management of portal hypertension by dr.zarin
TRANSCRIPT
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SURGICAL MANAGEMENT OF PORTAL HYPERTENSION
DR.MOHAMMAD ZARIN
ASSOCIATE PROFESSOR
SURGICAL “E” WARD
KMC/KTH PESHAWAR
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ANATOMY
• 6 – 8 cm
• Splenic + s. mesenteric
(behind neck of the pancreas )
• i. mesenteric , Lt gastric
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BLOOD SUPPLY OF THE LIVER
Hepatic Arterial Autoregularity Vasodilatation
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What do we know about Portal Hypertension?
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• As early as the 17th century, it was realized that
structural changes in the portal circulation could
cause gastrointestinal bleeding.
• In 1902, Gilbert and Carnot introduced the term
“Portal Hypertension" to describe this condition.
Introduction of Portal
Hypertension
Then, What's Portal Hypertension?
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DEFINITION
• Portal hypertension is defined as a pressure > 12 mmHg.
• Functional obstruction to blood flow from any point in the portal system's origin (in the splanchnic bed) through the hepatic veins (exit into the systemic circulation) or from an increase in blood flow in the system.
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Pre hepatic
PHT
1.Upper GIT bleeding
2.pallor
3.splenomegaly
PRESINUSOIDAL SINUSOIDAL
1.upper GIT bleeding
2.splenomegaly
3.jaundice
4.hepatomegaly
5.ascites
6.hepatic encephalopathy
PORTAL HYPERTENSION
post sinusoidal
post hepatic
abdominal pain with vomiting
massive ascites
tender hepatomegaly
upper GIT bleeding
jaundice
splenomegaly
upper GIT BLEED
the combination of GIT bleed and splenomegaly is pathognomonic of PTH.
left lobe of liver enlarged in intr hepatic PTH and caudate lobe enlarged in
post hepatic PTH
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CAUSES OF PORTAL HYPERTENSION
Pre-sinusoidal
Sinusoidal
Post Sinusoidal
BLOOD FLOW
LIVER
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Pharmacologic
Radiologic shuntTIPSS
Surgical Shunt
Balloon Tamponade
Pharmacologic and endoscopic therapy
are the usual 1st and
2nd interventionsEndoscopic
TREATMENT FOR ACUTE VARICEAL BLEEDING
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ENDOSCOPIC THERAPY
• Sclerosant injection
• Band ligation
• Became a standard form of therapy in acute variceal
bleeding
• Initial control of hemorrhage in 70 – 95%
• Re-bleeding 20 – 50%
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• Alternative to sclerotherapy
• Fewer rebleeding episodes
• Fewer endoscopic interventions
• Lower procedure related mortality and over
all mortality
BALLOON LIGATION
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BALLOON TEMPONADE
• Application of direct upward
pressure against varices at
G-E junction
• Should be intubated:
Prevent aspiration
Prevent airway
occlusion
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BALLOON POSITIONING
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1. Tube inserted to 50 cm
2. Auscultate in stomach
3. Inflate gastric balloon with 50 cc
4. Stat portable film
1. Re-confirm proximal position
2. Inflate GB 300-400 cc air
3. Pull to insure anchorage
4. Recheck film
5. 1-2 lbs of pully traction
TUBE POSITIONING AND GASTRIC BALLOON INFLATION
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• Creating an intrahepatic
portosystemic fistula to
decompress the portal
hypertension
• First performed in 1982
• (non- selective side to side
portosystemic shunt)
TIPS
(Transjagular Intrahepatic
Portosystemic Shunting)
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Cannulating the Rt hepatic vein via internal jugular vein
Passing needle through liver parenchyma to portal vein branch
Guide wire
Balloon dilatation
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Stenting the tract
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Meta-analysis comparing TIPS with
endoscopy in acute hemorrhage:
• Significant improvement in controlling the hemorrhage
• Coast : ↑rate of hepatic encephalopathy
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CONTRAINDICATIONS
• Right side heart failure
• Polycystic liver
• Portal vein thrombosis
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• Intraperitoneal bleeding due to perforation of the
hepatic capsule, hepatic, or portal veins
• TIPS embolization
• Acute right heart failure due to increased venous
return to right heart
COMPLICATIONS
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CONT…
Late
• recurrent bleeding due to TIPS stenosis or
thrombosis
• Infection
• hepatic encephalopathy
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Esophageal transection EEA stapler
Operative mortality 75%
Complications 25%:
Perforation
Stricture
Esophagitis
→ not useful in acute state
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PREVENTION OF RECURRENT VARICEAL BLEEDING
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Pharmacotherapy
• Re-bleeding without treatment 70% in 1 year
• Non-selective B blockers (propranolol)
• ↓portal pressure
• Effect is variable and unpredictable
• Less benefit with decompesated liver
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Endoscopic therapy
• Advocated as a means for complete eradication of
esophageal varices
• Once eliminated routine endoscopy 6-12 months
• Fewer rebleeding episodes than medical treatment
• 50 % rebleding in 1 year
• 30% need conversion
• Reserved for complaint patients
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TIPS
Bridge therapy → liver transplant
Advantiges over surgery:
No risk of general anesthesia
No post-operative complications
Limitations
Stenosis (50% in 1st year)
Encephalopathy (1/3)
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TIPS
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Surgical Therapy
• Most effective method in controlling portal
hypertension and recurrent bleeding
Portosystemic shunt procedures
Esophagogastric devascularization
Orthotopic liver transplantation
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• Non-selective shunt
• Manipulation and
dissection in porta
hepatica →
Scaring and fibrosis →
complicate future liver
transplant
PORTOSYSTEMIC SHUNT (SIDE-TO-SIDE)
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DSRS
• Selective shunt
• Some cases un accompanied
by refractory ascitis
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TOTAL SHUNTSEnd to Side Portocaval Side to Side Portocaval
Interposition Shunts Central Splenorenal
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PORTOSYSTEMIC SHUNT
• Decompressing the hypertensive portal Venus system into
the low pressure systemic venous circulation
• Toxins → systemic circulation → encephalopathy
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• To minimize these effects shunting operations have
evolved:
• Non-selective
• Selective
• partial
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NON SELECTIVE SHUNTS
• End to side portocaval (Eck
fistula):
• Higher rate of
encephalopathy among
operative shunting groups
• Better control of
rebleeding than medical
treatment
• Eck fistula – medical
therapy → same incidence
of encephalopathy
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• Side to Side portocaval shunt:
Maintain the anatomic continuity of the portal
vein
Encephalopathy rate : no difference
Decompress the sinusoidal pressure → better
ascitis control
Recommended for Budd Chiari Syndrome
More difficult than end to side
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• Interposition Mesocaval Shunt:
Prosthetic – autogennous vien
Avoid hilar dissection (future
transplant)
Shunt ligation in refractory post-op
encephalopathy
Drawback → thrombosis (35%)
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• Proximal Spleno-Renal Shunt:
Splenectomy + anastomosing proximal
Splenic vein to Lt Renal vein
Divert all portal flow into renal vein →
non selective
Shunt occlusion 18%
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SELECTIVE SHUNTS
• In response to post-op
complications of non-selective
procedures
• 1967 DSRS
• Distal Splenic vein to Lt renal
Vein
• Selectively decompress the
esophagogastric veins
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• Refractory ascitis
• Splenic vein thrombosis
• Previously underwent splenectomy
• Splenic vein diameter < 7 mm
CONTRAINDICATIONS
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• Coronary – Caval Shunt:
Described in Japan in 1984
Interposition graft between
L Gastric and inferior vena
cava
Little experience with this
procedure
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PARTIAL SHUNTS
• Small diameter interposition grafts
• Maintaining a degree of hepatopedal portal flow to the
liver
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ESOPHAGOGASTRIC DEVASCULARIZATION
• The most effective non-shunt operation
for preventing variceal bleeding:
Devascularization + transection +
splenectomy
Surgical procedure
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• Child A – mild B → non-transplant
surgery
• Child C – advanced B → transplant
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LIVER TRANSPLANTATION
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ORTHOTOPIC LIVER TRANSPLANTATION
• The most definitive form of therapy for
complications of portal hypertension
• Selective patients:
• Coast
• Unavailability
• Immunosuppresion
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• References
ACS Surgery : Principles and Practice 2004 Web,MD
Schwartz Principles of Surgery 7th Edition
Indian J Pediatr. 1998 Jul-Aug;65(4):585-91.
Johns Hopkins Gastroenterology & HepatologyResource Center http://hopkins-gi.nts.jhu.edu
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Thank You