Surgical management portal hypertension

1. Portal Hypertension
(surgical Mx)
By
Dr. Prakash Patel
Asst. Professor
GMC , Surat

2. Treatment
Operations for portal hypertension
Shunt operations.
The idea of these operations is to
lower the portal pressure by shunting
the portal blood away from the liver
It significantly reduces rebleeding of
varices by reducing portal pressure.

3. More availability of TIPSS and liver
transplantation , surgical shunts have
been reduced .
Morbidity and mortality is high with shunt
surgery.
Expert team is required for surgery.

4. TYPES
Selective
– Distal splenorenal shunt (warren’s Shunt)
Nonselective
– Portocaval shunt
End to side
Side to side
interposition graft
– Proximal spleno renal shunt
– Mesentrico caval shunt
End to side
H graft (jump graft)

5. Selection of Shunt
Location of varices is imp to select shunt
Selective shunt- variceal bleed from
oesophagus or stomach.
Non selective shunt – variceal bleed from
stoma (colostomy/ileostomy)
– Uncontrolled haemorrhoidal bleeding
– Small bowel varices
– Intractable ascites with variceal bleed
– Budd chiari syndrome before cirrhosis developed

6. Investigations before shunt
surgery
Visceral angiography- venous phase views
are more important.
Duplex ultrasonography
Get information regarding Anatomy and
patency of portal vein and its tributaries

7. Selective shunt (Warren shunt)
Indication of Selective Shunt
– Extrahepatic portal hypertension with portal
vein throbosis and splenic vein diameter is
>1cm
– Patient with liver disease (child class A or
class B) with adequate liver reserve
Contraindication
– Intractable ascites

8. Selective shunt (Warren shunt)
The Rt and Lt gastric vessels
are ligated.
The proximal end of splenic
vein is ligated while the
distal end is anastomosed to
the left renal vein.
The short gastric veins are
preserved and will
selectively decompress the
lower end of the
oesophagus.
The incidence of
encephalopathy is low, and
the liver functions remain
normal.

9. Advantage of selective shunt – it does not
divert complete blood flow from liver , so
there is less chance of hepatic
encephalopathy
Limitation- it can not control intractable
ascites

10. Non selective shunt
Contraindications-
– Thrombosis of portal vein
– Thrombosis of IVC
– Partial thrombosis or recanalised portal vein is
relative C/I because of risk of shunt
thrombosis is high

11. Total shunt operations
End to side porto
caval shunt
Portal vein is
divided from liver
and end is
anastomosed to
side of ivc
hepatic end is
ligated.

12. End to side portocaval shunt
Special care – to preserve the umbilical
vein in falciform ligament because it is the
only route for retrograde flow of portal
blood & hepatic sinusoid decompresion
postoperatively
If care not taken – medicaly intractable
ascites develops.
High chances of encephalopathy.

13. Total shunt operations
• Side of portal vein
is anastomosed
with side of IVC
• Advantage-
incidence of
encephalopathy is
less <10%
• Disadvantage –
control of bleeding
is 50-70%
Side to side
portocaval shunt

14. After completion of either type of
portacaval shunt, the adequacy of portal
decompression should be evaluated by
measuring the pressure gradient across
the anastomosis.
After a successful portacaval shunt, the
gradient should be less than 5 cm of saline

15. Partial shunt
Small-Diameter
porto caval
Interposition Shunt
(H graft)
Graft is 1.5- 3 cm
in length and 8-10
mm diameter
PTFE or decron
graft is used.

16. After anastomosis - check a palpable thrill
in the vena cava just cephalad to the
anastomosis -> if no fluid thril -> graft
patency is doubtful.
Pressure in portal vein and IVC should be
measure before and after anastomosis.
Before anastomosis portal pressure is high
After completion of anastomosis pressure
in portal vein reduces while pressure in
IVC is slightly raised

17. Pressure gradient should be <10 mm of
Hg for adequacy of procedure.
H graft is marked by placing hemoclip at
proximal and distal end to identify during
post operative radiological examination.

18. Porta-caval operation
very efficient in lowering the portal
pressure  no bleeding occurs from the
varices.
disadvantages:
deprives the liver of portal blood flow 
accelerates the onset of liver failure.
Recurrent hepatic encephalopathy in 30-
50% of patients.

19. Liver is dependent only on hepatic artery
for blood supply which may hampers liver
functions
In selective shunt -Preservation of hepatic
portal blood flow results in continued
delivery of hepatotrophic hormones, such
as insulin, to the liver, and continued
extraction of intestinally absorbed cerebral
toxins, which are metabolized by the liver
before entering the systemic circulation

20. Proximal spleno-renal shunt
indicated if the portal vein is thrombosed
or if splenectormy is indicated due to
hypersplenism .
The incidence of encephalopathy is less
than after porta caval shunt.
it is less effective In preventing further
bleeding.
If the splenic vein is less than 1 cm the
anastmosis is liable to thrombosis.

21. Proximal spleno-renal shunt
Splenectomy is done
Splenic vein is separated
from body of pancreas by
ligating and dividing
tributaries
Proximal end of splenic
vein is anastomosed with
left renal vein in end to
side fashion

22. Meso caval shunt
Indicated when there is portal vein
thrombosis and splenic vein diameter is
not adequate
Splenic vein thrombosis

23. Meso caval shunt
Meso caval H graft
PTFE or decron graft
is placed between
SMV and IVC
Anastomosis is done
at the level of root of
mesentry
There is high chances
of thrombosis

24. Meso- caval shunt
End to side meso
caval shunt
• IVC is divided just
above its lower end
• Lower cut end is
ligated
• Proximal end is
anstomosed with
SMV at root of
mesentry
• Mostly used in
children

25. Complications
EARLY COMPLICATIONS
– Haemorrhage from suture lines
– Occlusion of anastomosis by thrombosis
Most commnly with spleno renal and meso caval
anastomosis
– Hapatic coma following liver failure

26. LATE COMPLICATIONS
Portosystemic encephalopathy
– More often precipitated after large protein
meal or after upper GI bleeding.
– Treatment – restriction of high protein diet
– Removal of blood from GIT by enema or
lactulose
Graft thrombosis

27. Non-Shunt Operations
Options
Esophageal transection
Variceal ligation
Devascularize +/- splenectomy
Very limited role

28. There are many techniques for
performing devascularization.
1) Hassab Khairy operation
splenectomy & ligation of the Rt and Lt
gastric vessels, the short gastric
vessels and the vascular arcade along
the greater curvature of the stomach
leaving only the right gastroepiploic
vessels.

29. All vessels surrounding the lower 5-10
cm of the oesophagus are ligated.
There is no encephalopathy following
this operation and the portal blood flow
is intact.
There is a low incidence of rebleeding
following the operation, but it can
usually be controlled by sclerotherapy.

30. Sugiura procedure

31. Splenic Vein Thrombosis
Etiology:
Pancreatitis - Acute or Chronic
Pancreatic Carcinoma
Hallmark:
Isolated Gastric Varices
Treatment:
Splenectomy (if bleeding) +
devascularisation.
DSRS

32. Portal Vein Thrombosis
Etiology:
Congenital - “Cavernous Transformation”
Hallmark:
Normal Liver Function W/ Varices
Treatment:
Endo Tx
proximal spleno renal shunt
mesocaval shunt

33. Budd-Chiari Syndrome
characterized by hepatic venous outflow
obstruction at any level

34. Budd-Chiari Syndrome
Etiology
Congenital – web in suprahepatic IVC
Hypercoagulable: Estrogens, XRT,
Myeloproliferative disease
IVC Occlusion: RA Myxoma, Pericarditis, Membrane
Liver Mass
High Dose ChemoTx

35. Pathophysiology
Obstruction - by a thrombus
– from extrinsic compression (tumour, abscess,
cysts)
– membranous webs within the inferior vena
cava (IVC) may be congenital or with HCC ,
– postoperative complications following liver
transplantation.

36. obstruction leads to increased sinusoidal
pressure, sinusoidal congestion,
hepatomegaly,
patient having triad of hepatic pain, portal
hypertension and ascites.

37. Clinical features
Acute form – dengerous leads to rapid
enlargement of liver, severe abdominal
pain, vomiting , hypotension
Chronic form- resembles cirrhosis
– Hepatomegaly,dilated veins over abdomen,
pedal oedema, ascites, signs of liver failure ,
hemetemesis

38. Budd-Chiari Syndrome
Diagnosis
– USG
– CT scan /MRI
– CT angiography –to detect level of obstruction

39. – Protein c and s level , antithrombin III level
measurement to rule out hyper coagulabale
disease
– Bone marrow biopsy – myeloproliferative
disease
– Liver biopsy

40. Treatment
1)Medical management
Acute form – anticoagulation treatment
with heparin and warfarin
– Sodium restriction
– Diuretic therapy
– Paracentesis

41. 2) Interventional techinques and TIPSS
• Catheter-directed thrombolytic therapy,
angioplasty and stent placement can be
effective in the acute setting
• TIPSS – in acute or chronic form of
disease

42. 3) Surgical intervention
• Shunt surgery
• Liver transplant

43. Some Take Home Points
Selective shunt:  encephalopathy
Budd-Chiari: Classic triad of
abdominal pain , hepatomegaly
,ascites
Transplant for liver failure