Surgery for Portal Hypertension:Surgery for Portal Hypertension:Is it History?Is it History?

S K Mathur MS,FACSS K Mathur MS,FACSSr.Consultant SurgeonSr.Consultant Surgeon

Surgical GastroenterologySurgical GastroenterologyHPB Surgery & Liver TransplantationHPB Surgery & Liver Transplantation

Wockhardt HospitalsWockhardt Hospitals(Associated Hospital of Harvard Medical International)(Associated Hospital of Harvard Medical International)

& JR Railway Hospital & JR Railway Hospital MumbaiMumbai

Evolution of Treatment for Portal Evolution of Treatment for Portal Hypertension - Cleveland ClinicHypertension - Cleveland Clinic

0%

20%

40%

60%

80%

100%

1946-1964

1965-1980

1980-1990

1990-1994

TIPSS

Sclerotherapy

OLTx

Devasc

DSRS

Total shunts

Modified fromHermann Ann Surg 1996

Options for elective treatment of portal hypertension in Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era.cirrhotic patients in the transplantation era.

Bismuth HBismuth H, , Adam RAdam R, , MathurMathur S S, , Sherlock DSherlock D..

Am J Surg. 1990 Jul;160(1):105-10. Am J Surg. 1990 Jul;160(1):105-10. Hepatobiliary Surgery and Liver Transplant Unit, Hepatobiliary Surgery and Liver Transplant Unit,

Paul Brousse Hospital, Villejuif, France. Paul Brousse Hospital, Villejuif, France. – We propose that initial bleeding be controlled by We propose that initial bleeding be controlled by

endoscopic sclerotherapy, endoscopic sclerotherapy, – Grade A patients appear to be managed best by Grade A patients appear to be managed best by

a reduced-size portacaval shunt (RPS)a reduced-size portacaval shunt (RPS) with prospects of good survival and few with prospects of good survival and few

complications.complications.– Grade B patients can be managed by either Grade B patients can be managed by either

sclerotherapy, RPS, or OLT, depending upon sclerotherapy, RPS, or OLT, depending upon individual circumstances. individual circumstances.

– Grade C patients are best managed by liver Grade C patients are best managed by liver transplantation transplantation

Historical trend in Management of Historical trend in Management of Portal hypertensionPortal hypertension

KEM hospital, Mumbai KEM hospital, Mumbai

1950 1980 1990 2000

Surgery

Sclerotherapy

1983

Year

Long term results of chronicLong term results of chronicendoscopic variceal sclerotherapyendoscopic variceal sclerotherapy

SKM SKM World literatureWorld literature

Variceal obliteration 84% 62 - 95%Variceal obliteration 84% 62 - 95%

Mean no. EVS sessions 5.1+/-2.2 4 - 6.8Mean no. EVS sessions 5.1+/-2.2 4 - 6.8

Variceal recurrence rate 28% 19 - 62%Variceal recurrence rate 28% 19 - 62%

Recurrent variceal bleedRecurrent variceal bleed

- - Prior to obliteration 35% 22 - 58%Prior to obliteration 35% 22 - 58%

- Post obliteration 5% 3 - 23%- Post obliteration 5% 3 - 23%

30 day mortality 3% 1 - 12%30 day mortality 3% 1 - 12%

Mathur et.al Gastrointest. Endoscopy 1990

17

28

59

10

0

10

20

30

40

50

60

Teres et al1987

Rikkers et al1989

Henderson etal 1990

Spina et al1990

% rebleeders needing Surgical rescue

Shunt

Trials of Long term Trials of Long term Sclerotherapy V/s Splenornal shuntSclerotherapy V/s Splenornal shunt

No. of patientsNo. of patients :: 112 60 72 66 112 60 72 66

10-59% required surgery for failed EVS10-59% required surgery for failed EVS

Surgery for Portal HypertensionSurgery for Portal Hypertension Personal Personal

Series:1983 - 2007Series:1983 - 2007

542

66

124

EVS 542

Sx 190

n=608

23% Surgery in EVS Gr.

10%Primary Sx

Mathur SK

Portal Hypertension In India: Etiology Portal Hypertension In India: Etiology 1983-2007 1983-2007

87

277

236

8

CIRRHOSIS

NCPFBudd-Chiari

EHPVO39%

N=608*

14%

45%

*Personal series

Clinical ManifestationsClinical ManifestationsVariceal bleeding Variceal bleeding Ascitis CirrhosisAscitis CirrhosisLiver cell failureLiver cell failure

Non-Cirrhotic portal hypertensionNon-Cirrhotic portal hypertension

Symptomatic Splenomegaly Symptomatic Splenomegaly Hypersplenism Hypersplenism Growth retardation EHPVOGrowth retardation EHPVOBiliary ObstructionBiliary Obstruction MenorrhagiaMenorrhagia

Surgery for Portal HypertensionSurgery for Portal Hypertension Indications for SurgeryIndications for Surgery

for variceal Bleedfor variceal Bleed: - Esophageal: - Esophageal - Gastric fundic - Gastric fundic - Ectopic varices - Ectopic varices

Other IndicationsOther Indications:: *Symptomatic Splenomegaly*Symptomatic Splenomegaly *Symptomatic Hypersplenism*Symptomatic Hypersplenism *Growth retardation*Growth retardation *Portal Biliopathy*Portal Biliopathy * Menorrhagia * Menorrhagia

Portal HypertensionPortal HypertensionCurrent Surgical Options Current Surgical Options

Indications for SurgeryIndications for SurgeryPrimary TherapyPrimary Therapy

Rescue therapyRescue therapy

- Emergency Surgery- Emergency Surgery

- Elective Surgery- Elective Surgery

Indications for Primary SurgeryIndications for Primary SurgerySinistral PHT (Left sided)Sinistral PHT (Left sided)

n = 3n = 3

Isolated Splenic vein Isolated Splenic vein thrombosisthrombosis

bleed from fundal varicesbleed from fundal varices

Splenectomy : curative

PHT:Indications for SurgeryPHT:Indications for SurgeryPrimary therapyPrimary therapy

Ectopic variceal bleedEctopic variceal bleed

Jejunal / Ileal / stomal / Colonic / RectalJejunal / Ileal / stomal / Colonic / Rectal n = 1

- Biliary variceal bleed - Ruptured retropeitoneal varices

PHT: Indications for SurgeryPHT: Indications for Surgery

Bleeding Diffuse Fundal Gastric varicesBleeding Diffuse Fundal Gastric varices

Classification of Gastric Varices Hosking’sBJS 1988

Mathur’sJ Gastroenterol Hepatol 1988

Sarin’sAm J Gastro 1989

GOV1

GOV2

IGV1

IGV2

•Gv with OVType1

Type2

•Isolated GVType1

Type2

Baveno Consensus’96

ENDOSCOPIC AND RADIOLOGICALAPPRAISAL OF GASTRIC VARICES

Mathur SK et al. B.J.S. 1990

•FGV Incidence : 25%•FGV Bleed : 100%

Fundic Gastric VaricesFundic Gastric VaricesResults of Glue InjectionResults of Glue Injection

Initial Control 87 - 100%Initial Control 87 - 100%

Early rebleed 12.5 – 27%Early rebleed 12.5 – 27%

Late rebleed 54%Late rebleed 54%

Fatal Complications 1 – 3% Fatal Complications 1 – 3%

Mortality from bleed 6 – 8.5% Mortality from bleed 6 – 8.5%

((Endoscopy 1993, 1994, 2002)Endoscopy 1993, 1994, 2002)

Long-term results of endoscopic Histoacryl injection Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experiencesclerotherapy for gastric variceal bleeding: a 10-year experience

Akahoshi T et al. Surgery. 2002 Jan; 131(1 Suppl): S176-81.Akahoshi T et al. Surgery. 2002 Jan; 131(1 Suppl): S176-81.

n=52 , active bleeding 32 and recent bleeding 20 n=52 , active bleeding 32 and recent bleeding 20 mean Follw-up : 28.1 months mean Follw-up : 28.1 months RESULTS: RESULTS: Initial hemostasis was 96.2%. Initial hemostasis was 96.2%. (no bleeding occurred for 48 hours after sclerotherapy) (no bleeding occurred for 48 hours after sclerotherapy)

Cumulative non-bleeding rates at : Cumulative non-bleeding rates at : 1 5 10 years 1 5 10 years 64.7% 52.7% 48.2%64.7% 52.7% 48.2%CONCLUSIONS:CONCLUSIONS:

Histoacryl injection sclerotherapy is highly effective for the Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varicestreatment of bleeding gastric varicesbut the rate of recurrent bleeding is so high that further but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to methods or devices still need to be developed in order to prevent gastric variceal rebleeding.prevent gastric variceal rebleeding.

FGV: Post Glue InjectionFGV: Post Glue InjectionComplicationsComplications

Effect of TIPS on Fundal Gastric Effect of TIPS on Fundal Gastric Varices & Congestive GastropathyVarices & Congestive Gastropathy

FGV fails to resolve FGV fails to resolve

& Rebleed& Rebleed in 20 - 50 % of cases in 20 - 50 % of cases

Cause :Cause : presence of spontaneous splenorenal shunt presence of spontaneous splenorenal shunt which competes with TIPS for preferential flowwhich competes with TIPS for preferential flow

Portal gastropathy does not disappear completelyPortal gastropathy does not disappear completely

Sanyal et al Ann Intern Med 1997Sanyal et al Ann Intern Med 1997

Murphy et al J Vasc Interven Radial 1995Murphy et al J Vasc Interven Radial 1995

TIPS for FGVTIPS for FGV

Rebleed 20% (Mean F-U 36.7months)Rebleed 20% (Mean F-U 36.7months)

30 day Mortality 15%30 day Mortality 15% (Tripathi D et al GUT 2002)(Tripathi D et al GUT 2002)

Actuarial rebleed 36% over 12 monthsActuarial rebleed 36% over 12 months ( Hepatology 1999)( Hepatology 1999)

Indications for Primary SurgeryIndications for Primary SurgeryBleeding Fundal gastric varices : n = 71Bleeding Fundal gastric varices : n = 71

PostShunt

Rebleed 2%

Bleeding Fundal gastric varicesBleeding Fundal gastric varicesResults of SurgeryResults of Surgery

n=71n=71

Procedurs: -Shunts 20Procedurs: -Shunts 20

-Modified Sugiura 48-Modified Sugiura 48

-Splenectomy 03-Splenectomy 03

Rebleed: 2%Rebleed: 2%

(mean FU 48.4months SD27.3, range 3-124) (mean FU 48.4months SD27.3, range 3-124)

(personal unpublished series)(personal unpublished series)

Portal Hypertension Portal Hypertension Primary Elective Surgery Primary Elective Surgery Spleen related IndicationsSpleen related Indications

Symptomatic HypersplenismSymptomatic Hypersplenism

Symptomatic SplenomegalySymptomatic Splenomegaly

Growth RetardationGrowth Retardation

Portal HypertensionPortal HypertensionIndications for SurgeryIndications for Surgery

Symptomatic hypersplenism: Incidence : 7%

- WBC < 2000

- Platelets < 50,000

Recurrent sepsis

Spontaneous bleeding

Anaemia in absence of GI bleeding

Hypersplenism : 33%Hypersplenism : 33% - WBC < 4000/Cu mm.- WBC < 4000/Cu mm. - Platelets <1,00000- Platelets <1,00000

Portal HypertensionPortal HypertensionIndications for SurgeryIndications for Surgery

Symptomatic Splenomegaly : 1.5%Symptomatic Splenomegaly : 1.5%

- dragging pain & visible lump- dragging pain & visible lump

Extra hepatic Portal Hypertension Extra hepatic Portal Hypertension in Childrenin Children

Indications for SurgeryIndications for SurgeryGrowth retardation in EHPVO :Growth retardation in EHPVO :

IncidenceIncidence

* Sarin et.al. 51%* Sarin et.al. 51%

* Mathur et.al. 5%* Mathur et.al. 5%

Surgery For growth retardation : 1%

Extra hepatic Portal Hypertension Extra hepatic Portal Hypertension INDICATIONS FOR INDICATIONS FOR

PRIMARY ELECTIVE SURGERYPRIMARY ELECTIVE SURGERY

Other indicaionsOther indicaionsPortal billiopathyPortal billiopathy MenorrhagiaMenorrhagia

Spleen related IndicationsSpleen related IndicationsSymptomatic HypersplenismSymptomatic HypersplenismSymptomatic SplenomegalySymptomatic SplenomegalyGrowth RetardationGrowth Retardation

EHPVO:Portal BiliopathyEHPVO:Portal Biliopathy Bile duct abnormalities: 85 – 100%Bile duct abnormalities: 85 – 100%

Symptomatic: 1% Symptomatic: 1%

MRCPMRCP MR Cholangiogram + MR Cholangiogram + Superimposed PortogramSuperimposed Portogram

ERCP

Portal BiliopathyPortal BiliopathyCholangitisCholangitis

MRCPMRCP Endo SonoEndo Sono

O.V. O.V. Fundal G.V.Fundal G.V.

Peri dochalPeri dochalVaricesVaricesCBD CBD

obstructionobstruction

MRCP+MR ANGIOGRAPHYMRCP+MR ANGIOGRAPHY

Large calculi in Rt hep duct, CHD and prox CBD Large calculi in Rt hep duct, CHD and prox CBD with marked IHBR diln. CBD prominent but N. with marked IHBR diln. CBD prominent but N.

E/o EHPVO with portal cavernoma with E/o EHPVO with portal cavernoma with hepatopetal and hepatofugal collaterals and hepatopetal and hepatofugal collaterals and splenomegaly.splenomegaly.

Portal BiliopathyPortal BiliopathyTherapeutic OptionsTherapeutic Options

Sphincterotomy with endoscopic stone Sphincterotomy with endoscopic stone extraction.extraction.

Biliary stentingBiliary stenting

Shunt Surgery:Shunt Surgery:

- to relieve biliary obstruction- to relieve biliary obstruction

- to facilitate subsequent bile duct surgery- to facilitate subsequent bile duct surgery

Biliary Surgery in presence of Biliary Surgery in presence of Portal HypertensionPortal Hypertension

Bile duct obstruction due to portal biliopathy In EHPVO:Bile duct obstruction due to portal biliopathy In EHPVO: Direct bile duct surgery is hazardous :Direct bile duct surgery is hazardous : it can lead to profuse uncontrollable bleeding from it can lead to profuse uncontrollable bleeding from

collaterals around bile duct collaterals around bile duct

Can result in to mortalityCan result in to mortality Recommendation :Recommendation :

Porta-systemic shunt Porta-systemic shunt

6week interval6week interval

Biliary SurgeryBiliary Surgery A Chaudhary BJS 1998

Portal Biliopathy in EHPVO Portal Biliopathy in EHPVO Results of Porto Systemic ShuntResults of Porto Systemic Shunt

Personal : n=10 Personal : n=10

( 9 failed prior Endotherapy)( 9 failed prior Endotherapy)

- Shunt alone Success 7(70%)- Shunt alone Success 7(70%)

- Subsequent Biliary surgery 3(30%)- Subsequent Biliary surgery 3(30%)

Literature*: n=40Literature*: n=40

- Shunt alone success: 70-80%- Shunt alone success: 70-80%

- Subsequent biliary surgery: 20-50%- Subsequent biliary surgery: 20-50%

*Vibert E, Azoulay D et al. Ann Surg 2007*A Chaudhary BJS 1998

Portal HypertensionPortal HypertensionIndications for SurgeryIndications for Surgery for variceal Bleedfor variceal Bleed

Rescue therapyRescue therapy

- Emergency Intervention- Emergency Intervention

**Acute Variceal bleedAcute Variceal bleed

- Elective Intervention- Elective Intervention

* Recurrent Variceal bleed* Recurrent Variceal bleed

Etiology of PHT: - Etiology of PHT: - CirrhoticCirrhotic

- Non-cirrhotic- Non-cirrhotic

Q.Q. What to do for What to do for refractoryrefractory bleeding ? bleeding ?

Incidence : 20%–30% of Incidence : 20%–30% of patients patients

Case # 5

TIPS

TIPS

Distal-spleno-renal shuntDistal-spleno-renal shuntSplenic vein

Renal vein

SHUNT

TIPS Vs Surgery TIPS Vs Surgery Evidence based Medicine :Evidence based Medicine :

U.S. Preventive Services Task ForceU.S. Preventive Services Task Force for ranking for ranking evidence about the effectiveness of treatments :evidence about the effectiveness of treatments :

Level I: Evidence obtained from at least one Level I: Evidence obtained from at least one properly designed properly designed randomized controlled trialrandomized controlled trial. .

Level II-1: Evidence obtained from well-designed Level II-1: Evidence obtained from well-designed controlled trials without controlled trials without randomizationrandomization. .

Level II-2: Evidence obtained from well-designed Level II-2: Evidence obtained from well-designed cohortcohort or or case-controlcase-control analytic studies, preferably analytic studies, preferably from more than one center or research group. from more than one center or research group.

TIPSTIPSfor control of acute variceal bleedingfor control of acute variceal bleeding

Control of bleeding: 93 - 95 %Control of bleeding: 93 - 95 %1-month actuarial probability of rebleeding : 22%1-month actuarial probability of rebleeding : 22%

Operative mortality (30 days) : 28%.- 37% Operative mortality (30 days) : 28%.- 37% Complications : 13%Complications : 13%

- massive hemoperitoneum- massive hemoperitoneum - cardiorespiratory arrest & cardiac failure- cardiorespiratory arrest & cardiac failure - acute renal failure- acute renal failure - bacteremia- bacteremia

Banares R, Am J Gastroenterol. 1998Banares R, Am J Gastroenterol. 1998Bosch J. J Hepatol 2001Bosch J. J Hepatol 2001

Rescue TherapyRescue Therapy Emergency TIPS vs Surgery Emergency TIPS vs Surgery

Good risk patientsGood risk patients

Solitary RCT in Solitary RCT in good riskgood risk patients patients

active bleed failing first line Rx n = 70 active bleed failing first line Rx n = 70

TIPS vs small diameter P-C shuntTIPS vs small diameter P-C shunt

Failure of therapy:Failure of therapy:

56% TIPS vs 26% Surgery (P < 0.02)56% TIPS vs 26% Surgery (P < 0.02)

Rosemurgy Ann Surg 1996

Elective Rescue TherapyElective Rescue TherapyTIPSTIPS

v/s v/s

Surgical shuntsSurgical shunts

Ten years' follow-up of 472 patients following Ten years' follow-up of 472 patients following TIPSS insertion at a single centreTIPSS insertion at a single centre

Procedure-related mortality : 1.2%.Procedure-related mortality : 1.2%.

Rebleed: 13.7% (within 2 years of TIPS)Rebleed: 13.7% (within 2 years of TIPS) (principally from gastric and ectopic varices)(principally from gastric and ectopic varices)

Shunt patency rates: need for reinterventionsShunt patency rates: need for reinterventions

- - Primary 45.4% & 26.0% at 1 and 2 yearsPrimary 45.4% & 26.0% at 1 and 2 years

- Secondary assisted patency rate was 72.2%.- Secondary assisted patency rate was 72.2%.

hepatic encephalopathy: 29.9%hepatic encephalopathy: 29.9% (de novo encephalopathy: 11.5%) (de novo encephalopathy: 11.5%)

Tripathi D et al et al, Edinburgh,UK, Eur J Gastroenterol Hepatol. 2004;16:9-18., Edinburgh,UK, Eur J Gastroenterol Hepatol. 2004;16:9-18.

TIPS: PTFE covered V/s Uncoverd Stents TIPS: PTFE covered V/s Uncoverd Stents long-term results of a randomized long-term results of a randomized

multicentre studymulticentre study

Bureau C et al et al Liver Int. 2007 Aug;27:742-7. Liver Int. 2007 Aug;27:742-7.

N = 80 (follow-up for 2 yrs)N = 80 (follow-up for 2 yrs)

TIPS Stent Covered UncoveredTIPS Stent Covered Uncovered

Primary patency 76% 36% (P=0.001)Primary patency 76% 36% (P=0.001)

Rebleed 10% 29% (P<0.05)Rebleed 10% 29% (P<0.05)

Encephalopathy 33% 49% (P<0.05)Encephalopathy 33% 49% (P<0.05)

Probability of survival 58% 45% (NS) Probability of survival 58% 45% (NS) (2 years) (2 years)

DSRS v/s TIPSDSRS v/s TIPS(Retrospective Case Control Study) (Retrospective Case Control Study)

Good risk patients n=40Good risk patients n=40Conclusion :Conclusion :

TIPS - TIPS - Significantly higher incidence v/s DSRSSignificantly higher incidence v/s DSRS

* Rebleed episodes (p < 0.001)* Rebleed episodes (p < 0.001)

* Rehospitalization (p < 0.05)* Rehospitalization (p < 0.05)

* Shunt revision (p < 0.001)* Shunt revision (p < 0.001)

* * More expensive (p<0.005)More expensive (p<0.005)

30 day mortality : 20% v/s 0%30 day mortality : 20% v/s 0% (Helton et al Arch surg 2001)(Helton et al Arch surg 2001)

Distal splenorenal shunt versus TIPS Distal splenorenal shunt versus TIPS for variceal bleeding : a randomised trialfor variceal bleeding : a randomised trial

73 DSRS & 67 TIPS (Child Pugh A and B patients) Follow-up: 2-8yrs (mean46+/-26 months)•DSRS and TIPS similar in efficacy in the control of refractory variceal bleeding (rebleeding DSRS, 5.5%; TIPS, 10.5%; P = .29) •Re-intervention: significantly greater for TIPS compared with DSRS (DSRS, 11% v/s TIPS, 82%, p<0.001) •No difference in need for LT•The choice is dependent on available expertise.

Henderson JM, et al, Gastroenterology, May 2006

N=132 TIPS 66 HGPCS 66N=132 TIPS 66 HGPCS 66Mortality 10(15%) 13(20%) Mortality 10(15%) 13(20%) (Post procedure) (Post procedure)

Child-Pugh C 70% 84% Child-Pugh C 70% 84% Rebleed: 20(30%) 5(7.6%) Rebleed: 20(30%) 5(7.6%) Shunt stenosis 32(48.5%) 7(10.6%)Shunt stenosis 32(48.5%) 7(10.6%)

significantly higher after TIPS (P <0.001)significantly higher after TIPS (P <0.001)Encephalopathy: 30% 10% Encephalopathy: 30% 10%

H-Graft Portacaval Shunts Versus TIPSH-Graft Portacaval Shunts Versus TIPSTen-Year Follow-up of a Randomized Trial With Ten-Year Follow-up of a Randomized Trial With

Comparison to Predicted SurvivalsComparison to Predicted SurvivalsRosemurgy AS et al, Ann Surg. 2005; 241: 238–246. Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246.

H-Graft Portacaval Shunts Versus TIPSH-Graft Portacaval Shunts Versus TIPSTen-Year Follow-up of a Randomized Trial Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted SurvivalsWith Comparison to Predicted Survivals. .

Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246

H-Graft Portacaval Shunts Versus TIPSH-Graft Portacaval Shunts Versus TIPSTen-Year Follow-up of a Randomized Trial Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted SurvivalsWith Comparison to Predicted Survivals

TIPS (N = 66) HGPCS (N = 66) TIPS (N = 66) HGPCS (N = 66)

Through 24 months, actual survival was Through 24 months, actual survival was superior after HGPCS v/s TIPS (superior after HGPCS v/s TIPS (PP = 0.04). = 0.04).

Survival at 5 to 10 years was superior after Survival at 5 to 10 years was superior after HGPCS compared with TIPS for : HGPCS compared with TIPS for :

- Child's class A and B (- Child's class A and B (PP = 0.07) = 0.07)

- MELD scores less than 13 (- MELD scores less than 13 (PP = 0.04) = 0.04) Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246.Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246.

Evidence based ConclusionsEvidence based Conclusions

•for Child A & B & MELD < 13: for Child A & B & MELD < 13: * Surgical shunt has a role* Surgical shunt has a role - DSRS or HGPCS- DSRS or HGPCS

•for high risk Child C: TIPSfor high risk Child C: TIPS

Rescue Therapy in CirrhoticsRescue Therapy in CirrhoticsTIPS v/s Surgical shuntTIPS v/s Surgical shunt

Portal HypertensionPortal Hypertension Rescue TherapyRescue Therapy

TIPS Vs Surgical ShuntTIPS Vs Surgical Shunt

According to the Centre for Evidence-According to the Centre for Evidence-Based Medicine:Based Medicine:

"Evidence-based medicine is the "Evidence-based medicine is the conscientious, explicit and conscientious, explicit and judicious use of current best judicious use of current best evidence in making decisions about evidence in making decisions about the care of individual patients.”the care of individual patients.”

Surgery for Portal HypertensionSurgery for Portal HypertensionIs it History?Is it History?

CONCLUSIONS: NoCONCLUSIONS: No

Rescue Therapy: 10-20% * Cirrhotics:

- Good risk patients:

: Surgical Shunt not TIPS

- Poor risk patients: TIPS

* Non-Cirrhotic: Surgical Shunt or Devasc.

Surgery for Portal HypertensionSurgery for Portal HypertensionIs it History?Is it History?

CONCLUSIONS: NoCONCLUSIONS: NoSurgery is the Therapy of choice:Surgery is the Therapy of choice:

*Bleed from: *Bleed from:

- Diffuse Fundal Gastric Varices - Diffuse Fundal Gastric Varices

- Ectopic varices - Ectopic varices

* Symptomatic Splenomegaly * Symptomatic Splenomegaly

* Symptomatic Hypersplenism* Symptomatic Hypersplenism

* Growth retardation* Growth retardation

* * Billiary obstructionBilliary obstruction

* Menorrhagia* Menorrhagia

Randomized trial of emergency endoscopic sclerotherapy Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding versus emergency portacaval shunt for acutely bleeding

esophageal varices in cirrhosis. esophageal varices in cirrhosis. Orloff MJ J Am Coll Surg. 2009 July Orloff MJ J Am Coll Surg. 2009 July

BACKGROUND: The mortality rate of bleeding esophageal varices in cirrhosis is BACKGROUND: The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN: A total of 211 in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN: A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death. RESULTS: The percent of patients in Child's than 10 years of followup, or until death. RESULTS: The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS: EPCS patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS: EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027). the results of this trial (clinicaltrials.gov #NCT00690027).

Natural history in EHPVONatural history in EHPVO

Hepatopetal blood flow in portal cavernomaHepatopetal blood flow in portal cavernoma

Adequate hepatic portal perfusionAdequate hepatic portal perfusion

Preservation of hepatocyte functionPreservation of hepatocyte function

Normal life spanNormal life span

Acute Variceal BleedingAcute Variceal BleedingIndications for Em. Rescue TherapyIndications for Em. Rescue Therapy

Failure to control variceal hemorrhageFailure to control variceal hemorrhage : :

Continued bleed inspite ofContinued bleed inspite of::

Vasoactive drugs + Endotherapy + TamponadeVasoactive drugs + Endotherapy + Tamponade

Recurrent bleed within 72 hoursRecurrent bleed within 72 hours: :

inspite of 2 attempts at EVS / EVLinspite of 2 attempts at EVS / EVL

-- fresh blood in NG tube, fresh blood in NG tube,

- fall in HB> 2gm%, - fall in HB> 2gm%,

- need for more than 6 units of blood in 24 hours- need for more than 6 units of blood in 24 hours

Life threatening hemorrhage even after one Life threatening hemorrhage even after one sessionsession : Hypotension, Bp < 80 mmHg. : Hypotension, Bp < 80 mmHg.

INDICATIONS FOR INDICATIONS FOR ELECTIVE SURGERYELECTIVE SURGERY

Failure of chronic EVSFailure of chronic EVS

Rebleed in defaulter of EVSRebleed in defaulter of EVS

Inability to follow up Inability to follow up

- absence - absence from work from work - travel expense / distance- travel expense / distance

Single life threatening Single life threatening rebleedrebleed

Two significant rebleedsTwo significant rebleeds

- Hb fall > 2 gm%- Hb fall > 2 gm%

- 2 units blood- 2 units blood

Persistence of large Persistence of large varices after 6-10 varices after 6-10 sessions of EVSsessions of EVS

Development of Development of Fundal varices Fundal varices

Surgery for PHT Surgery for PHT

Emergency n=15Emergency n=15 -Bleeding Fundal Gastric Varices 11-Bleeding Fundal Gastric Varices 11 -Bleeding Oesophageal Varices 4-Bleeding Oesophageal Varices 4

Elective n= 51Elective n= 51– Fundal Gastric Variceal bleedFundal Gastric Variceal bleed 22 22– Hypersplenism 19Hypersplenism 19– Growth retardation 2Growth retardation 2– Inability to follow up 7Inability to follow up 7– Biliary Obstruction 3Biliary Obstruction 3– Menorrhagia 2Menorrhagia 2

Indications for Primary surgery

EVS:Indications for Elective SurgeryEVS:Indications for Elective Surgery

Gastric Varices 37Gastric Varices 37

Oesophageal Varices 24Oesophageal Varices 24

( failure of EVS) ( failure of EVS)

Inability to Follow up 15Inability to Follow up 15

Hypersplenism 24Hypersplenism 24

Splenomegaly 3Splenomegaly 3

Growth retardation 5Growth retardation 5

Bile duct obstruction 3Bile duct obstruction 3

Gastropathy bleed 1Gastropathy bleed 1

Ectopic Varices bleed 2Ectopic Varices bleed 2

Surgical Options in PHTSurgical Options in PHT Devascularisation ( Modified Sugiura ) 110Devascularisation ( Modified Sugiura ) 110

Emergency 73Emergency 73 Elective 37 Elective 37

Shunts : ( elective) 80Shunts : ( elective) 80 * DSRS 31* DSRS 31 * Proximal leinorenal 39 * Proximal leinorenal 39 * Side to side leinorenal 4* Side to side leinorenal 4 * Spleno- Adrenal 3* Spleno- Adrenal 3 * End renal-side splenic 1 * End renal-side splenic 1 * Mesocaval (PTFE graft) * Mesocaval (PTFE graft) 1 1 * Modified Spleno-renal shunt 1* Modified Spleno-renal shunt 1 ( ‘Y’ Shunt) ( ‘Y’ Shunt)

Surgery: Long term resultsSurgery: Long term results

0

2

4

6

8

10

12

14

16

18

EHO

NCPF

Cirr

Recurrence Rebleed Stricture Block Rebleed Enceph

Overall 6% 6% 12% 8% 6% 5%

DEVASCULARISATION53 SD 34 months (4-143 months)

SHUNT SURGERY 25 SD 29 months (4-107months)

%

NoNo singlesingle surgical procedure is surgical procedure is ideal for all patients or all ideal for all patients or all circumstances circumstances

Choice of SurgeryChoice of Surgery

Timing : Emergency vs electiveTiming : Emergency vs elective

Experience of surgeon with shunt surgeryExperience of surgeon with shunt surgery

Portal venous anatomyPortal venous anatomy

Indication for surgeryIndication for surgery

Site of bleedSite of bleed

Distal-spleno-renal shuntDistal-spleno-renal shunt