management of portal hypertension by dr.zarin

SURGICAL MANAGEMENT OF PORTAL HYPERTENSION

DR.MOHAMMAD ZARIN

ASSOCIATE PROFESSOR

SURGICAL “E” WARD

KMC/KTH PESHAWAR

ANATOMY

• 6 – 8 cm

• Splenic + s. mesenteric

(behind neck of the pancreas )

• i. mesenteric , Lt gastric

BLOOD SUPPLY OF THE LIVER

Hepatic Arterial Autoregularity Vasodilatation

What do we know about Portal Hypertension?

• 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?

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.

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

CAUSES OF PORTAL HYPERTENSION

Pre-sinusoidal

Sinusoidal

Post Sinusoidal

BLOOD FLOW

LIVER

Pharmacologic

Radiologic shuntTIPSS

Surgical Shunt

Balloon Tamponade

Pharmacologic and endoscopic therapy

are the usual 1st and

2nd interventionsEndoscopic

TREATMENT FOR ACUTE VARICEAL BLEEDING

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%

• Alternative to sclerotherapy

• Fewer rebleeding episodes

• Fewer endoscopic interventions

• Lower procedure related mortality and over

all mortality

BALLOON LIGATION

BALLOON TEMPONADE

• Application of direct upward

pressure against varices at

G-E junction

• Should be intubated:

Prevent aspiration

Prevent airway

occlusion

BALLOON POSITIONING

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

• 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)

Cannulating the Rt hepatic vein via internal jugular vein

Passing needle through liver parenchyma to portal vein branch

Guide wire

Balloon dilatation

Stenting the tract

Meta-analysis comparing TIPS with

endoscopy in acute hemorrhage:

• Significant improvement in controlling the hemorrhage

• Coast : ↑rate of hepatic encephalopathy

CONTRAINDICATIONS

• Right side heart failure

• Polycystic liver

• Portal vein thrombosis

• 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

CONT…

Late

• recurrent bleeding due to TIPS stenosis or

thrombosis

• Infection

• hepatic encephalopathy

Esophageal transection EEA stapler

Operative mortality 75%

Complications 25%:

Perforation

Stricture

Esophagitis

→ not useful in acute state

PREVENTION OF RECURRENT VARICEAL BLEEDING

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

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

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)

TIPS

Surgical Therapy

• Most effective method in controlling portal

hypertension and recurrent bleeding

Portosystemic shunt procedures

Esophagogastric devascularization

Orthotopic liver transplantation

• Non-selective shunt

• Manipulation and

dissection in porta

hepatica →

Scaring and fibrosis →

complicate future liver

transplant

PORTOSYSTEMIC SHUNT (SIDE-TO-SIDE)

DSRS

• Selective shunt

• Some cases un accompanied

by refractory ascitis

TOTAL SHUNTSEnd to Side Portocaval Side to Side Portocaval

Interposition Shunts Central Splenorenal

PORTOSYSTEMIC SHUNT

• Decompressing the hypertensive portal Venus system into

the low pressure systemic venous circulation

• Toxins → systemic circulation → encephalopathy

• To minimize these effects shunting operations have

evolved:

• Non-selective

• Selective

• partial

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

• 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

• Interposition Mesocaval Shunt:

Prosthetic – autogennous vien

Avoid hilar dissection (future

transplant)

Shunt ligation in refractory post-op

encephalopathy

Drawback → thrombosis (35%)

• 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%

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

• Refractory ascitis

• Splenic vein thrombosis

• Previously underwent splenectomy

• Splenic vein diameter < 7 mm

CONTRAINDICATIONS

• Coronary – Caval Shunt:

Described in Japan in 1984

Interposition graft between

L Gastric and inferior vena

cava

Little experience with this

procedure

PARTIAL SHUNTS

• Small diameter interposition grafts

• Maintaining a degree of hepatopedal portal flow to the

liver

ESOPHAGOGASTRIC DEVASCULARIZATION

• The most effective non-shunt operation

for preventing variceal bleeding:

Devascularization + transection +

splenectomy

Surgical procedure

• Child A – mild B → non-transplant

surgery

• Child C – advanced B → transplant

LIVER TRANSPLANTATION

ORTHOTOPIC LIVER TRANSPLANTATION

• The most definitive form of therapy for

complications of portal hypertension

• Selective patients:

• Coast

• Unavailability

• Immunosuppresion

• 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

Thank You