management of portal hypertension

2. SURGICAL MANAGEMENT OF
PORTAL HYPERTENSION
DR.MOHAMMAD ZARIN
ASSOCIATE PROFESSOR
SURGICAL “E” WARD
KMC/KTH PESHAWAR

3. ANATOMY
• 6 – 8 cm
• Splenic + s. mesenteric
(behind neck of the pancreas )
• i. mesenteric , Lt gastric

4. BLOOD SUPPLY OF THE LIVER
Hepatic Arterial Autoregularity Vasodilatation

5. What do we know about Portal Hypertension?

6. • 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?

7. 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.

8. 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

9. CAUSES OF PORTAL
HYPERTENSION
Pre-sinusoidal
Sinusoidal
Post Sinusoidal
BLOOD FLOW
LIVER

11. Pharmacologic
Radiologic shunt
TIPSS
Surgical Shunt
Balloon
Tamponade
Pharmacologic and
endoscopic therapy
are the usual 1st and
2nd interventionsEndoscopic
TREATMENT FOR
ACUTE VARICEAL BLEEDING

12. 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%

13. • Alternative to sclerotherapy
• Fewer rebleeding episodes
• Fewer endoscopic interventions
• Lower procedure related mortality and over
all mortality
BALLOON LIGATION

14. BALLOON TEMPONADE
• Application of direct upward
pressure against varices at
G-E junction
• Should be intubated:
Prevent aspiration
Prevent airway
occlusion

15. BALLOON POSITIONING

16. 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

17. • 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)

18.  Cannulating the Rt hepatic vein via internal jugular vein
 Passing needle through liver parenchyma to portal vein branch
 Guide wire
 Balloon dilatation

19.  Stenting the tract

21. Meta-analysis comparing TIPS with
endoscopy in acute hemorrhage:
• Significant improvement in controlling the hemorrhage
• Coast : ↑rate of hepatic encephalopathy

22. CONTRAINDICATIONS
• Right side heart failure
• Polycystic liver
• Portal vein thrombosis

23. • 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

24. CONT…
Late
• recurrent bleeding due to TIPS stenosis or
thrombosis
• Infection
• hepatic encephalopathy

25. Esophageal transection EEA stapler
 Operative mortality 75%
 Complications 25%:
 Perforation
 Stricture
 Esophagitis
→ not useful in acute state

26. PREVENTION OF RECURRENT
VARICEAL BLEEDING

27. 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

28. 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

29. 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)

30. TIPS

31. Surgical Therapy
• Most effective method in controlling portal
hypertension and recurrent bleeding
 Portosystemic shunt procedures
 Esophagogastric devascularization
 Orthotopic liver transplantation

32. • Non-selective shunt
• Manipulation and
dissection in porta
hepatica →
Scaring and fibrosis →
complicate future liver
transplant
PORTOSYSTEMIC SHUNT
(SIDE-TO-SIDE)

33. DSRS
• Selective shunt
• Some cases un accompanied
by refractory ascitis

34. TOTAL SHUNTS
End to Side Portocaval Side to Side Portocaval
Interposition Shunts Central Splenorenal

35. PORTOSYSTEMIC SHUNT
• Decompressing the hypertensive portal Venus system into
the low pressure systemic venous circulation
• Toxins → systemic circulation → encephalopathy

36. • To minimize these effects shunting operations have
evolved:
• Non-selective
• Selective
• partial

37. 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

38. • 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

39. • Interposition Mesocaval Shunt:
Prosthetic – autogennous vien
Avoid hilar dissection (future
transplant)
Shunt ligation in refractory post-op
encephalopathy
Drawback → thrombosis (35%)

40. • 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%

41. 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

42. • Refractory ascitis
• Splenic vein thrombosis
• Previously underwent splenectomy
• Splenic vein diameter < 7 mm
CONTRAINDICATIONS

43. • Coronary – Caval Shunt:
Described in Japan in 1984
Interposition graft between
L Gastric and inferior vena
cava
Little experience with this
procedure

44. PARTIAL SHUNTS
• Small diameter interposition grafts
• Maintaining a degree of hepatopedal portal flow to the
liver

45. ESOPHAGOGASTRIC
DEVASCULARIZATION
• The most effective non-shunt operation
for preventing variceal bleeding:
Devascularization + transection +
splenectomy
Surgical procedure

47. • Child A – mild B → non-transplant
surgery
• Child C – advanced B → transplant

48. LIVER TRANSPLANTATION

49. ORTHOTOPIC LIVER
TRANSPLANTATION
• The most definitive form of therapy for
complications of portal hypertension
• Selective patients:
• Coast
• Unavailability
• Immunosuppresion

50. • 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 & Hepatology
Resource Center http://hopkins-
gi.nts.jhu.edu

51. Thank You