Surgical Treatment Of Portal Hypertension Research Articles

P.409: Surgical treatment of portal hypertension. Analysis of 116 consecutive cases.

P.409: Surgical treatment of portal hypertension. Analysis of 116 consecutive cases.

Role of splenomegaly in surgical treatment of portal hypertension

Role of splenomegaly in surgical treatment of portal hypertension

Surgical Treatment of Portal Hypertension in Children.

Introduction: Portal hypertension is a syndrome characterized by increased pressure in the portal vein system and can be caused by impaired blood flow in the portal vein, hepatic veins, or inferior vena cava. The main complications of this condition are bleeding from varicose veins of the esophagus (in our study in 100% of patients), splenomegaly with hypersplenism (in our study in 98% of patients), ascites (in our study in 1 patient). The main goal of treating portal hypertension is to prevent bleeding from esophageal varices. However, today the goal of surgical treatment of portal hypertension in children is not only to prevent the development of bleeding but also the possible restoration of intrahepatic blood flow. Materials and Methods: A retrospective analysis of the results of treatment of portal hypertension in 75 children (41 boys, 34 girls) operated in our Center for the period from 2019 to 2022 was carried out. The mean age of the patients was 7 ± 1 years. Sixty-nine patients had an extrahepatic form of portal hypertension, and 6 patients had an intrahepatic form (liver fibrosis). In 14 patients (18.6%), the operation was repeated (a vascular shunt was previously applied in another hospital; 4 children were operated on repeatedly). Results: A good result was obtained in all children, and the risk of bleeding from varicose veins of the esophagus was eliminated. Vascular bypass surgery was performed in all cases: mesoportal bypass in 17 (22.7%) patients, splenorenal bypass in 37 (49.3%) patients, mesocaval bypass in 21 (28%) patients. In 10 (13%) cases, repeated bypass surgery was required due to dysfunction or thrombosis of the previously performed bypass. In 14 (18.6%) patients with mesoportal shunts, blood flow in the liver was completely restored. Conclusions: The main method of surgical treatment of portal hypertension today is portosystemic bypass surgery, which effectively prevents bleeding from varicose veins of the esophagus. Mesoportal shunting is a definitive treatment for extrahepatic portal hypertension that restores portal perfusion of the liver.

Vascular bypass surgery in the treatment of extrahepatic portal hypertension in children (review)

In children with extrahepatic portal hypertension (EPHT), the most frequent and life-threatening complication is bleeding from varicose veins of the esophagus and stomach. Therefore, the main task of HSV treatment is to prevent bleeding from the veins of the upper gastrointestinal tract. The most effective treatment is portosystemic bypass surgery, with effectiveness of 94%97%. However, the use of these operations is limited precisely by a decrease in portal liver perfusion and development of portosystemic encephalopathy. This study aimed to analyze domestic and foreign publications devoted to the surgical treatment of portal hypertension and the development of portosystemic encephalopathy during the postoperative period. A systematic search was carried out in PubMed, Web of Science, Scopus, MEDLINE, eLibrary, RSCI, and Cyberleninka; 345 references were analyzed, 110 articles were reviewed, and 97 publications on the surgical treatment of portal hypertension were selected for the review. The development of portosystemic encephalopathy during the postoperative period often occurs after the imposition of total portosystemic bypass surgery. To reduce the risk of developing portosystemic encephalopathy, selective shunts have been developed, which to some extent preserve the PPP. With distal splenorenal anastomosis, the frequency of portosystemic encephalopathy is 10%15%. An intermediate position is occupied by a side-to-side splenorenal anastomosis, which has signs of selective surgery. The results of the analysis of literature sources showed that discussions are still underway regarding the choice of the optimal treatment strategy for patients with EPHT, place and role of endoscopic methods for the prevention of gastrointestinal bleeding, and mesoportal shunt in the treatment of patients with EPHT. Nevertheless, the majority of world experts consider mesoportal shunt to be the most optimal operation for the primary and secondary prevention of varicose bleeding and other HSV complications. If it is impossible to perform, selective bypass surgery of the distal splenorenal anastomosis can be an alternative to a mesoportal shunt.

Progress and Prospects of Surgical Treatment of Portal Hypertension

Progress and Prospects of Surgical Treatment of Portal Hypertension

Chinese expert consensus for laparoscopic esophagogastric devascularization(2021)

Laparoscopic esophagogastric devascularization has the advantages of less trauma, less bleeding and faster recovery.In order to promote this technology in a scientific and standardized manner and to guide clinical practice, the Chinese Society of Spleen and Portal Hypertension Surgery, Chinese Medical Association, discussed and composed the "Chinese expert consensus for laparoscopic esophagogastric devascularization（2021）".This consensus adheres to the standardization and minimally invasive principles of surgical treatment of portal hypertension, and elaborates the surgical indications and contraindications, preoperative evaluation, surgical technical points and precautions, postoperative management and common complications, especially the prevention and treatment of portal vein thrombosis.

Chinese expert surgical procedure consensus on open pericardial devascularization(2021)

Although the treatment strategy of esophageal and gastric varices bleeding in portal hypertension has been diversified and multidisciplinary now,the surgical treatment represented by pericardial devascularization operation will still play an important and irreplaceable role in China. In order to standardize the surgical procedure,guide clinical practice and improve the level of surgical treatment of portal hypertension,Chinese Society of Spleen and Portal Hypertension Surgery,Chinese Surgical Society,Chinese Medical Association organized Chinese experts to formulate this consensus. The main contents include:the position of surgical treatment,surgical indications and contraindications,preoperative evaluation,key points and precautions of surgical procedure,perioperative treatment,prevention and treatment of postoperative complications. The consensus emphasizes the standardization of surgical treatment of portal hypertension,pay attention to the prevention and treatment of postoperative portal vein thrombosis,and expect to provide surgeons with clinical guidance.

Focusing the role of surgery in the treatment of liver cirrhotic portal hypertension

Portal hypertension treatment has always been regarded as complex and diverse. With the innovation of concepts and technologies, its treatment model has been transformed from a single-disciplinary diagnosis and treatment model to a multidisciplinary collaborative diagnosis and treatment model. In the multidisciplinary diagnosis and treatment model, the surgical treatment of portal hypertension is not a treatment that is about to disappear soon, but one of the indispensable treatment methods under the multidisciplinary diagnosis and treatment model, and it will play an increasingly important role. Surgeons should formulate individualized, standardized, and minimally invasive treatment methods under the input of new concepts, master the surgical indications and individualized surgical methods for different populations, and maximize the optimization surgical treatment methods for portal hypertension. Therefore, it is necessary to re-examine the role of surgical treatment in the diagnosis and treatment of liver cirrhotic portal hypertension.

Адекватность применения прогностических систем при оценке тяжести цирроза печени

Assessment of the severity of liver cirrhosis as a mandatory parameter includes a characteristic of the degree of its compensation. Detailed historical research has shown that this characteristic of liver disease has no authorship, no precise definition, and seems to be a matter of course for the medical community. Moreover, the term “decompensation” (the adjustment of certain functions due to the adaptation of other organs and systems) does not reflect the pathophysiology of changes developing in patients with terminal liver cirrhosis. When determining the degree of compensation for cirrhosis, physicians are forced to focus on the classification of Child and Turcotte in Pugh's modification. This system was developed to assess the outcome of surgical treatment of portal hypertension and validated to predict the survival of patients with liver cirrhosis (expectation of an event in the future) in the short and medium term, but cannot be orrectly applied to assess the severity of liver cirrhosis (at the time of assessment). The inadequacy of the Child-Pugh prognostic system for assessing the severity of liver cirrhosis was shown by the example of determining the possibility of using HCV protease inhibitors in patients with complicated (“decompensated”) liver cirrhosis. It is necessary to develop new principles for assessing the severity of liver cirrhosis, in particular, in relation to the disorders of drug metabolism and the potential toxicity of drugs and their metabolites.

ANATOMICAL VARIANTS OF INFERIOR MESENTERIC VEIN ACCORDING ON THE DATA OF MULTISPIRAL COMPUTED TOMOGRAPHY

Knowledge of the variants of the anatomical variability of the liver vascular bed can be of critical importance in liver resection, liver transplantation, laparoscopic operations, resection of the pancreas, surgical treatment of portal hypertension The main vessels of the hepatic portal vein system are characterized by pronounced anatomical variability in the formation of the portal vein trunk, the greatest variability is characterized by inferior mesenteric vein. The aim of the investigation was to study the variant anatomy of the inferior mesenteric vein according to multispiral computed tomography. The material was 100 multispiral computed tomograms of the abdominal organs from the archive of the clinics of the Samara State Medical University for 2018-2019. For mathematical modeling and the creation of three-dimensional models based on tomograms of the vascular bed, plugins were used in the programs «Luch» and «Autoplan». Variants of the portal vein formation, the angle of inflow of the inferior mesenteric vein into the superior mesenteric and splenic veins, the distance from the point of confluence of the inferior mesenteric vein to the point of confluence with the portal vein were studied. The study revealed that the inferior mesenteric vein in 40% of cases flows into the splenic vein, in 39% - into the angle of confluence of the superior mesenteric and splenic veins, in 16% - into the superior mesenteric vein. In 5% of cases, the absence of the inferior mesenteric vein was revealed. The angle of fusion of the inferior mesenteric vein with the superior mesenteric vein was statistically significantly greater than the angle of fusion of the inferior mesenteric vein with the splenic vein. The angles were 76.36 ± 1.53 ° and 64.89 ± 3.52 °, respectively (p = 0.004). The length of the common trunk of the inferior mesenteric and splenic veins was significantly greater than the common trunk of the mesenteric veins and amounted to 16.98 ± 1.09 mm and 9.37 ± 0.65 mm (p = 0.001), respectively. Thus, the study showed a high degree of anatomical variability of the inferior mesenteric vein.

The Surgical Treatment of Portal Hypertension.

A century and a half later, who has benefitted from the enormous amount of work done in portal hypertension? Clearly, the greatest beneficiaries have been patients: the progress generation over generation has been monumental, with outcomes achieved that could not have been imagined by the preceding generation. The groundwork laid by these pioneers has led to evidence‐based approaches to patients with portal hypertension today. This has allowed minimally invasive options for patients who are not candidates for transplant, as well as for those who need a bridge to transplant. Although the classic operative approaches to portal hypertension are uncommon today,52 the principles outlined through the current review have permitted advanced operative approaches for certain cancer resections and in other highly selected patients. We salute all of the pioneers in this field.

Attention to the surgical treatment of portal hypertension in China

Portal hypertension caused by liver cirrhosis is common and severely threatens the patients′ health. The dominant position of the conventional surgical treatment was strongly challenged by the pharmacological, endoscopic esophageal variceal ligation (EVL), transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation. So, what the prospect of surgical treatment is and whether it has disappeared? In fact, the surgical treatment is not only far from disappearing, but also play a unique and indispensable role, and could not be displaced by other treatments. Nowadays, the laparoscopic pericardial devascularization is widespread used, shows the increasingly prominent and distinct advantages of less injury and bleeding, fewer complications and faster recovery. The generalizing of multidisciplinary treatment (MDT) will combine advantages of varies subjects then provide the individual and precise diagnosis and treatment plan to patients. Authors should pay attention to the problems and then organize the clinical multicenter RCT studies, provide high level evidences, explore new surgical procedures, compose new clinical guidelines and consensuses which consistent with our national situations, thus to guide the clinical practice and will further improve the treatment of portal hypertension and raise our country′ voice in this subject. Key words: Portal hypertension; Surgical procedures, operative; Standardization; Individuation

Miniinvasive vascular interventions as an alternative surgical method for treatment of the patients, suffering hepatic cirrhosis and portal hypertension

Objective. Determination of efficacy of miniinvasive surgical treatment of portal hypertension (PG) in patients, suffering hepatic cirrhosis (HC) in immediate and late postoperative periods.
 Маterials and methods. Results of surgical treatment of 200 patients, suffering HC, were analyzed retrospectively: in 102 of them (Group I) HC and gastro-esophageal varices were diagnosed, in 98 (Group II) - HC with PG.
 Results. There was established, that miniinvasive surgical treatment in volume of the gastric veins embolization, аs well as operations of selective and partial portocaval shunting with the objective to correct a portal hypertension in patients, suffering HC, constitutes effective alternative method of surgical treatment.
 Conclusion. The decompression operations for portal system in patients with HC prevent the esophago-gastric hemorrhage occurrence in late period of follow-up and guarantee good survival of the patients, suffering compensated and subcompensated hepatic function.

Technical advancement in surgical treatment of portal hypertension

Recently, there have been many developments and improvements in portal hypertension surgery, but there are still many controversies regarding the surgical indications, the timing of surgery, and the choice of surgical procedures. Minimally invasive laparoscopy and robotics are the leading direction for the development of surgical techniques for portal hypertension. Surgical selection procedures should be based on evidence-based, but guidelines should not be blindly followed. Surgical development needs to strengthen multidisciplinary cooperation, and surgical reform is the driving force for surgical development.

Differentiated Surgical Treatment of Portal Hypertension and its Complications in Patients with Liver Cirrhosis Part I. Assessment of Diseases Severity and Choice of Surgical Intervention

Aim. To develop the system assessing degree of disease compensation and the algorithm for selection of method of surgical treatment. Material and Methods. Main parameters of nutritionally – metabolic status, central hemodynamics, porto-hepatic circula tion, oxygen regime of tissues and major clinical syndromes (ascites, jaundice, hepatic encephalopathy) depending on severity and degree of disease compensation were studied in 166 patients with liver cirrhosis and portal hypertension. Results. Intensity of catabolism and amino-acid disorganization amplifies accordingly to increased severity of disease in groups A, B and C by Child. It is accompanied by increased protein deficit in somatic and visceral protein parts of body and formation of moderate and severe malnutrition. In parallel with these changes there are compensatory changes in central hemodynamics including transition from normorkinetic type of circulation in the group A to hyperkinetic circulation in group B, “breaking” of compensation with formation of hypokinetic circulation in group C. It is accompanied by changes in porto-hepatic circulation and reflected on functional state of liver. The hypothesis of liver failure progression with formation of five functional classes is suggested. Violations of “trophic homeokinesis” supporting “vicious circle” play important role in pathogenesis of liver failure. Based on obtained data additional groups characterizing the transition from one class to another are determined. We presented quantitative objectification of changes of main parameters which characterize the severity of disease. It allows to modify the system assessing reserve potential in patients with liver cirrhosis and portal hypertension. Based on this classification the algorithm for selection of surgical treatment in these patients is poposed. Conclusion. The suggested classification assessing degree of disease compensation in patients with liver cirrhosis and portal hypertension is not an alternative to popular forecasting Child’s system but complements it in clinical situations which are difficult to assess the reserve potential and to choose surgical treatment. The classification will allow to compare obtained results in evaluation of effectiveness of different treatment strategies.

Nonconventional mesocaval prosthetic shunt interposition in refractory case with portal hypertension in a 10-kg female infant

Surgical treatment of portal hypertension in infants is challenging because of the high risk of shunt thrombosis. A 10-kg female infant underwent six failed procedures before being successfully treated by interposition of a 10-mm-diameter prosthetic graft between two 3-mm-diameter splanchnic veins and the inferior vena cava. Follow-up at 10 years demonstrates shunt patency and normal development without rebleeding. An aggressive surgical strategy is justified as long as even nonconventional techniques are available to prevent life-threatening complications of portal hypertension. Prosthetic grafts can be used when no autologous vein graft is available. Decellularized allografts with reduced immunogenicity may also be effective alternative materials. Keywords: mesocaval anastomosis, PHT, prosthetic shunt

Strategies to improve the surgical treatment of portal hypertension

The surgical treatment for portal hypertension (PHT) aims to control and prevent the gastroesophageal variceal bleeding. The choices of surgical timing and procedures are dependent on the liver reserve function. Except for Child-Pugh classification and model for end-stage liver disease scoring system, the future liver remrant and pre-albumin are the important evaluation indexes, meanwhile, the choice of surgical procedures would be dependent on portal hemodynamics that can reduce incidence of rebleeding of postoperative hepatic encephalopathy. Hepatic venous pressure gradient is the most important objective index forecasting bleeding risk and severity of PHT. Key words: Portal hypertension; Portal vein; Liver functional reserve; Surgical therapy

Current status and perspectives of surgical treatment of portal hypertension

Current status and perspectives of surgical treatment of portal hypertension

Surgical treatment for portal hypertension.

Surgical expertise that is likely to be lost

The Surgical Treatment for Portal Hypertension: A Systematic Review and Meta-Analysis

Aim. To compare the effectiveness of surgical procedures (selective or nonselective shunt, devascularization, and combined shunt and devascularization) in preventing recurrent variceal bleeding and other complications in patients with portal hypertension. Methods. A systematic literature search of the Medline and Cochrane Library databases was carried out, and a meta-analysis was conducted according to the guidelines of the Quality of Reporting Meta-Analyses (QUOROM) statement. Results. There were a significantly higher reduction in rebleeding, yet a significantly more common encephalopathy (P = 0.05) in patients who underwent the shunt procedure compared with patients who had only a devascularization procedure. Further, there were no significant differences in rebleeding, late mortality, and encephalopathy between selective versus non-selective shunt. Next, the decrease of portal vein pressure, portal vein diameter, and free portal pressure in patients who underwent combined treatment with shunt and devascularization was more pronounced compared with patients who were treated with devascularization alone (P < 0.05). Conclusions. This meta-analysis shows clinical advantages of combined shunt and devascularization over devascularization in the prevention of recurrent variceal bleeding and other complications in patients with portal hypertension.