Portal Hypertension - SUNY Downstate Medical Center · PMHx: Cirrhosis secondary to alcohol abuse, ascites, encephalopathy, esophageal varices s/p banding x 2 and sclerotherapy, HTN,

Portal Hypertension

Boyoung Song, MD SUNY Downstate

Department of Surgery

www.downstatesurgery.org

Case Presentation HPI: 57 year old male presented with several episodes of bright red blood per rectum and dizziness. No nausea, vomiting, hematemesis, abdominal pain. PMHx: Cirrhosis secondary to alcohol abuse, ascites, encephalopathy, esophageal varices s/p banding x 2 and sclerotherapy, HTN, CHF, 9 prior admissions to KCHC for melena and hematemesis (Child-Pugh Class C)


Case Presentation

PSHx: bilateral inguinal hernia repair (2007), exploratory laparotomy and repair of sigmoid perforation(2009) Meds: Propranolol, spironolactone, lactulose, lasix Social Hx: 1-2 pints of Vodka per day x 40 years (last use – one day prior to admission), no tobacco, no drugs Allergy: None


Case Presentation Vital Signs: 97.4 80/60 mmHg 96 bpm 97% Alert and Oriented, NAD S1 S2 RRR Chest clear bilaterally Soft distended abdomen with ascites, non-tender, + fluid wave, + caput medusa Bright red blood from the rectum, + thrombosed external and internal hemorrhoids, no active bleeding


Case Presentation

Laboratory Studies MELD Score: 19 [3.8 x log (e) (bilirubin mg/dL) + 11.2 x log (e) (INR) + 9.6 log (e) (creatinine

mg/dL)]


Case Presentation

ED Course: • Resuscitation with crystalloid and 3 units of packed RBCs via central line. • PPI and octreotide drips started immediately. • Intubated prior to EGD for airway protection. • EGD done revealing no evidence of recent bleed in upper GI tract. • Patient began to bleed per rectum profusely and became hypotensive.


Case Presentation

Interventional Radiology consulted and 7 pRBCs and 2FFP given. Further rectal exam revealed active bleeding from rectal varices which were suture ligated and temporized. Patient transferred to OR for exam under anesthesia


Case Presentation

OR: Exam under anesthesia in lithotomy position. Friable rectal mucosa with multiple bleeding varices which were clamped and suture ligated. Rectum packed and patient transferred to SICU. 4 pRBC transfused during OR; Vasopressin given for hypotension


Case Presentation SICU Course: HOD#1: Started on pressors. Additional RBC, FFP, platelets and cryoprecipitate given for DIC. MELD score: 24

HOD#2: Multi-organ failure, palliative care discussed MELD score: 26

HOD#3: Pt expires MELD score: 31


Questions?


Portal Hypertension

• Portal venous pressure >10 mmHg • Develops with increase in hepatic

vasculature resistance • Stimulation of vasodilators • Increase of portal blood flow due to excessive

release of endogenous vasodilators • Hyperdynamic state with increased cardiac

output and collateral formation.


Causes of Portal Hypertension

90% in USA and Europe

Most common cause worldwide


Complications • Variceal bleeding • Ascites • Encephalopathy • Portal gastropathy


Evaluation

• Assess liver disease Clinical and laboratory findings (Child-Pugh score and

MELD score)

• Assess portal circulation

• Assess presence of varices Mortality rate for each episode of hemorrhage = 50% Likelihood of recurrent bleeding without intervention = 75%


Non-Surgical Management of Portal Hypertension


Surgical Management of Portal Hypertension


Total Shunts

• Divert 100% of portal flow to vena cava • Effective ~95% for hemorrhage • 40-50% incidence of hepatic encephalopathy • No role as prophylactic procedure due to

poorer survival rate in shunted patients vs medically managed patients


Total Shunts

End-to-side portacaval shunt

Portal vein transected and anastomosed to the IVC.

Decompresses splanchnic system and controls bleeding effectively

No relief in ascites


Total Shunts

Side-to-side portocaval shunt

Hepatofugal portal flow effectively decompressing splanchnic system and obstructed sinusoids

Control BOTH variceal bleeding and ascites


Total Shunts

Mesocaval Shunt


Partial Shunts

• Partial decompression of the portal vein to a pressure less than the critical threshold for variceal hemorrhage

• 8mm shunts maintains hepatopedal blood flow and prevents encephalopathy


Selective Shunts Distal Splenorenal Shunt Splenic vein divided and

anastomosed to left renal vein.

Selectively decompresses gastric and splenic circulation

Control hemorrhage ~85% Encephalopathy <10% No survival benefit for

alcoholic patients


Devascularization Procedures

Hassab Procedure (1967)

Gastroesophageal decongestion and splenctomy

Low rebleed rate reported with use of endoscopic sclerotherapy (3.1% within 2 years)


Devascularization Procedure Sugiura and Futagawa

(1973) Thoracoabdominal

procedure for complete devascularization of thoracic esophagus and stomach with esophageal transection

Include splenectomy, vagotomy and pyloroplasty


Devascularization Procedure

Modified Sugiura Procedure Entirely abdominal

approach with re-anastomosis of the esophagus

Data regarding rebleeding is variable.

<10% from original surgeons

~30% from Europe and US


Treatment of Ascites Recirculate ascites into vascular compartment. Associated with congestive heart failure, consumptive coagulopathy, infection, venous thrombosis, occlusion.

No survival benefit of using shunt over medical therapy. May improve quality of life if patient has intractable ascites.


Liver Transplant

Goal is to restore hepatic function. For patients with end stage liver disease; not

necessarily for patients with manifestations of portal hypertension. Prioritized based on MELD score Hospital mortality <10% 80% 1-year survival 60-65% 5-year survival


Shunt or TIPS?

66 subjects undergoing TIPS vs 66 subject undergoing small diameter H-graft portacaval shunt.

Results revealed significant survival benefit in Child class A and B patients who underwent portacaval shunt. (A: 91 vs 19 months; B: 63 vs 21 months)

Survival was longer after TIPS for Child class C patients (45 vs 22 months)


Conclusions

• Manifestations of portal hypertension can be life threatening

• Careful surgical and non-surgical planning for management is essential based on patient’s functional status as well as hepatic reserve

• Surgical expertise is crucial for procedures for controlling complications of portal hypertension


References • Henderson MJ. Chapter 31. Portal Hypertension. In: Ashley SW, Zinner

MJ, eds. Maingot's Abdominal Operations. 11th ed. New York: McGraw-Hill; 2007

• Rosemurgy AS, et al: Prosthetic H-Graft Portacaval Shunts vs Transjugular Intrahepatic Portasystemic Stent Shunts: 18 year Follow up of a Randomized Trial. J of American College of Surgeon , 2012, 214:445-455

• Collins JC, Sarfeg IJ: Surgical Management of Portal Hypertension. West J Med 1995, 162:527-535

• Hsieh CB, Hsu KF. Chapter 75C. Esophageal Varices: Operative Devascularization and Splenectomy. In: Blumgart LH, Jarnagin WR. Surgery of the Liver, Biliary Tract and Pancreas. 5th ed. 2011

• Knechtle SJ, Galloway JR. Chapter 76A. Location of portosystemic Shunting. In: Blumgart LH, Jarnagin WR. Surgery of the Liver, Biliary Tract and Pancreas. 5th ed. 2011


QUESTIONS?


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Portal Hypertension - SUNY Downstate Medical Center · PMHx: Cirrhosis secondary to alcohol abuse, ascites, encephalopathy, esophageal varices s/p banding x 2 and sclerotherapy, HTN,