Obliteration Of Varices Research Articles

Portosinusoidální vaskulární choroba s portální hypertenzí – popis případu

Portosinusoidal vascular disease (PSVD) is a rarely recognized liver condition caused by the involvement of small hepatic vessels. The diagnosis is established based on a set of clinical and/or histopathological criteria, with the absolute requirement of excluding liver cirrhosis through biopsy. Clinically, PSVD often presents with complications related to portal hypertension, although not all patients exhibit these signs. This article discusses the case of a 71-year-old patient with known splenomegaly, which had not been fully investigated and lacked a hematological explanation. The patient was evaluated for severe symptomatic microcytic anemia, likely secondary to portal hypertension, despite the absence of overt bleeding symptoms. During hospitalization, ligation of large, high-risk esophageal varices was performed, and no other sources of anemia were identified. Pre- or post-hepatic causes of portal hypertension were ruled out. Liver elastography results were within normal ranges, and liver function tests were normal except for a marginal isolated elevation of gamma-glutamyltransferase. Liver function remained intact. Liver biopsy findings were consistent with a diagnosis of PSVD. The patient did not have any identifiable associated conditions and was not taking any medications known to pose a risk. Therefore, treatment was focused solely on managing the complications of portal hypertension. Outpatient follow-up included the eradication of esophageal varices. Treatment with oral iron supplements led to the normalization of hemoglobin levels, which remained stable for months after the discontinuation of therapy, and liver function tests continued to be normal.

Transjugular antegrade transvenous obliteration, with and without portal decompression, for management of rectal variceal hemorrhage

PurposeTo report antegrade transvenous obliteration, with or without concurrent portosystemic shunt creation, for the treatment of hemorrhagic rectal varices.Materials and methodsEight patients, including five (62.5%) females and three (37.5%) males, with mean age of 55.8 ± 13.8 years (range: 30–70 years), underwent transjugular-approach antegrade transvenous obliteration of rectal varices, with or without portosystemic shunt creation. Demographic data, procedural details, technical success of variceal obliteration, clinical success, adverse events, and follow-up outcomes were retrospectively recorded. Clinical success was defined as resolution of rectal hemorrhage.ResultsPortal venous access was achieved via a transjugular intrahepatic approach in all patients. The inferior mesenteric vein was selected, and foamy sclerosant (1:2:3 mixture by volume of ethiodized oil: sodium tetradecyl sulfate: air) was injected into the rectal varices with antegrade balloon occlusion in seven (87.5%) and without balloon occlusion in one (12.5%). Five of eight (62.5%) patients underwent concomitant transjugular intrahepatic portosystemic shunt (TIPS) creation (mean diameter 8.4 ± 0.9-mm) immediately following transvenous obliteration. Technical success of variceal obliteration was achieved in all patients. There were no immediate post-procedural adverse events. There were no reported occurrences of rectal ischemia, perforation, or stricture following obliteration. Two (40%) of the patients who underwent concomitant TIPS creation developed hepatic encephalopathy within 30 days of the procedure, which was medically managed. Clinical resolution of hemorrhage was achieved in all patients with no recurrent rectal variceal hemorrhage during mean follow-up of 666 ± 396 days (range: 14 − 1,224 days).ConclusionTransvenous obliteration, with or without concurrent TIPS creation, is feasible with promising results for the management of rectal variceal hemorrhage.

EUS-Guided Vascular Interventions: Recent Advances.

Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials.

A prospective, single-center, randomized, open-label study to investigate the efficacy and long-term outcome of cyanoacrylate glue for obliteration of all gastric varices (GOV1, GOV2, IGV1, IGV2) versus obliteration of gastric varices with stigmata of recent haemorrhage in cirrhotic patients presenting with first episode of variceal bleed

A prospective, single-center, randomized, open-label study to investigate the efficacy and long-term outcome of cyanoacrylate glue for obliteration of all gastric varices (GOV1, GOV2, IGV1, IGV2) versus obliteration of gastric varices with stigmata of recent haemorrhage in cirrhotic patients presenting with first episode of variceal bleed

Plug-Assisted Retrograde Transvenous Obliteration: A Modified Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices

AbstractGastric varices (GVs) and hepatic encephalopathy (HE) are major complications of portal hypertension in patients with liver cirrhosis. As most of the GVs drain into the left renal vein via a portosystemic shunt, the concept of retrograde treatment approach such as balloon-occluded retrograde transvenous obliteration using sclerosing agents has been introduced. Recently, plug-assisted retrograde transvenous obliteration (PARTO) has been alternatively performed, which uses vascular plug and gelfoam. PARTO utilizes a permanent vascular plug to reduce postprocedural monitoring time as well as to avoid the risk of balloon rupture–related complications. It also eliminates the sclerosing agents–related complications with the use of gelfoam as an embolics. In this review, we introduce technical aspects of PARTO and outline its potential for use as the treatment of GVs and HE.

Analysis of the effectiveness of the method of primary bleeding prevention in the treatment of portal hypertension in children

Objective. To evaluate the role of primary prevention of variceal bleeding in children with prehepatic portal vein obstruction. Materials and methods. The single–centre prospective cohort clinical trial involved 120 patients with extrahepatic obstruction of the hepatic portal vein who underwent primary or secondary prevention of variceal bleeding in 2016–2021. Laboratory, ultrasound, and endoscopic data were collected and evaluated before and after prophylactic treatment. Results. Episodes of variceal bleeding were observed in 3 (5.78%) patients who received primary prophylaxis, and rebleeding occurred in 19 (27.94%) patients who received secondary prophylaxis (p=0.013). Of the 53 (44.17%) patients who underwent endoscopic treatment, variceal bleeding occurred in 3 (5.66%), and 19 (28.36%) of the 67 (55.83%) patients who underwent surgery experienced rebleeding (p=0.001). Esophageal varices eradication was achieved in 83 (69.17%) patients: 44 (53.01%) patients who received primary prevention and 39 (46.99%) patients who received secondary prevention. Bleeding episodes occurred less frequently after eradication (p<0.001). After primary prevention, varicose veins disappeared more often than after secondary prevention (p=0.003). The incidence of varicose veins recurrence after achieving eradication did not differ in the groups (p=0.51). Conclusions. Primary prevention can reduce the high risk of bleeding in prehepatic portal vein obstruction. Prophylactic endoscopic ligation is important in the treatment of portal hypertension in children, which, together with portosystemic shunting, can potentially improve the results of preventive treatment.

Safety and Complication of Endoscopic Band Ligation

Background: Endoscopic band ligation (EBL) is a medical procedure commonly used to treat esophageal varices, which are swollen veins in the lining of the lower esophagus. Esophageal varices can be a serious complication of liver disease, particularly cirrhosis, and they pose a risk of bleeding. Objectives: The aim of the study was to evaluate the safety and complication of endoscopic band ligation. Methods: This prospective observational study was done in the department of Gastroenterology, Hepatology and Nutrition, BSHI. 60 subjects were included in this study from July 2019 – June 2021. Every case was treated with endoscopic band ligation. Cases were followed up for a minimum period of 1 year after the band ligation. Statistical analyses of the results were be obtained by using window-based Microsoft Excel and Statistical Packages for Social Sciences (SPSS-24). Results: Age of the children was 3-18 years with mean 7.27±2.21 years and male: female ratio was 2:1. Out of 60 children 34 (56.7%) were extra-hepatic and 26 (46.6%) were hepatic causes of portal hypertension. Maximum patients (46.6%) had grade III varices followed by (30%) patients had grade IV and (23%) patients had grade II with red sign. Most of the patients, (46%) required 2 sessions and (36%) patients required 3 sessions for variceal obliteration in both group and (16%) cases of extra-hepatic children required only 1 session whereas hepatic cases required multiple sessions. Among 60 patients, (83%) patients developed re-bleeding where (40%) patients had early re-bleeding and (43%) had late re-bleeding. No complications were noted except nausea and vomiting. Conclusion: It's essential for patients undergoing EBL to discuss the potential risks and benefits with their healthcare provider and to ensure that the procedure is performed by a qualified and experienced medical team. Additionally, patients should follow post-procedure instructions carefully to minimize the risk of complications and promote ....

Review of Commonly Used Embolics

AbstractAs interventional radiology has progressed, endovascular embolization has become a cornerstone of the specialty, used in a wide range of clinical indications including vessel occlusion in acute hemorrhage, cancer and benign tumor treatment, vascular malformations, variceal obliteration, and endoleak management. Fundamental knowledge of the various categories of embolics is vital for interventional radiologists. This review aims to provide a brief summary of the most common embolic agents currently in use, including discussions of their advantages, shortcomings, and common indications of each.

Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial

ObjectiveThis randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC).DesignPatients...

Endoscopic band ligation of esophageal varices from A to Z

Esophageal varices bleeding is a severe complication of portal hypertension. Endoscopic ligation (EL) is the “gold standard” for treatment of acute bleeding, and as well as an effective means of primary and secondary prevention. The technique of endoscopic ligation is well studied, does not present significant technical difficulties. However, in some cases it is accompanied by complications, the most dangerous of which is slipping of ligature. The marker of the effectiveness of EL is the eradication of esophageal varices, which is ensured by compliance with the algorithm of the technique and a step-by-step approach to endoscopic treatment.

The role of variceal bleeding primary prophylaxis in the management of extrahepatic portal vein obstruction in children

Extrahepatic portal vein obstruction is a major cause of pediatric symptomatic portal hypertension and can lead to profuse variceal hemorrhaging. Purpose - to evaluate the role of primary prophylaxis of the variceal bleeding in children with extrahepatic portal vein obstruction. Materials and methods. A one-center prospective cohort clinical study involved 120 patients with extrahepatic portal vein obstruction who underwent primary or secondary variceal bleeding prophylaxis in 2016-2021. The laboratory, ultrasound, and endoscopy data before and after treatment were collected and evaluated. Results. Variceal bleeding episodes occurred in 5.8% (n=3) of patients who underwent primary prophylaxis and rebleeding occurred in 27.9% (n=19) of those who underwent secondary prophylaxis. Bleeding episodes occurred less frequently in patients from primary prophylaxis group (p=0.013). In patients treated endoscopically (n=53, 44.17%) Variceal bleeding appeared less frequently (n=3, 5.66%) after treatment compared to patients who underwent surgery (n=67 (55.83%), 19 had rebleeding (28.35%)) (p=0.001). In 69.17% patients (n=83) esophageal varices eradication was achieved: in 53.01% (n=44) patients from the primary prophylaxis group and 46.99% (n=39) from the secondary prophylaxis group. Bleeding episodes occurred less frequently after the eradication achievement (p<0.001). The primary prophylaxis led to varices eradication more often than secondary (p=0.003). The varices recurrence episodes rates after the eradication achievement were not different between groups (p=0.51). Conclusions. Primary prophylaxis can reduce the bleeding risk in extrahepatic portal vein obstruction with high risk of variceal bleeding. The prophylaxis by endoscopic variceal banding is an important bridge in the treatment for pediatric patients with portal hypertension that along with portosystemic shunting could potentially improve prophylactic treatment results. The Committee on Clinical Investigation of Bogomolets National Medical University approved this study (Protocol No.141, 27.01.2021). All the studies were conducted according to implemented guidelines in consideration of GCP-ICH and Declaration of Helsinki. The written informed consent of all participants’ parents/guardians was achieved. No conflict of interests was declared by the authors.

Endoscopic Therapy of Gastric Varices: Safety and Efficacy of N-Butyl-2-Cyanoacrylate Injection.

Background Upper gastrointestinal bleeding (UGIB) is a common medical emergency that results in significant morbidity, mortality, and socioeconomic burden. Both types of cardio-fundal varices, gastro-esophageal varix 2 (GOV2) and isolated gastric varices type 1 (IGV1), can cause massive bleeding and often are difficult to treat compared to the other types of gastric varices. Endoscopic variceal band ligation (EVBL) is a less effective treatment modality for gastric varices than esophageal varices and is associated with high re-bleeding rates. N-butyl-2-cyanoacrylate (Histoacryl) injection is an effective and potential treatment option for fundal varices. This study aims to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate injection therapy in cardio-fundal varices. Objective To assess the efficacy and safety of n-butyl-2-cyanoacrylate injection therapy for fundal varices. Methods This retrospective observational cohort study was conducted at the Department of Gastroenterology, Allied Teaching Hospital, Gujranwala, over one year. All patients, irrespective of age and gender, presenting with UGIB and in whom fundal varices were diagnosed on gastroscopy followed by n-butyl 2-cyanoacrylate injection therapy were included in this study. The efficacy and safety of Histoacryl therapy were assessed by analyzing successful hemostasis, frequency of re-bleeding, obliteration, and regression of fundal varices on repeat endoscopy. Adverse events such as re-bleeding and mortality related to fundal variceal treatment were documented. Results A total of 60 patients were included in the study. Of these, 70% had IGV1, while the remaining 30% had GOV2. Hemostasis was achieved in 100% of patients following n-butyl-2-cyanoacrylate injection. Successful obliteration with regression of varices was observed in 91.3% of patients. Various adverse events were observed, with abdominal pain being the most common observed complication in 18.3% of participants. However, only 8.3% of participants developed re-bleeding due to ulcer formation at the injection site, and no death occurred directly due to fundal variceal treatment. Conclusion N-butyl-2-cyanoacrylate injection therapy is a lifesaving, effective, and safe intervention for controlling bleeding from cardio-fundal varices, leading to improved health status and a consequent decrease in episodes of recurrent bleeding. Its side effects are few and infrequent. However, larger-scale studies are needed to further evaluate the safety and effectiveness of n-butyl-2-cyanoacrylate injection therapy. These studies will be crucial in establishing comprehensive guidelines for the management of fundal varices.

Usefulness of antegrade foam sclerotherapy for portal hypertensive variceal bleeding.

This study investigates the usefulness of antegrade variceal embolization using sclerosant foam to evaluate technical success and clinical outcomes in cases of hypertensive variceal bleeding. A total of 16 patients underwent percutaneous antegrade variceal embolization using foam sclerotherapy from August 2019 to January 2022. Among the patients, 12 cases were of gastroesophageal varices, two were rectal varices, and one case each was duodenal and jejunal varices, respectively. Sodium tetradecyl sulfate (STS) foam was used as a detergent for variceal bleeding sclerotherapy at various anatomical locations. The detergent was used in a foam form to promote clinical outcomes and enable the effective embolization of the entire blood vessel wall, including the ventral side, against gravity. Furthermore, STS foam could be used to help sufficiently deliver the drug to distal segments. A balloon catheter was also used to block the antegrade flow and prevent the dilution of the sclerosant. Technical success was defined as the completion of sclerotherapy for variceal bleeding as planned before the procedure to achieve the disappearance of variceal bleeding. Clinical success was defined as the complete obliteration of varices without recurrent bleeding during the follow-up period after the procedure. Technical success was 81.3%, and clinical success was 84.6%. Additionally, 15/16 of the procedures were emergencies, and there were no complications related to the procedure. Antegrade foam sclerotherapy using 3% STS for variceal bleeding is clinically safe and effective. Moreover, antegrade foam sclerotherapy can be a useful treatment option for patients with active variceal bleeding in emergency cases.

Endoscopic variceal ligation in primary and secondary prevention of variceal bleeding: a retrospective study in Digestive Endoscopy Unit, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar

IntroductionEndoscopic variceal ligation (EVL) is a crucial procedure for the primary and secondary prevention of variceal bleeding. The objective of this study was to evaluate the efficacy and tolerability of EVL in the prevention of variceal bleeding.MethodsThis was a retrospective, single-center study over 8 years, from January 2013 to December 2020, including all patients who came for EVL in primary or secondary prevention.ResultsFifty-seven patients (male/female: 39/18) were included. The mean age of the patients was 40.02 ± 12.32 years (range: 19–68). Portal hypertension was secondary to cirrhosis in 13 patients (22.8%) and to a non-cirrhotic cause in 44 patients (77.2%). EVL was indicated for primary and secondary prevention in 5.3% and 94.7%, respectively. All patients had received propranolol with a mean daily dose of 108.07 ± 38.52 mg (extremes: 80–160). Eradication of varices was achieved in 33 patients (57.9%) with an average of 3.06 ± 0.70 sessions (extremes: 1–5) and an average duration of 10.12 ± 6.21 months (extremes: 1–24). Ten patients (17.5%) had variceal bleeding, and one patient (1.8%) died. There was no significant difference between patients with cirrhotic and non-cirrhotic portal hypertension in terms of varices eradication, variceal bleeding, and mortality. Gender (HR: 37.18; CI: 0.14–18.4; p = 0.009) and the number of previous bleeds (HR: 1.34; CI: 1.01–1.80; p = 0.041) were independent predictors of variceal bleeding during EVL. Dysphagia (73.7%) and retrosternal pain (78.9%) were the main adverse events after ligation.ConclusionEVL is an efficient technique to eradicate varices. Its tolerance is good with post-ligation signs that are rapidly regressive.

Balloon-occluded Esophageal Varices Obliteration Versus Ligation for the Management of F2 Esophageal Varices: A Randomized Controlled Trial.

To compare balloon-occluded esophageal varices obliteration (BEVO) with esophageal variceal ligation (EVL) in the management of cirrhotic patients with type F2 esophageal varices (F2-EVs). A total of 157 patients with F2-EVs were randomly assigned to either BEVO (n=79) or EVL (n=78) group in the prospective study between July 2021 and December 2021. Primary outcomes included recurrence and eradication rates. Secondary outcomes included rebleeding rate, and procedural complications. The recurrence rate of EVs was notably lower in the BEVO group than in the EVL group (3.80% vs. 21.79%; P =0.001). The rate of complete eradication in the BEVO group was significantly higher than that of the EVL group (96.20% vs. 74.36%; P <0.001). The incidence of rebleeding in the BEVO group was markedly lower than that of the EVL group (7.59% vs. 20.51%; P =0.02). There was a higher incidence of transient dysphagia in the EVL group than in the BEVO group (10.26% vs. 1.27%; P =0.015). BEVO exerted an effective treatment option for F2-EVs.

Influence of COVID-19 on Patients with Esophageal Varices under Prophylactic Endoscopic Band Ligation Therapy

Background and Objectives: Endoscopic band ligation (EBL) plays a critical role in patients with clinically significant portal hypertension, as variceal eradication (VE) is essential to prevent further variceal upper gastrointestinal bleeding (GI). The emergence of COVID-19 has led to a dramatic reduction in endoscopic activity. Our study aimed to evaluate the effect of COVID-19 on VE, GI, and 6-month mortality of patients treated with prophylactic EBL therapy. In addition, our goal was to identify the risk factors for our proposed outcomes. Methods: A single-center retrospective cohort study included patients with esophageal varices treated with prophylactic EBL therapy between 2017 and 2021. To demonstrate the impact of COVID-19 on two independent groups on prophylactic EBL therapy with 1 year of follow-up, March 2019 was selected as the cut-off date. Clinical, laboratory, and endoscopic data were recovered from electronic reports. Results: Ninety-seven patients underwent 398 prophylactic EBL sessions, 75 men (77.3%) with mean age 59 ± 12 years. Most achieved VE (60.8%), 14.4% had GI bleeding post-therapy, and 15.5% died at 6 months. The rate of variceal obliteration was significantly lower in the pandemic group (40.9% vs. 77.4% in the pre-pandemic group, p = 0.001). Mean number of EBL sessions and pandemic group were independently associated with incomplete VE, while MELD-Na, portal vein thrombosis and failed VE were identified as risk factors associated with mortality at 6 months. Conclusions: Almost 60% of patients in the pandemic group failed to eradicate esophageal varices. Failure to achieve this result conferred a higher risk of GI bleeding and death at 6 months, the latter also significantly associated with the MELD-Na score and portal vein thrombosis. Our study is among the first to demonstrate the impact of COVID-19 in patients receiving prophylactic EBL therapy.

Gastro‑oesophageal reflux disease in liver cirrhosis: Possible pathogenesis and clinical intervention (Review).

Oesophageal variceal bleeding is a common complication of decompensated liver cirrhosis (LC). Some studies have reported that reflux oesophagitis (RE) is a risk factor for upper gastrointestinal bleeding, and greatly impacts the quality of life. However, the frequency and mechanism of gastro-oesophageal reflux disease (GERD) in LC remain unclear. The present review explored the possible pathogenesis, and analysed the advantages and disadvantages of the interventional measures and the need for implementation of these measures. By combining the comprehensive terms associated with LC, GERD and RE, EMBASE, Medline/PubMed and the Cochrane Library were systematically searched. The underlying pathological mechanism of GERD in LC was summarized: Transient relaxation of the lower oesophageal sphincter, delayed gastric emptying, increased intra-abdominal pressure, increased intragastric pressure and excessive nitric oxide production destroyed the 'anti-reflux barrier', causing gastric content reflux. Proton pump inhibitors (PPIs) have been widely used empirically to lower the risk of oesophageal venous rupture and bleeding. However, long-term use of acid inhibitors in patients with LC may induce complications, such as spontaneous bacterial peritonitis. The metabolic half-life of PPIs is prolonged in patients with severe liver function impairment. Therefore, the indications for using acid inhibitors lack clarity. However, after endoscopic oesophageal variceal eradication, additional benefits may be gained from the long-term use of PPIs in small doses.

Addressing Portal Hypertension: Exploring the Crucial Role of Partial Splenic Embolization in Critical Situations

Background: Esophageal varices are one of the most common symptoms of direct outcomes of portal hypertension besides ascites, hepatorenal syndrome, and hypersplenism. Nonselective beta-blockers or band ligation are currently the effective primary preventive options for variceal hemorrhage. The use of partial splenic arterial embolization for the management of variceal hemorrhage in patients with portal hypertension has been described in a small number of reports. Case Report: A girl, 6 y.o., was hospitalized with hematemesis with hypovolemic shock. Laboratory findings show anemia and thrombocytopenia. Radiology and endoscopy show grade III esophageal varices with hepatosplenomegaly. Because of the high risk of morbidity in surgical procedures, partial splenic embolization was performed to treat portal hypertension. Discussion: The combination of varices and a low platelet count puts these patients at high risk for catastrophic hemorrhage. Partial splenic embolization reduces splenic blood volume, resulting in a decrease in venous drainage and a reduction in portal venous flow and pressure. Conclusion: The use of partial splenic arterial embolization to manage variceal hemorrhage in patients with portal hypertension has been described. Embolization can be used alone or in combination with other therapies, like endoscopic ligation or retrograde transvenous variceal obliteration, to treat a variety of conditions. Keywords: Embolization, esophageal varices, splenomegaly, portal hypertension

Successful Treatment of Intractable Rectal Varices with Gelfoam Slurry Embolisation and Coiling.

Rectal varices are an infrequent outcome of portal hypertension formed by portocaval anastomosis between the superior rectal vein with the inferior mesenteric vein of the portal system upstream, and the middle and inferior rectal vein draining into the internal iliac and internal pudendal vein of the systemic circulation, respectively. Portal system variations are extremely rare.Most common modality of recurrent rectal varices bleed is a transhepatic intrajugular portosystemic shunt. The absolute contraindications to this include congestive heart failure among others.In the presence of multiple co-morbidities and contraindication for TIPS, various interventional radiological modalities on a case-by-case basis are available including percutaneous transhepatic rectal varices obliteration.

Portosystemic Shunt Surgery for Extrahepatic Portal Venous Obstruction Beyond Endoscopic Variceal Eradication: Two Decades of Pediatric Surgical Experience

This exclusively surgical series on pediatric extrahepatic portal venous obstruction (EHPVO) defines surgical indications beyond endoscopic eradication of esophageal varices (EEEV), the selection of an appropriate surgical procedure, and the long-term post-surgical outcome. EHPVO management protocol at the reporting institute has been endotherapy untilesophageal variceal eradication and surgery for select adverse sequelae manifesting after EEEV. One hundred and thirty-nine EHPVO cases underwent surgery for the following indications in combination: i) massive splenomegaly with severe hypersplenism (n=132, 95%); ii) growth retardation (GR, n=95, 68%); iii) isolated gastric (IGV) and ectopic varices (n=49, 35%); iv) Portal cavernoma cholangiopathy (PCC) (n=07, 5%). A portosystemic shunt (PSS) was performed in 119 (86%) cases. Types of PSS performed were as follows: central end-to-side splenorenal shunt with splenectomy (n=104); side-to-side splenorenal shunt (n=4); mesocaval shunt (n=1); inferior mesenteric vein (IMV) to left renal vein shunt (n=2); IMV to inferior vena cava shunt (n=3); H-graft interposition splenorenal shunt (n=1); spleno-adrenal shunt (n=3); makeshift shunt (n=1). Esophagogastric devascularization (n=20, 14%) was opted for only for non-shuntable anatomy. At a median follow-up (FU) of 41 (range: 6-228) months, PSS block was detected in 13 (11%) cases, with recurrent variceal bleeding in 4 cases. PCC-related cholestasis regressed in 5 of 7 cases. Issues of splenomegaly were resolved, and growth z-scores improved significantly. Endotherapy for secondary prophylaxis untilEEEV has resulted in a shift in surgical indications for EHPVO. Beyond EEEV, surgery was indicated predominantly for non-variceal sequelae, namely massive splenomegaly with severe hypersplenism, GR, and PCC. Varices warranted surgery infrequently butmore often from sites less amenable to endotherapy, i.e., IGV and ectopic varices. The selection of PSS was tailored to anatomy and surgical indications. On long-term FU post surgery, PSS block was detected in 13% of patients. PCC-related cholestasis regressed in 71%, and issues of splenomegaly resolved with significantly improved growth Z scores.