Options in the Options in the Treatment of Portal Treatment of Portal HypertensionHypertension

Portal Hypertension, itself, is not an Portal Hypertension, itself, is not an indication for treatmentindication for treatmentOnly the complications of Portal Only the complications of Portal Hypertension need treatmentHypertension need treatment

The Complications of The Complications of Portal HypertensionPortal Hypertension

UPPER DIGESTIVE BLEEDINGUPPER DIGESTIVE BLEEDING

ASCITISASCITIS

UPPER DIGESTIVE UPPER DIGESTIVE BLEEDINGBLEEDING

The most common and severe The most common and severe complication of portal hypertensioncomplication of portal hypertension Causes – esophagian varices, gastric Causes – esophagian varices, gastric

varices, portal gastropathyvarices, portal gastropathy

ASCITESASCITES

Surgical treatment needed in cases with Surgical treatment needed in cases with poor respond to medical treatmentpoor respond to medical treatment

There are only few forms of portal There are only few forms of portal

hypertension associated with ascitis, which hypertension associated with ascitis, which have a benefit after surgical treatmenthave a benefit after surgical treatment

Budd - Chiari syndromeBudd - Chiari syndrome

SPLENOMEGALYSPLENOMEGALY

Splenectomy is indicated as singular Splenectomy is indicated as singular procedure in few instances:procedure in few instances: Segmentary portal hypertension (splenic Segmentary portal hypertension (splenic

vein thrombosis, chronic pancreatitis, vein thrombosis, chronic pancreatitis, arterio-venous fistula)arterio-venous fistula)

Giant splenomegaly which interfere with a Giant splenomegaly which interfere with a normal growingnormal growing

Severe hypersplenism in the absence of Severe hypersplenism in the absence of esophageal varices esophageal varices

Surgical procedures used in Surgical procedures used in portal hypertension portal hypertension

treatmenttreatment Direct control of bleedingDirect control of bleeding

Suture of esophageal varices (esophageal transection)Suture of esophageal varices (esophageal transection) Eso-gastric resection Eso-gastric resection Devascularization proceduresDevascularization procedures

Indirect control of bleeding: porto-sistemic shuntsIndirect control of bleeding: porto-sistemic shunts Porto-caval shuntsPorto-caval shunts Mezenterico-caval shuntsMezenterico-caval shunts Spleno-renal shuntsSpleno-renal shunts

Transgastric suture Transgastric suture (esophageal transection) of (esophageal transection) of

esophageal varicesesophageal varices

Easy to performe, practicable in every surgical Easy to performe, practicable in every surgical departmentdepartment

Must be performed as the last choice of treatment Must be performed as the last choice of treatment after all medical or endoscopic procedures after all medical or endoscopic procedures

As singular procedure in emergencyAs singular procedure in emergency Bleeding is controlled in 70% casesBleeding is controlled in 70% cases Recurrent variceal bleeding in the first year- 35%Recurrent variceal bleeding in the first year- 35% Mortality (cirrhosis) - 50%Mortality (cirrhosis) - 50%

The eso-gastric resectionThe eso-gastric resection

Ablation of esophageal and gastric variAblation of esophageal and gastric varicesces AAzzyygo-portal disgo-portal disjunctionjunction Usually performed as a polar superior Usually performed as a polar superior

esogastric resectionesogastric resection PostPostoperatoperativeive mmortalitortality is too high comparative y is too high comparative

with the benefits (with the benefits (50-70%)50-70%) Is still indicated in bleeding from gastric Is still indicated in bleeding from gastric

varices, if we have no other possibility of varices, if we have no other possibility of surgical treatment.surgical treatment.

Operative Operative DevascularisationDevascularisation

Reduce blood flow to varicesReduce blood flow to varices Interrupt bleeding sourceInterrupt bleeding source Eliminate the complications of Eliminate the complications of

splenomegaly (hypersplenism) splenomegaly (hypersplenism)

Types of operative Types of operative procedures(1)procedures(1)

Hassab operationHassab operation SplenectomySplenectomy Devascularization of the upper stomachDevascularization of the upper stomach

Types of operative Types of operative procedures(2)procedures(2)

Sugiura procedureSugiura procedure Extensive transthoracic Extensive transthoracic

paraoesophageal paraoesophageal devascularization and devascularization and esophageal transection esophageal transection combined with splenectomy, combined with splenectomy, devascularization of the upper devascularization of the upper stomach, stomach,

Disadvantage: thoracic Disadvantage: thoracic approachapproach

Good results especially in Good results especially in JapanJapan Overall mortality - 5,2 %, Overall mortality - 5,2 %, Mortality distribution: 4,3% Mortality distribution: 4,3%

(Child A, B), 17%(Child C)(Child A, B), 17%(Child C) Recurrent variceal bleeding Recurrent variceal bleeding

rate < 5 %rate < 5 %

Sugiura M, Futagawa S. Esophageal transection with paraesophagogastric devascularization in the treatment of esophageal varices. World J Surg 1984;8:673.

Only abdominal approachOnly abdominal approach Same results as Sugiura proceduresSame results as Sugiura procedures

ProcedureProcedure Ligation of paraesofageal veins (left and Ligation of paraesofageal veins (left and

right), devascularization of the stomach with right), devascularization of the stomach with preserving of right gastroepiploic veinpreserving of right gastroepiploic vein

Varices ligation or esophageal transectionVarices ligation or esophageal transection SplenectomySplenectomy

Types of operative Types of operative procedures(3)procedures(3)

Advantages of Advantages of Devascularization OperationsDevascularization Operations

Easy techniqueEasy technique Low mortalityLow mortality Low recurrent variceal bleeding rateLow recurrent variceal bleeding rate Postoperative encephalopathy is rare Postoperative encephalopathy is rare

- preserving of portal blood flow -- preserving of portal blood flow - Liver function well preservedLiver function well preserved

Idezucki Y, Sanjo K, Bandai Y, Kawasaki S, Ohashi KCurrent strategy for oesophageal varices in Japan. American Journal of Surgery 1990 160:98–104

Portasystemic shuntPortasystemic shunt

Portacaval shuntsPortacaval shunts End-to-SideEnd-to-Side Side-to-SideSide-to-Side

H-graft shuntH-graft shunt

Splenorenal ShuntsSplenorenal Shunts Selective: distal splenorenal shuntSelective: distal splenorenal shunt Non-selective: central splenorenal shunt Non-selective: central splenorenal shunt

Mesocaval Shunt Mesocaval Shunt Side-to-SideSide-to-Side

H-graft shuntH-graft shunt

Disadvantages of Disadvantages of portasystemic shuntsportasystemic shunts

Technically more difficultTechnically more difficult

Because of reducing of portal blood flow Because of reducing of portal blood flow two severe complication can occur:two severe complication can occur: Impaired Liver FunctionImpaired Liver Function Hepatic EncephalopathyHepatic Encephalopathy

PORTACAVAL SHUNTSPORTACAVAL SHUNTS

Portacaval ShuntPortacaval Shunt End-to-Side End-to-Side

Highly effective in splanchnic Highly effective in splanchnic blood decompressionblood decompression

Relatively easy to perform Relatively easy to perform Produce a sustained fall in Produce a sustained fall in

portaI pressure and prevent portaI pressure and prevent recurrence of hemorrhagerecurrence of hemorrhage

Sinusoid vessels are not Sinusoid vessels are not decompressed and ascitis decompressed and ascitis can appear or exacerbate.can appear or exacerbate.

A future liver transplant can A future liver transplant can be impairedbe impaired

Portacaval ShuntPortacaval Shunt Side-to-Side Side-to-Side

Successful in Successful in decompressing the decompressing the splanchnic systemsplanchnic system

Low risk of recurrent vertical Low risk of recurrent vertical bleedingbleeding

High risk of hepatic High risk of hepatic encephalopathy encephalopathy

Sinusoid vessels are well Sinusoid vessels are well decompressed decompressed

Ascites is diminish or Ascites is diminish or reducedreduced

Portacaval ShuntPortacaval Shunt Side-to-Side Side-to-Side

Technically more difficult:Technically more difficult: Well dissection and Well dissection and

mobilization of portal and mobilization of portal and inferior caval veininferior caval vein

Sometimes dissection can Sometimes dissection can be very difficult because be very difficult because of bleeding from of bleeding from pancreatic collateral pancreatic collateral branchesbranches

Hypertrophy caudate lobe Hypertrophy caudate lobe in cirrhosis and Budd in cirrhosis and Budd Chiari syndrome need Chiari syndrome need sometimes partial sometimes partial resections of caudate resections of caudate which complicated the which complicated the operationoperation

PortacavalPortacaval H-graft shunt H-graft shunt Interposing a synthetic Interposing a synthetic

graft of various graft of various diameters between diameters between portal and caval vein portal and caval vein

Aim – decompress the Aim – decompress the whole portal venous bed, whole portal venous bed, whilst maintaining a whilst maintaining a pressure gradient to pressure gradient to preserve adequate preserve adequate hepatic portal flowhepatic portal flow

Reduce risk of Reduce risk of encephalopathy and liver encephalopathy and liver failurefailure

PortacavalPortacaval H-graft H-graft shuntshunt

2 Technical Versions2 Technical Versions Graft diameter - 16 mmGraft diameter - 16 mm

Important portacaval flowImportant portacaval flow Graft diameter - 8mmGraft diameter - 8mm

Reasonable portocaval flowReasonable portocaval flow Reduce the portal hipertension Reduce the portal hipertension

enough to avoid risk of enough to avoid risk of bleedingbleeding

Sometimes increase risk of Sometimes increase risk of ascitis which often respond on ascitis which often respond on medical treatmentmedical treatment

Very important: ligation of Very important: ligation of coronary,right gastroepiploic coronary,right gastroepiploic veins which can compromise veins which can compromise the aim of the operationthe aim of the operation

Sarfeh IJ, Rypins EB, Mason GR. A systematic appraisal of portacaval H-graft diameters: clinical and hemodynamic perspectives. Ann Surg 1986;204:356.

SPLENORENAL SHUNTSSPLENORENAL SHUNTS

Splenorenal central shuntSplenorenal central shunt

Technique:Technique: Splenectomy, Splenectomy, Dissection of splenic vein from Dissection of splenic vein from

posterior surface of the posterior surface of the pancreaspancreas

Dissection of the renal vein Dissection of the renal vein Splenorenal anastomosis end Splenorenal anastomosis end

to sideto side Low portal encephalopathy riskLow portal encephalopathy risk High risk of thrombosis when High risk of thrombosis when

splenic vein diameter < 12mmsplenic vein diameter < 12mm Recurrent variceal bleeding higher Recurrent variceal bleeding higher

than other portosystemic shunts than other portosystemic shunts Adequate in splenomegaly Adequate in splenomegaly

associated with severe associated with severe hypersplenismhypersplenism

SPLENORENAL CENTRAL SHUNTSPLENORENAL CENTRAL SHUNT

splenic veinsplenic vein

left renal left renal vein veinvein vein

Proximal Proximal end to side end to side

anastomosisanastomosis

SpleenSpleen

Splenorenal distal shuntSplenorenal distal shunt( Warren)( Warren)

Selective shunt – divide portal Selective shunt – divide portal system:system: High pressure sector High pressure sector

mezenteric and portal mezenteric and portal veinsveins

Low pressure sector, Low pressure sector, gastric and splenic veins gastric and splenic veins

Henderson JM, Warren WD, Millikan WJ, Galloway JR, Kawasaki S, Kutner MH. Distal splenorenal shunt with splenopancreatic disconnection: a 4-year assessment. Ann Surg 1989;210:332.

Splenorenal distal shuntSplenorenal distal shunt( Warren)( Warren)

TechniqueTechnique

The gastroepiploic arcade The gastroepiploic arcade should be interrupted and should be interrupted and taken down from the pylorus taken down from the pylorus to the first short gastric to the first short gastric vessels.vessels.

Dissection of the splenic vein Dissection of the splenic vein from posterior pancreatic from posterior pancreatic surface with isolation, ligation surface with isolation, ligation and division of the thin walled and division of the thin walled tributaries from the pancreas tributaries from the pancreas to the splenic veinto the splenic vein

Splenorenal distal shuntSplenorenal distal shunt(Warren)(Warren)

Dividing the splenic vein Dividing the splenic vein before junction with before junction with superior mesenteric superior mesenteric vein.vein.

End to side spleno-renal End to side spleno-renal anastomosisanastomosis

Ligation of left gastric Ligation of left gastric and right gastroepiploic and right gastroepiploic pediclepedicleHenderson JM. Surgical treatment of portal hypertension – Baillieres Best Pract Res Clin Gastroenterol - 01-Dec-2000; 14(6): 911-25

SPLENORENAL DISTAL SHUNTSPLENORENAL DISTAL SHUNT

Splenorenal distal shuntSplenorenal distal shunt

AdvantagesAdvantages Slow but efficient varices decompresion Slow but efficient varices decompresion Low risk of portal encephalopathy ( <10%) Low risk of portal encephalopathy ( <10%)

relative to other shunts (32%-50%)relative to other shunts (32%-50%) Reccurent variceal bleeding: 7%-13% at 5 Reccurent variceal bleeding: 7%-13% at 5

yearsyears

Boyer TD, Kokenes DD, Hetzler G, Kutner MH, Henderson JM.Effect of distal splenorenal shunt on survival of patients with primary biliary cirrhosis. Hepatology, 1994, 20(6):1482-1486.

Splenorenal distal shuntSplenorenal distal shunt

DisadvantagesDisadvantages::

Sometimes very difficult technically because of Sometimes very difficult technically because of venous pancreatic branches venous pancreatic branches

Postoperative complicationsPostoperative complications Acute pancreatitis, pancreatic pseudocystAcute pancreatitis, pancreatic pseudocyst

Avoided in presence of ascitisAvoided in presence of ascitis Mortality between 1%-19% according to situation:Mortality between 1%-19% according to situation:

elective operation or emergency, liver failure or notelective operation or emergency, liver failure or not

Mesocaval ShuntMesocaval Shunt

Advantage: useful to patients Advantage: useful to patients with splenectomy and to the with splenectomy and to the children (diameter of superior children (diameter of superior mesenteric vein > diameter mesenteric vein > diameter of splenic vein)of splenic vein)

Usually a synthetic graft Usually a synthetic graft (8mm) is interposed between (8mm) is interposed between mesenteric and cava veinmesenteric and cava vein

High risk of thrombosisHigh risk of thrombosis Low varices decompression Low varices decompression

and small risk of and small risk of encephalopathyencephalopathy

Gliedman M L, Margulies M The mesocaval shunt for portal decompression. In: Haimovici H (ed.) Surgical management of vascular diseases. 1984, Lippincott, Philadelphia, p 841

The aims of the treatment of The aims of the treatment of portal hypertension:portal hypertension:

Prevent BleedingPrevent BleedingStop the BleedingStop the BleedingPrevent Recurrent Variceal Prevent Recurrent Variceal

BleedingBleeding

Surgical prevention in Surgical prevention in portal hypertensionportal hypertension

The place of surgical prevention is after The place of surgical prevention is after failure of failure of medicalmedical and and endoscopicendoscopic treatmenttreatment

Surgical procedures are choused by:Surgical procedures are choused by: EfficiencyEfficiency Postoperative complications and mortalityPostoperative complications and mortality Type of portal hypertensionType of portal hypertension Possibility in future to continue with an other Possibility in future to continue with an other

surgical procedure in case of relapse or failure surgical procedure in case of relapse or failure

Surgical treatment of upper Surgical treatment of upper digestive bleeding (1)digestive bleeding (1)

Indicated after endoscopic and medical treatment, Indicated after endoscopic and medical treatment, Sengstaken-Blakemore tube, TIPSS Sengstaken-Blakemore tube, TIPSS

Surgical treatment depending of severity of bleeding Surgical treatment depending of severity of bleeding and liver dysfunction and liver dysfunction

For esophageal varices the most indicated treatment For esophageal varices the most indicated treatment is varices ligation or esophageal transection. is varices ligation or esophageal transection.

In cases of portal gastropathy or gastric varices In cases of portal gastropathy or gastric varices surgical treatment is operative devascularisation or surgical treatment is operative devascularisation or esogastric resection esogastric resection

Cello J P, Grendell J H, Crass R A, Weber T E, Trunkey D DEndoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up.New England Journal of Medicine 1987 316:11–15

Surgical treatment of upper Surgical treatment of upper digestive bleeding (2)digestive bleeding (2)

Portasystemic shuntsPortasystemic shunts Not recommended in emergency because of high Not recommended in emergency because of high

mortalitymortality

Mitchell R L, Ignatius J ADistal splenorenal shunt: standard procedure for elective and emergency treatment of bleeding esophageal varices.American Journal of Surgery 1988 156:169–172

Terblanche J, Burroughs A K, Hobbs K E FControversies in the management of bleeding esophageal varices.New England Journal of Medicine 1989 320:1393–1398, 1469–1475

Prevention of recurrent Prevention of recurrent upper digestive bleeding upper digestive bleeding

Surgical procedures are indicated after Surgical procedures are indicated after failure of endoscopic treatmentfailure of endoscopic treatment

Gastric varicesGastric varices Portal gastropathyPortal gastropathy Depending of portal hypertension type Depending of portal hypertension type

and liver resourcesand liver resources

Surgical treatment according of Surgical treatment according of portal hypertension (PH) typeportal hypertension (PH) type

PRESINUSOIDALPRESINUSOIDALSINUSOIDALSINUSOIDAL

POSTSINUSOIDALPOSTSINUSOIDAL

PRESINUSOIDALPRESINUSOIDAL

EXTRAHEPATIC EXTRAHEPATIC

INTRAHEPATICINTRAHEPATIC

Presinusoidal PHPresinusoidal PH

Segmentary PH – splenic vein thrombosis or Segmentary PH – splenic vein thrombosis or extrinsec compresion (chronic pancreatitis), extrinsec compresion (chronic pancreatitis), splenic arteriovenous fistula splenic arteriovenous fistula Splenectomy +/- distal pancreatectomySplenectomy +/- distal pancreatectomy

Portal vein obstaclePortal vein obstacle Mesocaval shuntMesocaval shunt Devascularisations proceduresDevascularisations procedures

SplenoportalSplenoportal thrombosisthrombosis Devascularisations proceduresDevascularisations procedures

ExtrahepaticExtrahepatic

Presinusoidal Presinusoidal PHPH

Most of patients with preserved liver functionMost of patients with preserved liver function Splenorenal distal shuntSplenorenal distal shunt (Warren) first choice(Warren) first choice 8 mm graft portacaval shunt 8 mm graft portacaval shunt Devascularisation operationsDevascularisation operations

!!!!!! Also applied on children with spleen preserving when Also applied on children with spleen preserving when shunt operationsshunt operations are planned in the futureare planned in the future

IntrahepaticIntrahepatic

Sinusoidal PH Sinusoidal PH (Cirrhosis)(Cirrhosis)

Surgical treatment have to preserve portal Surgical treatment have to preserve portal blood flowblood flow

Most of this patients are candidates for liver Most of this patients are candidates for liver transplanttransplant

Liver function not impairedLiver function not impaired If is planned a liver transplant in future If is planned a liver transplant in future splenorenal distal shunt splenorenal distal shunt

Warren Warren is the first choiceis the first choice If not,If not, portacaval H graft shunt portacaval H graft shunt oror devascularisation operations devascularisation operations

are indicatedare indicated

!!! In case of severe hypersplenism are recommended:!!! In case of severe hypersplenism are recommended: Splenorenal central shunt Splenorenal central shunt Devascularisation operationsDevascularisation operations

Impaired liver function:Impaired liver function: Liver transplantLiver transplant TIPSSTIPSS (waiting list) (waiting list) Devascularisation operationsDevascularisation operations if a future liver transplant is not if a future liver transplant is not

feasiblefeasible

Sinusoidal PHSinusoidal PH

Postsinusoidal PHPostsinusoidal PH

Liver function well preservedLiver function well preserved Ascitis – the most common findingAscitis – the most common finding Side to side portacaval shuntSide to side portacaval shunt

Successful in decompressing the splanchnic Successful in decompressing the splanchnic systemsystem

Hypertrophy of caudate lobe needs some Hypertrophy of caudate lobe needs some time partial resections of caudate which time partial resections of caudate which complicated the operationcomplicated the operation

H graft portacaval shuntH graft portacaval shunt

Caval vein not obstructedCaval vein not obstructed

Postsinusoidal PH with Postsinusoidal PH with caval vein obstructioncaval vein obstruction

Mesoatrial shunt Mesoatrial shunt

Postsinusoidal PH with Postsinusoidal PH with liver failureliver failure

Liver transplantLiver transplant

Fundeni Clinical institute Fundeni Clinical institute Department of General Surgery and Liver Department of General Surgery and Liver

TransplantTransplant

1990 - 20021990 - 2002 163 Operative devascularisation 163 Operative devascularisation 54 Portasystemic shunts54 Portasystemic shunts

25 splenorenal central shunts25 splenorenal central shunts 16 splenorenal proximal shunts16 splenorenal proximal shunts 6 portacaval shunts6 portacaval shunts

3 with 8 mm graft3 with 8 mm graft 1 end to side 1 end to side 2 side to side2 side to side

6 mesocaval: 5 with 8mm graft6 mesocaval: 5 with 8mm graft 1 mesoatrial1 mesoatrial

Mortality (1)Mortality (1)

Operative devascularisation 18 Operative devascularisation 18 patients from163 patients from163 (10,7%)(10,7%)

Causes:Causes: Peritonitis: gastric wall necrosis (Peritonitis: gastric wall necrosis (33)) Hepatic failure (Hepatic failure (1515) Child B,C ) Child B,C

Mortality (1)Mortality (1)

Portasystemic shunts 8 patients from 54 Portasystemic shunts 8 patients from 54 (14,8%)(14,8%) 4 splenorenal central shunts4 splenorenal central shunts 2 splenorenal distal shunts2 splenorenal distal shunts 2 mesocaval shunt2 mesocaval shunt

Causes:Causes: hepatic failure hepatic failure

6 intraoperative bleeding 6 intraoperative bleeding

Conclusions (1)Conclusions (1)

Surgical treatment of PH is not standardized Surgical treatment of PH is not standardized The most common complication of PH The most common complication of PH

treated istreated is BLEEDINGBLEEDING Surgical treatment only in case of failure of Surgical treatment only in case of failure of

endoscopic treatmentendoscopic treatment Surgical treatment is very efficient in Surgical treatment is very efficient in

prevention of recurrent upper digestive prevention of recurrent upper digestive bleedingbleeding

Conclusions (2)Conclusions (2)

Portasystemic shuntsPortasystemic shunts are the most efficient are the most efficient treatment in prevention oftreatment in prevention of recurrent bleedingrecurrent bleeding Splenorenal distal shunt (Warren)Splenorenal distal shunt (Warren) best choicebest choice

Liver function well preserved Liver function well preserved Cirrhosis (Child A)Cirrhosis (Child A)

Devascularisation operationsDevascularisation operations Portasistemic shunts not feasiblePortasistemic shunts not feasible Liver function impairedLiver function impaired

Conclusions (3)Conclusions (3)

Impaired liver function:Impaired liver function:

LIVER TRANSPLANTLIVER TRANSPLANT