Personal reflections on the surgical treatment of portal hypertension

Reports, early in this century, on the treatment of portal hypertension by surgical diversion of the portal blood flow about the liver were largely ignored because of the anticipated high mortality. Whipple, Blakemore and Lord in the early 1940's described a technique of performing a splenorenal or portacaval shunt with an epithelial lined vitallium tube. Blalock, whom I assisted, was one of the first outside of the Whipple Group to successfully perform such an operation. Although he used the vitallium tube technique in his first cases he soon became convinced that the results were better with a direct suture anastomosis. Venous shunts, which seemed such a logical way to treat portal hypertension, were widely and quickly adopted. Little attention was paid to the problem of portal encephalopathy which had been described in experimental animals years before by Pavlov. As some of the follow up studies on these shunted patients began to appear it was evident that this was a common and at times a severe problem. Some of the earliest doubts about the shunt operation were expressed by surgeons in Japan. The most successful methods developed to date for the treatment of portal hypertension provided a shunt for blood from the esophageal variceal region while at the same time preserving portal blood flow through the liver. Two of these methods have been (1) the distal or selective splenorenal shunt proposed by Warren & Zeppa and (2) the coronary caval shunt first described by Inokuchi. These methods, although somewhat more difficult technically than end to side portacaval shunts, reduce portal hypertension and preserve blood flow through the liver thereby lowering significantly the incidence of encephalopathy. The vascular stapling instrument developed by Professor Inokuchi in the 1950's has allowed him to perform this and other types of difficult vascular surgery with excellent results.