Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts

BACKGROUND AND OBJECTIVES. There is no standard treatment for gastric varices. Transjugular retrograde obliteration (TJO) is one way of obliterating gastric varices with gastrorenal shunts, in which blood flow is abundant. Our aim was to examine our experience with TJO during an 8-year period and to determine the long-term effects of this treatment. METHODS. We performed TJO procedures in 52 patients to obliterate gastric varices. All the patients had liver cirrhosis. Sixteen had hepatocellular carcinoma (HCC) without vascular invasion. We inserted an angiographic catheter with an occlusive balloon through the right internal jugular vein into the gastrorenal shunt or the gastric varices. After controlling the other blood-draining routes with a microcoil or absolute ethanol, or both, we injected 5% ethanolamine oleate with iopamidol into the gastric varices under fluoroscopy. RESULTS. The gastric varices were successfully obliterated by TJO in all cases. The complications were all minor and transient. The mortality rate for TJO was 0%. There was no recurrence and no bleeding of gastric varices at all after TJO. Patient survival differed depending on the presence or absence of HCC (P <.05). The development of HCC in the cirrhotic liver was the most common cause of late death. Gastrointestinal bleeding was not a cause of death. The occurrence rate of esophageal varices after TJO was high, but these varices could be treated easily by endoscopic injection sclerotherapy before they bled. CONCLUSIONS. Portal blood flow through the gastrorenal shunt is diverted to the porto-azygos venous system after the gastrorenal shunt is obliterated by TJO. TJO is a safe option that we recommend for treating gastric varices with gastrorenal shunts, provided that the TJO is followed by endoscopic injection sclerotherapy.     

Hemodynamic Effects of Combined Therapy Using Partial Splenic Embolization and Transjugular Retrograde Obliteration for Gastric Varices with Gastrorenal Shunt

Background  

The purpose of the present study was to investigate the short-term effects of combined therapy using partial splenic embolization (PSE) and transjugular retrograde obliteration (TJO) on the portal hemodynamics of gastric varices with a gastrorenal shunt.     

Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices.

BACKGROUND/AIM: The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose. METHODS: Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43-71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes. RESULTS: We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 +/- 66 mm H(2)O, whereas in patients with isolated gastric varices it was 262 +/- 44 mm H(2)O (p < 0.01). CONCLUSION: We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices.     

Urgent transjugular retrograde obliteration for prophylaxis of rebleeding from gastric varices in patients with a spontaneous portosplenorenal shunt

BACKGROUND: Bleeding isolated gastric varices with a spontaneous portosplenorenal shunt are difficult to control. The urgent use of transjugular retrograde obliteration (TJO) to prevent early rebleeding and to improve early mortality has not yet been demonstrated. We report our experience with this technique in patients with isolated gastric varices after treatment of acute bleeding. METHODS: We reviewed our experience of 6 patients with isolated gastric varices with a spontaneous portosplenoral shunt treated with TJO after treatment of acute bleeding. We basically applied endoscopic glue embolization using cyanoacrylate monomer for treatment of acute bleeding. TJO was a method using an occlusive balloon catheter to control a spontaneous portosplenorenal shunt flow while injecting sclerosant retrograde into the gastric varices. RESULTS: Treatment of acute bleeding was achieved immediately by endoscopic glue embolization, endoscopic variceal ligation, and ligating the varices with sutures following anterior gastrotomy in 4, 1 and 1 patients, respectively, and then TJO was performed. Permanent hemostasis and variceal eradication was achieved in these 6, and they all survived. They were alive for 6-66 months without gastric variceal recurrence. CONCLUSIONS: We conclude that urgent TJO is effective in the prophylaxis of early and late rebleeding from isolated gastric varices in patients with a spontaneous portosplenorenal shunt.     

门静脉高压症并胃静脉曲张断流术中自发性胃肾分流道的保护及其意义

目的 探讨门静脉高压症并胃静脉曲张及自发性胃肾分流道时选择性断流的手术方法及其临床疗效。方法 对手术前门静脉CT检查发现有胃静脉曲张伴自发性胃肾分流道的患者,在脾切除术后离断结扎胃静脉曲张的输入血管,保留自发性胃肾分流道。纵行离断肝胃韧带。不对食管下段及胃底贲门进行游离。观察门静脉压力变化、手术时间、手术出血量、术后胃肠功能恢复情况、门静脉血栓发生率、胃静脉曲张消失率以及复发出血率。结果 本组共31例,手术时间（221±128）min,手术出血量（326±228）mL,术中门静脉自由压力为切脾前（35.5±17.52）cmH2O、切脾后（26.5±21.35）cmH2O、断流后（28.3±22.61）cmH2O。术后平均胃管拔除时间（2.8±1.5）d,无胃瘫及肝性脑病发生,术后随访时间22个月（6～48个月）,无复发出血,胃静脉曲张消失26例（83.87%）、明显缩小5例（16.13%）,CT显示原胃肾分流道通畅,发生门静脉血栓3例（9.68%）。结论 保护自发性胃肾分流道的选择性断流术可有效降低胃食道静脉曲张的压力,达到防治出血的目的;同时不影响来自肠系膜上、下静脉血流进入肝脏代谢,达到选择性分流术的效果。不游离食管下段及胃底贲门可简化手术操作,降低手术并发症。     

Balloon-occluded retrograde transvenous obliteration performed in a pediatric patient with isolated gastric fundal varices

Background

For giant gastric varices in association with portal hypertension, endoscopic treatment often is difficult. Although balloon-occluded retrograde transvenous obliteration (B-RTO) has been performed successfully in adult cirrhotic patients, there has been no report in pediatric patients.

Methods

A 10-year-old girl with biliary atresia (BA) who had been free of jaundice after hepatic portoenterostomy was detected to have isolated gastric fundal varices by routine endoscopy. They gradually enlarged up to 4 cm in diameter, showing a tense appearance, so prophylactic treatment was conducted. Magnetic resonance angiography showed the blood flow of the varices mainly drained by a large gastrorenal shunt. A balloon catheter was introduced into the gastrorenal shunt via the femoral vein and was inflated to occlude the outflow of the varices. Five percent ethanolamine oleate was injected into the varices, and the outflow occlusion was kept for more than 30 minutes. Extensive thrombosis was achieved by an additional embolotherapy after 17 months. Throughout the course, the patient has been doing well without bleeding or worsening of the liver function tests.

Conclusions

B-RTO for isolated gastric fundal varices has been performed safely in a pediatric patient and seems effective in reducing the variceal size and tension.     

Experience with a left gastric venacaval shunt for esophageal varices

A left gastric venacaval shunt for esophageal varices was performed in six patients in attempts to selectively decrease left gastric venous pressure without decreasing portal venous pressure. The left gastric venous pressure decreased from 140–390 mmH₂O to 140–200 mmH₂O after the left gastric venacaval shunt, while the portal venous pressure remained at 140–370 mmH₂O, postoperatively. Even when the portal venous pressure increased up to 320–400 mmH₂O with a temporary occlusion of the portal vein, there were no significant changes in the left gastric venous pressure. Five patients are doing well, one to 36 months postoperatively. One patient died of hepatic failure with bleeding on the 21 st postoperative day. The left gastric venacaval shunt decreased the incidence of rebleeding and prevented postoperative hepatoencephalopathy and hepatic failure.     

Hemodynamic Patterns in Human Hepatic Cirrhosis: A Prospective Randomized Study of the Hemodynamic Sequelae of Distal Splenorenal (Warren) and Mesocaval Shunts

Increasingly successful operative management of gastroesophageal variceal hemorrhage has been achieved by newer techniques of portal venous reconstruction. Although it is postulated that the clinical success may be due to more selectivity in portal venous shunting, direct determination of the effect of portasystemic shunt on portal vein blood flow has not been possible. Direct determinations of portal vein blood flow were performed preoperative on unanesthetized, hemodynamically stable cirrhotic patients by observation of radiopaque water-insoluble droplets. Patients were then randomized into elective distal splenorenal (Warren) or mesocaval shunt and determinations were performed postoperatively under similar conditions when clinically possible. Although portal vein blood flow was not significantly different before (929 +/- 147 ml/min) or after 899 +/- 271 ml/min) distal splenorenal shunt, there was a large change in portal vein blood flow after mesocaval shunt, decreasing from 772 +/- 177 ml/min (hepatopetal) to -1021 +/- 310 ml/min (hepatofugal) p < 0.01). After either procedure total hepatic blood flow (as determined by cardiac green clearance) was not significantly changed, nor was renal blood flow; however, cardiac output was significantly increased after mesocaval shunt. Thus the theoretical hemodynamic goals of the selective distal splenorenal shunt, i.e., preservation of the hepatopetal flow within the portal vein, is achieved as determined in the early postoperative period. The correlation between these changes and the eventual clinical outcome remains to be determined.     

Azygos venous blood flow in portal hypertension

Azygos venous blood flow estimated by the continuous thermodilution method was measured in 48 patients with portal hypertension. In patients with cirrhosis, azygos venous blood flow was 326 +/- 139ml/min (mean SD) and was significantly higher than in patients without portal hypertension (163 +/- 61ml/min). In patients with idiopathic portal hypertension and extrahepatic portal obstruction, azygos venous blood flow was 411 +/- 227ml/min and 328 +/- 85ml/min respectively. Azygos venous blood flow was significantly correlated with the hepatic venous pressure gradient but neither with cardiac output nor with size of esophageal varices. In eleven cirrhotic patients, azygos venous blood flow and other hemodynamic parameters were measured before and after the nonshunting operation of esophageal transection, splenectomy and esophagogastric devascularization. Azygos venous blood flow and hepatic venous pressure gradient were significantly reduced after operation. On the other hand, cardiac output did not change significantly after surgical procedure. Relatively high postoperative azygos venous blood flow indicates its important role in the postoperative collateral circulation.     

Assessment of portosystemic shunt patency and function with magnetic resonance imaging

Magnetic resonance imaging (MRI) was performed in seven patients before and after portosystemic shunting to evaluate venous changes accompanying nonselective and selective shunt construction. The size and number of the intrahepatic portal and hepatic veins, left perirenal veins, and left upper quadrant varices were evaluated at MRI before and after shunt construction. MRI correctly diagnosed patent shunts in all seven patients. A marked decrease in the size of intrahepatic veins after a total or nonselective shunt suggests adequate portal vein and variceal decompression. Dilatation of left perirenal veins in the presence of a patent mesorenal or splenorenal shunt suggests hypertension of the left renal vein and possibly inadequate decompression of esophageal varices.     

Intraoperative estimation of liver blood flow in man.

The intraoperative measurement of the afferent circulation of the liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anaesthetized patients having carcinoma of the splanchnic area, mainly in the head of the pancreas, by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.276 l/min, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.     

Isolated gastric varices: prevalence,clinical relevance and natural history

BACKGROUND: Isolated ectopic gastric varices (IGV2) are present either in the body or antrum of the stomach or upper duodenum. The prevalence, natural history and clinical significance of these varices has not been adequately described. MATERIALS AND METHODS: Consecutive patients with portal hypertension, prospectively studied and diagnosed to have IGV2, were assessed for their time of appearance - primary (at first presentation) or secondary (after obliteration of oesophageal varices), association with other varices, portal hypertensive gastropathy and any overt bleeding. RESULTS: Fifty-three of the 1128 (4.7%) patients had IGV2. The IGV2 were commonly seen in the antrum (53%), duodenum (32%), or at both sites (11%) and rarely in body and fundus (4%). IGV2 were predominantly (84.9%) secondary in origin, developing after oesophageal variceal obliteration. The median time for emergence of secondary IGV2 was 8.2 months for patients with cirrhosis, 12.8 months for non-cirrhotic portal fibrosis and 10.8 months for extra-hepatic portal vein obstruction. Eight (15%) patients had primary IGV2, 6 of them had underlying portal vein obstruction. Portal gastropathy (p < 0.05) and UGI bleeding were more common in the secondary than in primary IGV2. Bleeding due to IGV2 was seen only in 3 (5.7%) patients during a mean follow-up of 36.3 +/- 12.1 months, and could be successfully managed with endoscopic ligation or obliteration. CONCLUSIONS: Isolated ectopic gastric varices are not uncommon and generally develop following obliteration of main variceal columns. They rarely bleed and often can be managed with endoscopic interventions.     

Differential effects on portal and effective hepatic blood flow. A comparison between transjugular intrahepatic portasystemic shunt and small-diameter H-graft portacaval shunt.

OBJECTIVE: This study was undertaken to determine the effects of transjugular intrahepatic portasystemic shunt (TIPS) and small-diameter prosthetic H-graft portacaval shunt (HGPCS) on portal and effective hepatic blood flow. SUMMARY BACKGROUND DATA: Mortality after TIPS is higher than after HGPCS for bleeding varices. This higher mortality is because of hepatic failure, possibly a result of excessive diminution of hepatic blood flow. METHODS: Forty patients randomized prospectively to undergo TIPS or HGPCS had effective hepatic blood flow determined 1 day preshunt and 5 days postshunt using low-dose galactose clearance. Portal blood flow was determined using color-flow Doppler ultrasound. RESULTS: Treatment groups were similar in age, gender, and Child's class. Each procedure significantly reduced portal pressures and portasystemic pressure gradients. Portal flow after TIPS increased (21 mL/second +/- 11.9 to 31 mL/second +/- 16.9, p < 0.05), whereas it remained unchanged after HGPCS (26 mL/second +/- 27.7 to 14 mL/second +/- 41.1, p = n.s.). Effective hepatic blood flow was diminished significantly after TIPS (1684 mL/minute +/- 2161 to 676 mL/minute +/- 451, p < 0.05) and was unaffected by HGPCS (1901 mL/ minute +/- 1818 to 1662 mL/minute +/- 1035, p = n.s.). CONCLUSIONS: Both TIPS and HGPCS achieved significant reductions in portal vein pressure gradients. Portal flow increased after TIPS, although most portal flow was diverted through the shunt. Effective hepatic flow is reduced significantly after TIPS but well preserved after HGPCS. Hepatic decompensation and mortality after TIPS may be because, at least in part, of reductions in nutrient hepatic flow.     

Effects of nonshunting operations on portal venous pressure and hepatic blood flow

A comparative analysis has been presented of the effect of the nonshunting operation on portal venous pressure and effective hepatic blood flow in patients with liver cirrhosis and idiopathic portal hypertension. A reduction of portal pressure after splenectomy with esophagogastric devascularization in 17 patients with idiopathic portal hypertension was significantly greater than that in 79 patients with liver cirrhosis (-21 +/- 4.1 percent versus -8.9 +/- 1.6 percent, p less than 0.01). Clearance of galactose from the blood, which approximates effective hepatic blood flow, was decreased after the nonshunting operation by 6.7 percent in five patients with liver cirrhosis (p value not significant). On the other hand, there was a 19.4 percent reduction (statistically significant) in galactose clearance in four patients with idiopathic portal hypertension (p less than 0.05). Based on these data, we suggest that in patients with idiopathic portal hypertension, the splenic circuit largely contributes to the portal hypertension, the effective hepatic blood flow, or both. We recommend a nonshunting operation for the treatment of esophageal varices from the hemodynamic viewpoint in cirrhotic patients.     

Short-term portal hemodynamic effects of endoscopic embolization for esophageal varices

BACKGROUND/AIM: Endoscopic embolization (EE) is a specialized treatment that obliterates esophageal varices along with their associated blood supply. The purpose of this study was to investigate the short-term effects of EE for esophageal varices on portal hemodynamics and liver function. METHODS: Thirty patients with esophageal varices were included in this study. The portal blood flow was measured by an ultrasonic duplex Doppler system before and after EE. EE was performed by freehand intravariceal injection of 5% ethanolamine oleate with iopamidol with the aid of a balloon attached to the tip of an endoscope under fluoroscopy. RESULTS: For the blood supply system, endoscopic varicography at the time of EE was able to show the vessels of the cardiac branch of the left gastric vein in 93% of the cases, the cardiac venous plexus in 90%, the trunk of the left gastric vein in 27%, the lesser curvature branch of the left gastric vein in 10%, the fundic branch of the short gastric vein in 13%, and the posterior gastric vein in 13%. For the blood drainage system, endoscopic varicography was able to show the paraesophageal vein in 39% of the cases, the inferior phrenic vein in 17%, and the mediastinal vein in 13%. No clotting was detected after EE in the intra- and extraportal veins in any of the cases. The flow velocities in the main portal vein before and after EE were 14.2+/-3.2 and 15.5+/-3.5 cm/s, respectively, showing no significant change. The cross-sectional area of the portal vein before and after EE was 0.96+/-0.21 and 1.04+/-0.23 cm(2), and the flow volume of the portal vein was 817+/-288 and 930+/-189 ml/min, both also showing no significant change. The blood laboratory parameters showed no significant change after EE. CONCLUSIONS: We conclude that neither portal blood flow nor liver function were damaged by EE, although both the varices and their associated blood supply were obliterated.     

Subdiaphragmatic venous hemodynamics in the Fontan circulation

OBJECTIVE: We investigated the subdiaphragmatic venous physiology in patients subjected to the Fontan operation to understand some of the early and late problems of this circulation. METHODS: Flows were evaluated by Doppler ultrasonography in the subhepatic inferior vena cava, hepatic vein, and portal vein during respiratory monitoring and with a tilt table. Twenty control subjects (group A) and 56 patients who had the Fontan operation, 27 in functional class I (group B) and 29 in class III or IV (group C), were studied. Inspiratory/expiratory flow ratio was calculated to reflect respiratory effects, and upright/supine flow ratio was calculated to assess gravity effects. Inferior vena caval, hepatic venous, and wedged hepatic venous pressures were measured during catheterization in 21 control subjects and 25 Fontan patients. The difference between wedged and hepatic venous pressures represents the transhepatic venous pressure gradient. RESULTS: Fontan hepatic venous flow depended more on inspiration than control, but without difference between groups B and C (inspiratory/expiratory flow ratios: 1.7, 2.9, and 2.9, respectively; P <.02). Normal portal venous flow was higher in expiration; this effect was lost in group B and reversed in group C (inspiratory/expiratory flow ratios: 0.8, 1.0, and 1.3; P <.0005). Gravity reduced portal venous flow in groups A and B, but progression to functional class III or IV (group C) exacerbated this effect (upright/supine flow ratios: 0.8, 0.7, and 0.5; P <.01). Inferior vena caval, hepatic venous, and wedged hepatic venous pressures (in millimeters of mercury) in the Fontan groups were all elevated compared with the control group (inferior vena cava, 14.4 +/- 4.4 vs 5.9 +/- 2.3; hepatic vein, 14.7 +/- 4.5 vs 5.9 +/- 1.9; wedged hepatic vein, 14.7 +/- 4.0 vs 8.3 +/- 2.6; P <.0001). However, transhepatic venous pressure gradient in the Fontan group was lower than in the control group (0.5 +/- 0.5 vs 2.4 +/- 2.0; P <.001). Univariate analysis of inferior vena caval pressure and transhepatic venous pressure gradient showed significant inverse correlation (r = 0.6, P <.002). CONCLUSIONS: In patients who are in functionally poorer condition after the Fontan operation, portal venous flow loses normal expiratory augmentation and adverse gravity influence is enhanced. These suboptimal flow dynamics, coupled with higher splanchnic venous pressures and lower transhepatic venous pressure gradients, suggest that hepatic sinusoids are congested, acting as "open tubes." Transhepatic gradient loss is incrementally worse with higher caval pressures. These observations may be responsible for late gastrointestinal problems in patients who have had the Fontan operation.     

生长抑素对肝硬变门静脉高压症患者门静脉,肝静脉血流和门静？…

目的 了解生长抑素对肝硬变门静脉高压症患门静脉、肝表脉血液动力学及门静脉压力的影响。方法 用彩色多普勒超声系统测定了２０例肝硬变门静脉高压症患使用生长抑素前后门静脉主干及左、中、右３支肝静脉的内径、最大血流速度及其血流量。其中１５例患测定生长抑素前后门静脉压力的变化。结果 １５例患使用生长抑素后１、１．５小时,门静脉压力由用药前的２．７７±０．２６ｋＰａ下降至２．４２±０．２７ｋＰａ和２．     

Sonographic evaluation of the portal venous system after elective endoscopic sclerotherapy of esophageal varices

Summary In order to evaluate possible changes in the portal venous system after endoscopic sclerosis of esophageal varices, 25 cirrhotic patients underwent abdominal ultrasonography before the first session of sclerotherapy and after eradication of esophageal varices had been achieved. The caliber of the portal, splenic, and superior mesenteric veins was measured sonographically in each case. Sonographic results were compared statistically before and after sclerotherapy. Neither evidence of significant variations in the caliber of the portal veins nor thrombotic obliteration was seen. These results support the view that sclerotherapy has no significant negative side effects on the portal venous system.     

Endoscopic sclerotherapy in the treatment of gastric varices

Of 309 patients with portal hypertension, gastric varices were found in 48 (16 per cent). While the majority (88 per cent) of the patients had gastric varices in association with oesophageal varices, 6 (12 per cent) patients had 'isolated' gastric varices. Gastric varices were seen significantly (P less than 0.01) more often with grade 4 than with grade 3 varices. In 11 (28 per cent) of the 40 patients who completed sclerotherapy for oesophageal varices, gastric varices disappeared concurrently on eradication of oesophageal varices or during the following 6 months. Of the initial five patients with gastric varices who received direct intravariceal injections, four rebled; this technique was therefore replaced by combination (paravariceal + intravariceal) gastric variceal sclerotherapy. Emergency combination sclerotherapy successfully controlled bleeding from gastric varices in six of the eight treated patients. Thirty-two patients entered a programme of elective combination gastric variceal sclerotherapy. Variceal obliteration was achieved in 12 cases (38 per cent) and reduction in size was noted in another 7 patients (22 per cent) after a minimum of four courses. There were 11 (23 per cent) deaths, 8 due to uncontrolled bleeding from gastric varices and 3 due to hepatic coma. The other complications of gastric variceal sclerotherapy were minor and included retrosternal pain, fever and dysphagia. It is concluded that gastric varices often coexist with large oesophageal varices. If they persist for 6 months after eradication of oesophageal varices, a combination of paravariceal and intravariceal sclerotherapy should be attempted for their obliteration.     

Pre- and postoperative splanchnic hemodynamics measured by indocyanine green clearance in patients with portal hypertension]

In this study, plasma indocyanine green clearance (PIGC) and hepatic blood flow (HBF) were measured in patients with portal hypertension before and after pericardial devascularization or side-to-side mesocaval shunt (MS), and the relationship between PIGC and plasma albumin level was investigated. It was found that there was no change in PIGC after the patients underwent pericardial devascularization (portoazygous disconnection). There were a significant decrease of PIGC (averaging 16.28 +/- 8.3%,) and a decrease of HBF (averaging 17.71%, p less than 0.001) after the patients underwent MS. It was also found that there was a positive relationship between PIGC and plasma albumin level in patients with portal hypertension.