operative encephalopathy than more conventional forms of portal decompressive surgery.     

Effect of distal splenorenal shunt plus splenopancreatic disconnection on glucose and amino acid metabolism

BACKGROUND/AIMS: The Warren-Zeppa distal selective splenorenal shunt (DSRS) is aimed at decompressing esophageal varices by a distal splenorenal shunt, at the same time ligaturing left gastric, gastroepiploic and umbilical veins. In the long-term follow-up the loss of shunt selectivity was observed in several cases. Therefore, Inokuti and Warren reported splenopancreatic disconnection (SPD) to prevent splenic collaterals from stealing portal venous blood. METHODOLOGY: This report presents metabolic data (K-glucose, IRI in iv-GTT, Fischer ratio) of 10 cirrhotic patients operated with DSRS plus SPD. RESULTS: K-glucose of iv-GTT was improved from 2.3 +/- 0.2 to 2.5 +/- 0.2. Fischer ratio was also improved from 1.58 to 2.0 after the operation. IRI behavior tends to be lower after operation as a result of devascularlization of the collateral circulation by the selective shunt. CONCLUSIONS: From these results it seems that DSRS+SPD has favorable effects on glucose and amino acid metabolism.     

Closure of Interposition Mesocaval Shunt in a Case of Idiopathic Portal Hypertension

Interposition mesocaval shunt for hemorrhagic esophageal varices was carried out in a patient with idiopathic portal hypertension without preoperative hepatic dysfunction. The esophageal varices were controlled, but the hemodynamics of the portal vein subsequently underwent gradual change and attacks of hepatic encephalopathy occurred frequently the following year. Therefore, the shunt was closed after about 2 yr. Hepatic encephalopathy disappeared after this surgery, but the varices obviously worsened on the 5th postoperative day and bled spontaneously on the 33rd postoperative day. A distal splenorenal shunt constructed 35 days after the operation resulted in the reduction, but not the complete disappearance, of esophageal varices. Episodes of hepatic encephalopathy or bleeding from the esophageal varices were not observed in the 24 months following the second shunt surgery.     

Relationship between encephalopathy and portal vein-vena cava shunt： Value of computed tomography during arterial portography

AIM: TO assess the value of computed tomography during arterial portography (CTAP) in portal vein-vena cava shunt,and analysis of the episode risk in encephalopathy.METHODS: Twenty-nine patients with portal-systemic encephalopathy due to portal hypertension were classified by West Haven method into grade Ⅰ(29 cases), gradeⅡ(16 cases), grade Ⅲ(10 cases), grade Ⅳ( 4 cases). All the patients were scanned by spiraI-CT. Plane scans, artery phase and portal vein phase enhancement scans were performed, and the source images were thinly reconstructed to 1.25 mm. We reconstructed the celiac trunk, portal vein,inferior vena cava and their branches and subjected them to three-dimensional vessel analysis by volume rendering(VR) technique and multiplanar volume reconstruction (MPVR) technique. The blood vessel reconstruction technique was used to evaluate the scope and extent of portal vein-vena cava shunt, portal vein emboli and the fistula of hepatic artery- portal vein. The relationship between the episode risk of portal-systemic encephalopathy and the scope and extent of portal vein-vena cava shunt,portal vein emboli and fistula of hepatic artery- portal vein was studied.RESULTS: The three-dimensional vessel reconstruction technique of spiraI-CT could display celiac trunk, portal vein,inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cavashunt, portal vein emboli and the fistula of hepatic artery- portal vein. In twenty-nine patients with portal-systemicencephalopathy, grade Ⅰ accounted for 89.7% esophageal varices, 86.2% paragastric varices; grade Ⅱ accounted for 68.75% cirsomphalos, 56.25% paraesophageal varices,62.5% retroperitoneal varices and 81.25% dilated azygos vein; grade Ⅲ accounted for 80% cirsomphalos, 60%paraesophageal varices, 70% retroperitoneal varices, 90% dilated azygos vein, and part of the patients in grades Ⅱand Ⅲ had portal vein emboli and fistula of hepatic arteryportal vein; grade Ⅳ accounted for 75% dilated left renal vein, 50% paragallbladder varices, all the patients had fistula of hepatic artery- portal vein.CONCLUSION: The three-dimensional vessel reconstruction technique of spiraI-CT can clearly display celiac trunk, portal vein, inferior vena cava and their branches at any planes and angles and the scope and extent of portal vein-vena cava shunt. The technique is valuable for evaluating the episode risk in portal-systemic encephalopathy.     

Results of a randomized trial of end-to-side portacaval shunt and distal splenorenal shunt in alcoholic liver disease and variceal bleeding

Since 1976, we have compared the end-to-side portacaval shunt (PCS) with the distal splenorenal shunt (DSRS) in patients with alcoholic liver disease and recurrent variceal bleeding. Fifty-four patients were randomly assigned to receive either shunt procedure. There were 27 patients in each group and both groups were highly comparable in clinical and laboratory characteristics. Median follow-up was 31 mo in each group. Postoperative complications and operative mortality (7% after PCS, 12% after DSRS) were comparable. Spontaneous portasystemic encephalopathy developed in 32% of the patients at risk after PCS and in 39% after DSRS. Rebleeding from varices occurred in 4% of the patients after PCS and in 27% after DSRS. Cumulative survival was not significantly different between groups (5-yr survival: 31% after PCS, 43% after DSRS). We have failed to demonstrate superiority of DSRS in our patients with alcoholic liver disease with respect to postoperative encephalopathy or survival, and have experienced an unusually high rate of variceal rebleeding after DSRS.     

Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding： A lesson from the past

INTRODUCTION The selective distal splenorenal shunt (DSRS) proposed by Warren[1] in 1967 has been considered to be the best procedure available for surgical decompression of patients with portal hypertension[2-4]. DSRS has been compared with sclerotherapy…     

Fundal varices: problem and management.

BACKGROUND/AIMS: The pathophysiology of gastric varices may be due to generalized or segmental portal hypertension. A considerable debate has arisen regarding the role of injection sclerotherapy in the pathogenesis of gastric varices. METHODOLOGY: During the period from 1987 to 1997, a total of 1686 cases with bleeding varices were presented to our center and 225 cases (13.3%) with bleeding gastric varices were diagnosed. There were 198 males and 27 females with a total mean age of 45.7 years (+/- 7.6). Primary fundal varices (FV) were found in 121 (54%) cases and secondary FV were found in 104 (46%) cases. All patients with isolated FV presented with repeated attacks of upper gastrointestinal bleeding. RESULTS: The pathological diagnosis was studied in 120 cases; it was schistosomal in 8.3% of cases, non-schistosomal in 33.3% of cases, and mixed (Schistosomal with post viral cirrhosis) in 58.3% of cases. Seventy-five cases were subjected to splenectomy and gastroesophageal decongestion (SGED), 64 cases were subjected to distal splenorenal shunt (DSRS), and 86 cases were subjected to sclerotherapy. Mortality after DSRS was 7.8%, after SGED it was 12%, and after sclerotherapy it was 21%. Rebleeding was the major complication and occurred in 3% after DSRS, in 13% after SGED, and in 18% of cases after sclerotherapy. CONCLUSIONS: Gastric varices are not an uncommon condition as a cause of upper gastrointestinal bleeding. Our findings support the hypothesis that gastric varices may be considered a late sequel of injection sclerotherapy, though they may also be considered as one of the pathophysiologies of generalized portal hypertension. Finally, DSRS was found to be the treatment of choice in the management of fundal varices.     

Appraisal of DSRS with SPGD for esophagogastric varices: a retrospective comparative study according to the underlying liver diseases

BACKGROUND/AIMS: The differences in long-term results of distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for portal hypertension of different etiologies including non-cirrhotic portal hypertension have yet to be reported. The data are important to determine the indications and contraindications for this procedure. METHODOLOGY: Records of 54 patients of esophagogastric varices who survived 3 years or longer after DSRS with SPGD operation were reviewed. Patients were divided into three groups based on underlying liver disease; posthepatitic cirrhosis (HC) group, alcoholic cirrhosis (AC) group, and idiopathic portal hypertension (IPH) group. RESULTS: The only serious long-term complication of DSRS with SPGD was portal thrombosis in two patients in the IPH group. Postoperative bleeding occurred in two cases of each group; one in IPH group was the only variceal bleeding and others were bleeding from portal hypertensive gastropathy. Hepatocellular carcinoma (HCC) was developed in 28.6% patients in both the HC group and AC group. In all the cases, treatment for HCC was accomplished without aggravation of the varices. The cumulative survival rate was similar in the three groups, and no patient died of gastrointestinal bleeding. CONCLUSIONS: A favorable outcome was achieved by DSRS with SPGD operation both in the patients with cirrhosis or IPH. Underlying liver disease is not a factor when considering DSRS with SPGD for portal hypertension.     

肝硬化非常见侧支循环临床特点研究

目的 探讨肝硬化患者门体循环之间非常见侧支循环形成的临床特点及意义。方法 对临床确诊为肝硬化的患者运用64排螺旋CT和三维血管成像结合电子胃镜检查,观察其门体循环之间非常见侧支循环的形成。结果 ①700例肝硬化患者中118例(16.86%)存在非常见侧支循环,依次为脾肾静脉分流、胃肾静脉分流、椎旁静脉分流、腹膜后静脉分流、胃脾分流和心膈角静脉分流。②非常见侧支循环形成与肝硬化Child-Pugh分级相关(P<0.01)。③与常见侧支循环形成组比较,非常见侧支循环组较少出现重度食管和(或)胃底静脉曲张、重度门静脉高压性胃病及大量腹水(P<0.01)。④非常见侧支循环组中肝性脑病和慢性血氨升高的发生率高于常见侧支循环组(P<0.01)。结论 ①肝硬化患者中非常见侧支循环并不"非常见";②非常见侧支循环形成与肝功能Child-Pugh分级有关;③非常见侧支循环形成可缓解门静脉高压引起的相关并发症,但增大了肝性脑病和慢性血氨升高的发病率。     

Transjugular intrahepatic portosystemic shunt: current status

The transjugular intrahepatic portosystemic shunt (TIPS) was developed in the 1980s for treatment of complications of portal hypertension. Once it was shown that the shunt could be placed with relative ease, TIPS was rapidly applied to the treatment of many of the complications of portal hypertension. These complications include actively bleeding gastroesophageal varices, prevention of rebleeding from varices, control of refractory cirrhotic ascites and hepatic hydrothorax, and treatment of hepatorenal failure and hepatopulmonary syndrome. TIPS has also been used as therapy for Budd-Chiari syndrome and veno-occlusive disease. Despite these broad applications, TIPS has been compared with other forms of therapy in only 2 situations: prevention of rebleeding from varices and control of refractory cirrhotic ascites. In the trials, TIPS was shown to provide better control of these 2 complications of portal hypertension than standard forms of therapy. However, there was no improvement in survival and the incidence of encephalopathy was greater for patients receiving a TIPS. Thus, the use of TIPS for the control of ascites and prevention of rebleeding from varices should be limited to a select group of patients. There have been no controlled trials for the other indications listed. Despite the apparent efficacy of TIPS in many of these situations, its use should be limited to salvage therapy pending the publication of controlled trials showing it is a better treatment than other forms of therapy.     

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt(TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.     

Analysis of postoperative pancreatitis in DSRS with SPD.

BACKGROUND/AIMS: Distal splenorenal shunt with splenopancreatic disconnection (DSRS + SPD) evolved to prevent the development of a pancreatic siphon, to improve maintenance as well as quality of portal perfusion and to achieve better long-term survival. We report several cases of postoperative pancreatitis in DSRS + SPD. Recently, oxygen-derived free radicals have been reported to play an important role in pathogenesis of acute pancreatitis. METHODOLOGY: In this study, ten cases of DSRS + SPD were examined intraoperatively. The local changes in oxygen-derived free radicals were obtained by measuring lipid peroxide and an endogenous scavenger (SOD) in the development of DSRS + SPD-induced pancreatitis. RESULTS: Lipid peroxide activity as the offense system was not changed before or after SPD. However, SOD activity as a defense system was significantly lowered after SPD compared to before SPD. CONCLUSIONS: These results indicate that an imbalance of both systems might be the cause of postoperative pancreatitis.     

Reversal of hepatic encephalopathy and alteration in amino acid profiles after blocking a surgical splenorenal shunt by interventional radiological techniques

Portal-systemic shunts are effective in preventing haemorrhage from varices in portal hypertension, but at the price of hepatic encephalopathy. We describe the blockage of a splenorenal shunt using interventional radiology, in a patient with incapacitating chronic encephalopathy. The procedure successfully reversed encephalopathy, without haemodynamic disturbances or haemorrhage from recurrent varices and was associated with a return of the plasma amino acid profile towards normal, with a reduction in aromatic amino acids and an increase in branch chain amino acids. This observation supports the hypothesis that changes in plasma amino acid profiles in patients with portal-systemic shunting are due to the diversion of portal blood rather than the underlying chronic liver disease.     

Ten years' follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre

BACKGROUND: Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is increasingly used for the management of portal hypertension. We report on 10 years' experience at a single centre. METHODS: Data held in a dedicated database was retrieved on 497 patients referred for TIPSS. The efficacy of TIPSS and its complications were assessed. RESULTS: Most patients were male (59.4%) with alcoholic liver disease (63.6%), and bleeding varices (86.8%). Technical success was achieved in 474 (95.4%) patients. A total of 13.4% of patients bled at portal pressure gradients < or = 12 mmHg, principally from gastric and ectopic varices. Procedure-related mortality was 1.2%. The mean follow-up period of surviving patients was 33.3 +/- 1.9 months. Primary shunt patency rates were 45.4% and 26.0% at 1 and 2 years, respectively, while the overall secondary assisted patency rate was 72.2%. Variceal rebleeding rate was 13.7%, with all episodes occurring within 2 years of TIPSS insertion, and almost all due to shunt dysfunction. The overall mortality rate was 60.4%, mainly resulting from end-stage liver failure (42.5%). Patients who bled from gastric varices had lower mortality than those from oesophageal varices (53.9% versus 61.5%, P < 0.01). The overall rate of hepatic encephalopathy was 29.9% (de novo encephalopathy was 11.5%), with pre-TIPSS encephalopathy being an independent predicting variable. Refractory ascites responded to TIPSS in 72% of cases, although the incidence of encephalopathy was high in this group (36.0%). CONCLUSIONS: TIPSS is effective in the management of variceal bleeding, and has a low complication rate. With surveillance, good patency can be achieved. Careful selection of patients is needed to reduce the encephalopathy rate.     

An ultrasonic duplex system facilitates detection of portal hemodynamic changes following selective shunts for esophageal varices

We used an ultrasonic duplex system (US system) to assess portal hemodynamics in 52 patients with liver cirrhosis and esophageal varices, who underwent 2 types of distal splenorenal shunt (DSRS), conventional DSRS (group A, 8 patients) or DSRS with splenopancreatic disconnection (group B, 44 patients). The portal blood flow rate (PBF) was determined in 64 out of 70 patients (91.4%) and the shunt flow rate (SVF) in 39 out of 42 patients (92.9%) who had angiographically confirmed patent portal vein and shunt vein, during the peri- and postoperative period. In group A, a remarkably small amount of postoperative PBF (193 ml/min) and a concomitant increase in SVF (1039 ml/min) were evident. Such ultrasonic findings were compatible with a reduction in portal vein diameter, in accordance with the poor portal perfusion grade of the liver, and a transpancreatic stealing of the portal blood flow to the shunt, as evidenced by postoperative angiography. In contrast, the reduction in PBF was minimal, that is 663 ml/min preoperatively to 562 ml/min at discharge, and 536 ml/min at late follow-up, in group B patients. Significant alterations in portal circulation of the group B patients were not evident angiographically. This US system is most useful to assess portal hemodynamics in patients with a selective shunt.     

Treatment of refractory hepatic encephalopathy associated with insertion of a transjugular intrahepatic portosystemic shunt through new endovascular techniques: a case report

Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used treatment in the management of the complications of portal hypertension. However, one of the complications of this technique is refractory or recurrent hepatic encephalopathy, which poses a difficult clinical problem. We report the case of a patient who underwent TIPS insertion to control bleeding due to esophageal varices. The patient subsequently developed refractory hepatic encephalopathy, requiring reduction of the caliber of the shunt.     

Tratamiento de la encefalopatía hepática resistente asociada a la creación de una derivación percutánea portosistémica intrahepática mediante nuevas técnicas endovasculares: a propósito de un caso clínico

Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is an increasingly used treatment in the management of the complications of portal hypertension. However, one of the complications of this technique is refractory or recurrent hepatic encephalopathy, which poses a difficult clinical problem. We report the case of a patient who underwent TIPS insertion to control bleeding due to esophageal varices. The patient subsequently developed refractory hepatic encephalopathy, requiring reduction of the caliber of the shunt.     

Selective transplenic decompression of oesophageal varices by distal splenorenal and splenocaval shunt

The usefulness of selective transplenic decompression of oesophageal varices by distal splenorenal shunt and splenocaval shunt was evaluated in the control of gastrointestinal haemorrhage in patients with portal hypertension of varied aetiology. (Decompression was successful in 69 out of 78 cases.) It was shown that it is superior to total portosystemic shunts, as the incidence of encephalopathy was very low compared with the data from our series of portocaval shunts. The operative mortality has been progressively lowered and has now reached levels comparable with portocaval shunt. Distal splenorenal shunt when performed as an emergency procedure to arrest bleeding has limited usefulness but when performed as an elective or prophylactic procedure its results are comparable with those of portocaval shunt without the untoward complications such as encephalopathy. A modified selective decompression of varices has been described in which the distal end of the splenic vein is anastomosed to the inferior vena cava. Though no long term follow-up studies are available, we believe that this shunt is likely to prove superior to distal splenorenal shunt as it has both the advantages of the distal splenoral and the haemodynamic advantage of end-to-side portocaval shunt. We conclude that in patients with portal hypertension of varied aetiology, who have not had a haemorrhagic episode but in whom varices have been demonstrated or who have had one episode of haemorrhage from varices, the splenocaval shunt when feasible or the distal splenorenal shunt offers the optimal method of management at present in India.