The Choice of Surgical Management in Patients with Portal Hypertension

Aim. To improve the results of surgical treatment of patients with syndrome of portal hypertension. Material and Methods. One hundred and sixty nine patients with syndrome of portal hypertension who underwent elective surgery were examined. 100 patients had liver cirrhosis and 69 patients – extrahepatic portal vein obstruction. Portocaval shunting was scheduled for all patients. Selective portocaval shunting was preferred in cirrhotic patients;
maximal shunting using “side to side” or “H-type” mesentericocaval or splenorenal anastomoses was chosen for those who had extrahepatic portal vein obstruction. Results. Selective portocaval shunting was performed in 26 of 100 patients with liver cirrhosis. Seventy six patients underwent gastrotomy with direct oesophagogastric varices ligation. In case of extrahepatic portal vein obstruction portocaval shunting was applied in 69 patients and direct oesophagogastric varices ligation – in 26 patients. Shunt
surgery was rejected due to high activity of the pathological process in liver, presence of hepatic encephalopathy, heart failure; and also according to ultrasonography and computed tomography of portal system. Satisfactory short-term results were obtained in 97% of patients. Overall mortality was 0,8%. Conclusion. Phased preoperative examination protocol should be applied for the optimization of surgical management in patients with portal hypertension: patients’ selection based on clinical and laboratory data, assessment of central hemodynamics and neurological status. It is necessary to determine hemodynamic and topographic features using ultrasonography and 3D computed tomography of portal and caval systems to forecast the ability to perform different types of portocaval shunting; to define type and extent of surgical intervention depending on intraoperative data

1. Eramishantsev A.K. Pervichnaja vnepechenochnaja portal'naja gipertenzija i ee khirurgicheskoe lechenie [Primary extrahepatic portal hypertension and its surgical treatment: diss. ... doc. of med. sci.]. Moscow, 1983. 325 p. (In Russian)

2. Lebezev V.M. Portokaval'noe shuntirovanie u bol'nyh s portal'noj gipertenziej [Portocaval shunting in patients with portal hypertension: diss. ... doct. med. sci.]. Moscow, 1994. 213 p. (In Russian)

3. Schertsinger A.G. Patogenez, diagnostika, profilaktika, lechenie krovotechenij iz varikoznyh ven pishhevoda i zheludka u bol'nyh s portal'noj gipertenziej [Pathogenesis, diagnosis, prevention and treatment of bleeding from esophageal and gastricvaricose veins in patients with portal hypertension: diss. ... doct. med. sci.]. Moscow, 1986. 310 p. (In Russian)

4. Luqman Z., Khan M.R., Alam M., Atiq M., Sophie Z. An analysis of surgical shunts for the management of portal hypertension at Aga Khan University Hospital. J. Ayub. Med. Coll. Abbottabad. 2004; 16 (4): 70–74.

5. Wolff M., Hirner A. Surgical treatment of portal hypertension. Zentralbl. Chir. 2005; 130 (3): 238–245.

6. Zhang Z.T. On Surgical manangment of portal hypertension due to liver cirrhosis at era evidence – based medicine. Cgin. J. Hepatobiliary Surg. (Chin). 2008; 14: 77–78.

7. Bokhyan T.S. Parcial'nye portokaval'nye anastomozy u bol'nyh s cirrozom pecheni i portal'noj gipertenziej [Partial portacaval anastomoses in patients with liver cirrhosis and portal hypertension: diss. ... doct. med. sci.]. Moscow, 2000. 202 p. (In Russian)

8. Kamalov Yu.R. Abdominal'noe ul'trazvukovoe issledovanie pri sindrome portal'noj gipertenzii: Metodicheskoe posobie [Abdominal ultrasound in case of portal hypertension: a textbook]. Moscow, 2004. 48 p. (In Russian)

9. Shipov O.Yu. Diagnostika portal'noj gipertenzii pri ul'trazvukovoj angiografii pecheni [Diagnosis of portal hypertension during ultrasonic angiography of the liver: diss. ... cand. med. sci.]. Moscow, 2002. 110 p. (In Russian)

10. Aydin U., Yazici P., Kilic M. Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for splenorenal shunt. BMC Surg. 2007; 7: 7.

11. Brancatelli G., Baron R.L., Feaerle M.P., Sparacia G., Pealer K. Focal confluent fibrosis in cirrhotic liver natural history studied with serial CT. Am. J. Rentgenol. 2009; 192 (5): 1341–1347. doi: 10.2214/AJR.07.2782.

12. de Franchis R. Non invasive (and minimally invasive) diagnosis of oesophagel varices. J. Hepatol. 2008; 49 (4): 520–527. doi: 10.1016/j.jhep.2008.07.009.

13. Li F.H., Hao J., Xia J.K., Li H.L., Fang H. Hemodynamic analysus of esophageal varices in patients with liver cirrhosis using color doppler ultrasound. World J. Gastroenterol. 2005; 11 (29): 4560–4565.

14. Moubarak E., Bouvier A., Boursier J., Lebigot J., Ridereau-Zins C., Thouveny F., Willoteaux S., Aube C. Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review. Abdom. Imaging. 2012; 37 (5): 746–766.

15. Robinson K.A., Middelton W.D., Al-Sukaiti R., Teefey S.A., Dahiya N. Doppler sonography of portal hupertension. Ultrasound Q. 2009; 25 (1): 3–13. doi: 10.1097/RUQ.0b013e31819c8685.

16. Sgouros S.N., Vasiliadis K.V., Pereira S.P. Systematic review: endoscopic and imaging-based techniques in the assessment of portal haemodynamics and the risk of variceal bleeding. Aliment. Pharmacol. Ther. 2009; 30 (10): 965–976. doi: 10.1111/j.1365-2036.2009.04135.x.