Surgery for Portal Hypertension: History or Future

Surgery for Portal Hypertension: Is it History? S K Mathur MS,FACS Sr.Consultant Surgeon Surgical Gastroenterology HPB Surgery & Liver Transplantation Wockhardt Hospitals (Associated Hospital of Harvard Medical International) & JR Railway Hospital Mumbai

Evolution of Treatment for Portal Hypertension - Cleveland Clinic Modified from Hermann Ann Surg 1996

Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era. Bismuth H , Adam R , Mathur S , Sherlock D . Am J Surg. 1990 Jul;160(1):105-10. Hepatobiliary Surgery and Liver Transplant Unit, Paul Brousse Hospital, Villejuif, France. ,[object Object],[object Object],[object Object],[object Object],[object Object]

Historical trend in Management of Portal hypertension KEM hospital, Mumbai 1950 1980 1990 2000 Surgery Sclerotherapy 1983 Year

Long term results of chronic endoscopic variceal sclerotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Mathur et.al Gastrointest. Endoscopy 1990

Trials of Long term Sclerotherapy V/s Splenornal shunt No. of patients : 112 60 72 66 10-59% required surgery for failed EVS

Surgery for Portal Hypertension Personal Series:1983 - 2007 EVS 542 Sx 190 n=608 23% Surgery in EVS Gr. 10%Primary Sx Mathur SK

Portal Hypertension In India: Etiology 1983-2007 N=608* 14% 45% *Personal series

Clinical Manifestations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Surgery for Portal Hypertension Indications for Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Portal Hypertension Current Surgical Options Indications for Surgery ,[object Object],[object Object],[object Object],[object Object]

Indications for Primary Surgery Sinistral PHT (Left sided) ,[object Object],[object Object],[object Object],Splenectomy : curative

PHT:Indications for Surgery Primary therapy ,[object Object],[object Object],n = 1 - Biliary variceal bleed - Ruptured retropeitoneal varices

PHT: Indications for Surgery ,[object Object]

Classification of Gastric Varices Hosking’s BJS 1988 Mathur’s J Gastroenterol Hepatol 1988 Sarin’s Am J Gastro 1989 GOV1 GOV2 IGV1 IGV2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Baveno Consensus’96

ENDOSCOPIC AND RADIOLOGICAL APPRAISAL OF GASTRIC VARICES Mathur SK et al. B.J.S. 1990 ,[object Object],[object Object]

Fundic Gastric Varices Results of Glue Injection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience Akahoshi T et al. Surgery. 2002 Jan; 131(1 Suppl): S176-81. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

FGV: Post Glue Injection Complications

Effect of TIPS on Fundal Gastric Varices & Congestive Gastropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

TIPS for FGV ,[object Object],[object Object],[object Object],[object Object],[object Object]

Indications for Primary Surgery ,[object Object],Post Shunt Rebleed 2%

Bleeding Fundal gastric varices Results of Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Portal Hypertension Primary Elective Surgery Spleen related Indications ,[object Object],[object Object],[object Object]

Portal Hypertension Indications for Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hypersplenism : 33% - WBC < 4000/Cu mm. - Platelets <1,00000

Portal Hypertension Indications for Surgery ,[object Object],[object Object]

Extra hepatic Portal Hypertension in Children Indications for Surgery ,[object Object],[object Object],[object Object],[object Object],Surgery For growth retardation : 1%

Extra hepatic Portal Hypertension INDICATIONS FOR PRIMARY ELECTIVE SURGERY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

EHPVO:Portal Biliopathy Bile duct abnormalities: 85 – 100% Symptomatic: 1% MRCP MR Cholangiogram + Superimposed Portogram ERCP

Portal Biliopathy Cholangitis MRCP Endo Sono O.V. Fundal G.V. Peri dochal Varices CBD obstruction

MRCP+MR ANGIOGRAPHY ,[object Object],[object Object]

Portal Biliopathy Therapeutic Options ,[object Object],[object Object],[object Object],[object Object],[object Object]

Biliary Surgery in presence of Portal Hypertension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],A Chaudhary BJS 1998

Portal Biliopathy in EHPVO Results of Porto Systemic Shunt ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],*Vibert E, Azoulay D et al. Ann Surg 2007 *A Chaudhary BJS 1998

Portal Hypertension Indications for Surgery for variceal Bleed ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Q. What to do for refractory bleeding ? ,[object Object]

Distal-spleno-renal shunt Splenic vein Renal vein SHUNT

TIPS Vs Surgery Evidence based Medicine : ,[object Object],[object Object],[object Object],[object Object]

TIPS for control of acute variceal bleeding ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Banares R, Am J Gastroenterol. 1998 Bosch J. J Hepatol 2001

Rescue Therapy Emergency TIPS vs Surgery Good risk patients ,[object Object],[object Object],[object Object],[object Object],[object Object],Rosemurgy Ann Surg 1996

[object Object],[object Object],[object Object]

Ten years' follow-up of 472 patients following TIPSS insertion at a single centre ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Tripathi D et al , Edinburgh,UK, Eur J Gastroenterol Hepatol. 2004;16:9-18.

TIPS: PTFE covered V/s Uncoverd Stents long-term results of a randomized multicentre study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Bureau C et al Liver Int. 2007 Aug;27:742-7.

DSRS v/s TIPS (Retrospective Case Control Study) Good risk patients n=40 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Distal splenorenal shunt versus TIPS for variceal bleeding : a randomised trial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Henderson JM, et al, Gastroenterology, May 2006

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246. H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals . Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246

H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals ,[object Object],[object Object],[object Object],[object Object],[object Object],Rosemurgy AS et al, Ann Surg. 2005; 241: 238–246.

Rescue Therapy in Cirrhotics TIPS v/s Surgical shunt ,[object Object],[object Object],[object Object],[object Object],[object Object]

Portal Hypertension Rescue Therapy TIPS Vs Surgical Shunt ,[object Object],[object Object]

Surgery for Portal Hypertension Is it History? CONCLUSIONS: No ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Surgery for Portal Hypertension Is it History? CONCLUSIONS: No ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. Orloff MJ J Am Coll Surg. 2009 July ,[object Object]

Natural history in EHPVO Hepatopetal blood flow in portal cavernoma Adequate hepatic portal perfusion Preservation of hepatocyte function Normal life span

Acute Variceal Bleeding Indications for Em. Rescue Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

INDICATIONS FOR ELECTIVE SURGERY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Surgery for PHT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Indications for Primary surgery

EVS:Indications for Elective Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Surgical Options in PHT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Surgery: Long term results Recurrence Rebleed Stricture Block Rebleed Enceph Overall 6% 6% 12% 8% 6% 5% DEVASCULARISATION 53 SD 34 months (4-143 months) SHUNT SURGERY 25 SD 29 months (4-107months) %

Choice of Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object]

Surgery for Portal Hypertension: History or Future

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Surgery for Portal Hypertension: History or Future

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