The surgeon''s role in the management of portal hypertension.

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.     

Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison

HYPOTHESIS: In good-risk patients with variceal bleeding undergoing portal decompression, surgical shunt is more effective, more durable, and less costly than angiographic shunt (transjugular intrahepatic portasystemic shunt [TIPS]). DESIGN: Retrospective case-control study. SETTING: Academic referral center for liver disease. PATIENTS: Patients with Child-Pugh class A or B cirrhosis with at least 1 prior episode of bleeding from portal hypertension (gastroesophageal varices, portal hypertensive gastropathy). INTERVENTION: Portal decompression by angiographic (TIPS) or surgical (portacaval, distal splenorenal) shunt. MAIN OUTCOME MEASURES: Thirty-day and long-term mortality, postintervention diagnostic procedures (endoscopic, ultrasonographic, and angiographic studies), hospital readmissions, variceal rebleeding episodes, blood transfusions, shunt revisions, and hospital and professional charges. RESULTS: Patients with Child-Pugh class A or B cirrhosis undergoing TIPS (n = 20) or surgical shunt (n = 20) were followed up for 385 and 456 patient-months, respectively. Thirty-day mortality was greater following TIPS compared with surgical shunt (20% vs 0%; P =.20); long-term mortality did not differ. Significantly more rebleeding episodes (P<.001); rehospitalizations (P<.05); diagnostic studies of all types (P<.001); shunt revisions (P<.001); and hospital (P<.005), professional (P<.05), and total (P<. 005) charges occurred following TIPS compared with surgical shunt. CONCLUSIONS: Operative portal decompression is more effective, more durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding. Good-risk patients with portal hypertensive bleeding should be referred for surgical shunt.     

Portal hypertension and ascites

Portal hypertension is secondary to increased resistance to blood flow and increased blood flow through the portal system. The most common cause is liver cirrhosis. The most severe and life-threatening presentation of portal hypertension is acute variceal bleeding. Pharmacotherapy with vasoactive agents (terlipressin or somatostatin), endoscopic band ligation and radiological treatment with transjugular intrahepatic portosystemic shunt (TIPSS) are the most common treatment options for variceal bleeding. However, where surgical expertise exists, portosystemic shunts can be considered for refractory bleeding in patients without significant liver failure, especially when TIPSS is unavailable or contraindicated. Diuretic therapy with spironolactone and furosemide are the basis for the management of ascites. If ascites becomes refractory, repeat large volume paracentesis and TIPSS are potential treatment options. Liver transplantation offers the definitive treatment for portal hypertension secondary to cirrhosis as it cures the underlying liver disease.     

Portal hypertension and ascites

Portal hypertension is secondary to increased resistance to blood flow and increased blood flow through the portal system. The commonest cause is liver cirrhosis. The most severe and life-threatening presentation of portal hypertension is acute variceal bleeding. Pharmacotherapy with vasoactive agents (terlipressin or somatostatin), endoscopic band ligation and radiological treatment with transjugular intra-hepatic portosystemic shunt (TIPSS) are the commonest treatment options for variceal bleeding. However, where surgical expertise exists, portosystemic shunts can be considered for refractory bleeding in patients without significant liver failure, especially when TIPSS is unavailable or contraindicated. Diuretic therapy with spironolactone and furosemide are the basis for the management of ascites. If ascites becomes refractory, repeat large volume paracentesis and TIPSS are potential treatment options. Liver transplantation offers the definitive treatment for portal hypertension secondary to cirrhosis as it cures the underlying liver disease.     

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??Surgical therapy procedure in cirrhosis with portal hypertension WU Zhi-yong, CHEN Wei. Department of General Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
Corresponding author??WU Zhi-yong, E-mail??zhiyongwu@gmail.com
Abstract Bleeding from esophagogastric varices is the most life-threatening complication of portal hypertension, which is the main target of traditional surgical therapy. It has been reached a consensus that non-operative therapy is primary during the period of acute variceal bleeding, such as pharmacotherapy, endoscopic therapy, triplelumen tube balloon tamponade and so on. In the case of refractory bleeding, emergency operation is suitable in patients provided that the liver dysfunction is not too severe ( Child- Pugh class A or B ). Devascularization is the most suitable choice in emergency operation so long as there is hepatopetal blood flow in the portal vein. Transjugular intrahepatic portosystem shunt (TIPS) is suitable for the patients of Child-Pugh class C who are in emergency state. Most patients who survive a first variceal hemorrhage episode should receive surgical treatment to prevent recurrent episodes. The etiological factor(s) should be defined before operation, and it also should be evaluated that the hepatic functional reserve, degree of portal hypertension and hemodynamics of the liver and portal system. Mainly for the traditional surgical method includes devascularization, shunt surgery and shunt combined with devascularization surgery. We emphasize that selection of operative method must be based on portal vein hemodynamics, and the operative modality must have a definite hemodynamic status. Among those who bleed in portal hypertension, patients with only liver function Child-Pugh class C who can not be improved by medical treatment (end-stage liver disease) are suitable for liver transplantation.     

Beneficial Effect of Partial Portal Decompression Using the Inferior Mesenteric Vein for Intractable Gastroesophageal Variceal Bleeding in Patients With Liver Cirrhosis

BACKGROUND: Use of the inferior mesenteric vein (IMV) for partial portal decompression has not been recommended as a first-line option for intractable gastroesophageal variceal bleeding because of the thin diameter of the vein. Although these indications remain relevant, few reports have compared partial portal decompression using the IMV with other therapies. We propose that partial portal decompression using the IMV is a useful alternative treatment for intractable variceal bleeding. METHODS: We performed partial portal decompression using the IMV in eight patients with intractable variceal bleeding that had been uncontrolled using medical and endoscopic therapies. All patients were classified into Child's class B or C. The surgical data, morbidity, and mortality were assessed. RESULTS: Mean portal venous pressure significantly decreased from 26.9 +/- 2.0 mmHg before the surgery to 19.8 +/- 3.9 mmHg after the surgery. The operative mortality rate was 0%. The mean duration of hospital stay was 25.5 +/- 13.3 days. Although one patient experienced recurrent bleeding, shunt patency was well maintained in all patients during the follow-up period (mean 28.9 +/- 14.1 months). Six patients are still alive and well without ascites or hepatic encephalopathy. Two of the Child's class C patients who underwent emergency shunt died owing to hepatic decompensation. CONCLUSION: Partial portal decompression using the IMV can be a safe, effective way to treat intractable variceal bleeding in patients with liver cirrhosis. However, use of the shunt procedure may have the most survival benefits for cirrhotic patients with preserved liver function.     

精准外科时代门静脉高压症的外科治疗策略

门静脉高压症最危重的并发症是食管静脉曲张破裂出血。药物治疗和内镜套扎是食管静脉曲张出血的一线治疗方法,非手术治疗失败或再出血时可考虑外科手术治疗。应根据患者的病因、病期和肝功能代偿状况,依据循证医学和精准外科治疗的理念,个体化选择分流术、断流术、肝脏移植等外科手术治疗。对于某些特殊类型的非肝硬化造成的肝外型门静脉高压症,Meso—Rex转流术可作为治愈性手术方法;而对于区域性的门静脉高压症,也可能通过外科手术治愈。     

Distal splenorenal shunt in children.

The distal splenorenal end-to-side anastomosis (Warren shunt) decompresses esophageal varices while maintaining high portal hypertension and avoiding reduction of portal venous blood inflow to the liver. The Warren shunt was performed in seven consecutive patients with portal hypertension, including post-necrotic cirrhosis, portal thrombosis, and schistosomiasis, all with recurrent esophageal bleeding. Five shunts remained patent and two thrombosed. There was no mortality. If long-term follow-up evaluations indicate its effectiveness in preventing esophageal hemorrhage, the distal selective splenorenal shunt would be the more physiologic and safer procedure in children with portal hypertension.     

Portal hypertension and ascites

Portal hypertension occurs secondary to increased resistance to portal blood flow. It is a principle consequence of liver cirrhosis and leads to severe life-threatening complications, such as variceal bleeding, ascites and hepatic encephalopathy. Acute variceal bleeding is a medical and surgical emergency requiring a multidisciplinary management approach. Prompt resuscitation along with pharmacotherapy agents (terlipressin or somatostatin analogues) followed by early endoscopic variceal banding is the cornerstone of effective treatment. Refractory bleeding despite endoscopic band ligation requires emergency trans-jugular intrahepatic portosystemic shunt (TIPSS). Diuretic therapy with spironolactone and furosemide are the first line of management of ascites. If ascites becomes refractory, repeat large volume paracentesis (LVP) and TIPSS are potential treatment options. Liver transplantation remains the only curative option for all patients with portal hypertension, but a careful selection policy and assessment is mandatory when considering transplantation.     

Gastroportal shunt for portal hypertension in children

PurposeExtrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension.MethodsThe mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months).ResultsThe gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding.ConclusionsThe gastroportal shunt is an effective treatment of extrahepatic portal hypertension.     

Portal venous decompression with H-type mesocaval shunt using autologous vein graft: a North American experience

BACKGROUND/PURPOSE: Portal hypertension in children often is caused by prehepatic venous obstruction or intrahepatic fibrosis without cirrhosis. This situation is uniquely amenable to shunting; this report details the experience of 3 North American centers with an H-type mesocaval shunt using autologous vein, which has been widely used in European centers. METHODS: Retrospective chart review was conducted of records from 1980 through 1999 at 3 North American institutions. Charts were reviewed for etiology of portal hypertension, diagnostic workup, preoperative management, operative results and complications, postoperative shunt patency, patient well-being, and eventual need for liver transplantation. RESULTS: Twenty patients were identified with prehepatic causes of venous obstruction undergoing shunt therapy. Eleven had portal venous thrombosis or cavernous transformation. Of these, 3 had umbilical catheters placed in the neonatal period. Five children had American-Indian cirrhosis, 1 had congenital hepatic fibrosis, and 3 had hepatic fibrosis associated with polycystic kidney disease. Patients presented at a median age of 3.7 years and underwent follow-up for an average of 4.3 years after surgery. These patients had an average of 3.6 bleeding episodes, (with 3.9 attempts at sclerotherapy) and received 3 units of blood preoperatively. Average age at operation was 8 years, average weight was 30 kg, and perioperative blood requirement was 200 mL. In general, patients did well postoperatively; 2 patients required reoperation for lymphatic leaks, and there was 1 death caused by a leaking G-tube, unrelated to shunt functioning. Two patients had transient encephalopathy postoperatively, and 1 patient had severe pancreatitis. All shunts remain patent, with good function and no further bleeding. CONCLUSIONS: These results are encouraging, and we would suggest that the H-type mesocaval shunt utilizing autologous vein be considered for wider use in pediatric patients with prehepatic cause of portal hypertension. An algorithm for the work-up of pediatric patients with variceal bleeding is presented, with the recommendation that shunt surgery be considered early in patients with a prehepatic or fibrotic causes of portal hypertension.     

Surgical treatment of portal hypertension

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.     

Current state of portosystemic shunt surgery

BACKGROUND: A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective, and durable procedures to treat variceal bleeding in patients with low operative risk and good liver function. DISCUSSION: In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) and a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or transjugular intrahepatic portosystemic shunt insertion fails to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) should be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.     

Effect of propranolol and sclerotherapy in bleeding esophageal varices. A case report

Portal hypertension and variceal bleeding are discussed in relation to the history of a patient with primary biliary cirrhosis. Beta-blockade and sclerotherapy failed to prevent recurrent bleeding and a shunt operation had to be done. In this patient the portal venous pressure increased despite continuous propranolol administration.     

Hemodynamics of the interposition mesocaval shunt.

Eighty interposition mesocaval shunts, using a knitted Dacron large diameter prosthesis, have been performed during the past five and one-half years. Patients were evaluated from the standpoint of protection from recurrent esophageal hemorrhage, shunt patency, encephalopathy and cumulative survival analysis. In a selected group of patients, hemodynamic measurements were also obtained in the pre, intra, and postoperative periods. These included measurements of wedged hepatic vein pressure, superior mesentric venous blood flow, and residual superior mesenteric, hepatic sinusoidal and inferior vena cava pressures following the shunt procedure. Additionally, direct shunt flow measurements utilizing a square wave of electromagnetic flowmeter were also performed. Results indicate that the shunt patency is 95%; adequate decompression of the portal system was accomplished; recurrent variceal hemorrhage did not occur if the shunt remained patent; the incidence of encephalopathy was low (11%); and the operative mortality for the entire series was 9%. Continued perfusion of the liver was documented in 44% of patients and appears to be a function of the residual total portal resistance largely controlled by inferior vena caval pressure at the level of graft replacement. Life survivhat the interposition mesocaval shunt appears to be an effective technique for the control of variceal hemorrhage, has important hemodynamic advantages and can be applied to most patients for the control of variceal hemorrhage due to portal hypertension.     

Partial portacaval shunt: renaissance of an old concept.

BACKGROUND. Partial diversion of the portal system aims to reduce portal pressure sufficiently to prevent variceal hemorrhage but still maintain adequate hepatic portal flow. METHODS. Partial portacaval shunts were performed in 25 patients with cirrhosis with portal hypertension and esophageal varices, either as a primary procedure (n = 16) or for failure of endoscopic sclerotherapy (n = 9), with ringed polytetrafluoroethylene prostheses (8, 10, or 12 mm). RESULTS. All patients have now been followed up for at least 1 year. The operative mortality rate (2 months) was 4%. In 24 patients who survived beyond the initial perioperative period, there was no recurrence of variceal bleeding. Cumulative shunt patency (up to 4 years) is 96%. Acute encephalopathy was detected in two patients (8%), but no patients had signs of chronic encephalopathy. Intraoperative pressure measurements revealed a significant correlation between decreasing diameter of the graft and the percentage reduction of the portacaval pressure gradient. Selective angiography, performed 1 year after surgery, revealed that hepatopetal flow was maintained in 70% of patients with a 10 mm shunt. CONCLUSIONS. It is possible to achieve a partial portacaval shunt, related to the diameter of the prosthesis, that preserves hepatopetal flow in the majority of patients and is associated with a very low incidence of shunt thrombosis. This effectively prevents recurrent variceal bleeding and significant postoperative encephalopathy. The performance of subsequent orthotopic liver transplantation is not compromised. The technique is recommended, either as a primary procedure or when sclerotherapy has failed, in patients with good liver function who are unlikely to require early liver transplantation (grade A and some grade B cirrhosis).     

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??Diagnosis and treatment of idiopathic portal hypertension: a report of 28 cases MA Xiu-xian, XUE Ming-hui, SUN Yu-ling, et al. Department of General Surgery, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China Corresonding author: SUN Yu-ling, E-mail: ylsun@zzu.edu.cn Abstract Objective To investigate the clinical features, diagnosis and treatment of idiopathic portal hypertension. Methods The clinical data of 28 patients with idiopathic portal hypertension treated between 1987 and 2008 at the First Affiliated Hospital of Zhengzhou University were analyzed retrospectively. Results The operations included splenectomy and disconnection (14patients), the shunt from splenic vein to inferior vena cave and severed around cardiac blood vessels (8 patients), splenorenal shunt and gastric coronary vein suture (4 patients), splenectomy and the shunt from superior mesenteric vein to inferior vena cave by C-bridge ( 1 patient ), severed lower esophageal and around cardiac blood vessels ( 1 patient ) . Twenty-seven patients were followed up for six months to 17 years, who were in good condition. Hypersplenism, significant ascites, further bleeding and liver encephalopathy were disappeared. All liver function were normal. Esophageal varices was disappeared in 16 patients. Esophageal varices marked improvement in 9 patients. Esophageal varices did not change in 3 patients. Conclusion Cureing bleeding and prevention of recurrence of IPH are the key issue. The patients have no liver failure preferred surgical treatment which might be portal azygous disconnection or portosystemic shunt. The patients who can not tolerate surgery or were variceal bleeding after operation might be used endoscopic injection sclerotherapy or endoscopic ligation treatment.     

Gastric portal hypertension.

Extrahepatic portal hypertension may spontaneously decompress by routes which produce gastric or esophageal portal hypertension. A syndrome of gastric portal hypertension has been identified in five patients with extrahepatic portal obstruction and gastric variceal hemorrhage. Patients were nonalcoholic with good liver function who had tolerated previous bleeding episodes well. Endoscopy and upper gastrointestinal series were not helpful in diagnosing bleeding gastric varices. The definitive diagnostic test was venous phase mesenteric arteriography of the gas-distended stomach, with confirmation of the bleeding site by splenoportography. Portosystemic shunting in two patients and splenectomy in three patients failed to stop gastric variceal bleeding. Emergency total gastrectomy was required in two patients and suture ligation in a third to prevent exigent bleeding.Gastric portal hypertension should be suspected in patients with upper gastrointestinal bleeding and good liver function. Since there is no standard therapy, recurrent bleeding requiring multiple operations is common. Determination of both location of obstruction and route of decompression are prerequisites to choosing the correct operation. Portocaval shunts in two patients failed to provide effective decompression due to compartmentalization of the portal hypertension to the gastric venous bed. In patients with a patent splenic vein, a distal splenorenal shunt may be effective. However, with splenic vein occlusion splenectomy may be ineffective, and a direct approach such as total gastrectomy or variceal ligation may be necessary to prevent exsanguination.     

Current indication of a modified Sugiura procedure in the management of variceal bleeding

BACKGROUND: The role of gastroesophageal devascularization (Sugiura-rype procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has nor been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. STUDY DESIGN: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. RESULTS: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. CONCLUSIONS: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.     

Evaluation of selective transsplenic decompression of gastroesophageal varices

A distal splenorenal shunt and selective gastric devascularization have been utilized in the management of gastroesophageal variceal bleeding in sixteen patients with portal hypertension. There was a single operative death in a patient with severe hepatic decompensation and uncontrollable bleeding. The three late deaths were not related to the operation or to liver failure. Neither variceal bleeding nor encephalopathy has occurred postoperatively. The data suggest that the concept that selective transsplenic decompression of gastroesophageal varices preserves hepatic portal flow and hepatic function is sound. The low morbidity and mortality suggest that further clinical use of this operative procedure is indicated.