During the second half of the 20th century, one of the most interesting and thriving fields in surgery was the treatment of portal hypertension. Shunt surgeries are designed to redirect the flow of blood or abdominal fluid through other areas of the body. Such patients are most commonly treated with ss pcsmesocaval shunts mcs, cavoatrial shunt cas, and mesoatrial shunts mas. A great number of surgical techniques were developed shunts and devascularization procedures, with many publications supporting or rejecting their applications. A critical appraisal of shunt procedures with emphasis on distal splenorenal shunt in children nitin sharma 1, minu bajpai 1, arbinder kumar 1, shashi paul 2, manisha jana 3 1 department of pediatric surgery, all india institute of medical sciences, new delhi, india 2 department of pediatrics, all india institute of medical sciences, new delhi, india 3 department of. Portalsystemic shunts in the treatment of portal hypertension. Choices for the treatment of variceal bleeding include surgical shunts and endoscopic sclerotherapy.
Selective surgical shunts for treating complications of. All anomalous portocaval connections were assessed for anatomical pattern. Surgical management of noncirrhotic portal hypertension. From the department of general surgery, the cleveland clinic foundation and the cleveland clinic educational foundation, cleveland, ohio department of general surgery, the cleveland clinic foundation.
Shunt operations for portal hypertension sciencedirect. Transjugular intrahepatic portosystemic shunts tips. Hemorrhage from esophageal varices is the most common cause of death from portal hypertension. Surgical treatment for portal hypertension mercado. The rex shunt procedure for portal hypertension portal. Outcomes after surgery for ncph shunt surgery effectively prevents rebleeding from esophageal varices and also improves portal gastropathy, portal biliopathy, and growth retardation.
The results of prospective clinical trials of the effect of portacaval shunt surgery on survival of cirrhotic patients with portal hypertension created a dilemma for vascular surgeons interested in portal circulation. The rex shunt procedure for portal hypertension the rex shunt procedure is a relatively new treatment procedure for portal hypertension that has been performed on children with positive results. The backup of pressure also causes the spleen to become enlarged. As such, after a brief learning curve in interventional radiology, we initiated a prospective randomized trial comparing the operatively placed, smalldiameter ie, 8 mm prosthetic hgpcs to the radiologically placed tips shunt in the management of complicated portal hypertension. Radiologists should be familiar with this entity, understand the surgical procedure, and recognize the pre and postoperative imaging features. In eight other patients multiple procedures were necessary table 1. Shunting procedure, dsrs, was suggested to be useful for the management of esophagogastricvarices in patients with iph 61. Prioritized based on meld score hospital mortality surgery of the liver, biliary tract and pancreas. Surgical shunts provide better control of rebleeding when compared to the combination therapy of beta. See commentary portal hypertensionthe surgical pendulum. Noncirrhotic portal hypertension ncph is a heterogeneous group of. As early as the 17th century, the association was made between gastrointestinal bleeding and perturbations in portal circulation. Experience with the rex shunt mesentericoleft portal bypass in children with extrahepatic portal hypertension.
To compare the effectiveness of surgical procedures selective or nonselective shunt, devascularization, and combined shunt and. Portal hypertension is a term used to describe elevated pressures in the portal venous system a major vein that leads to the liver. Shunt operations are classified as total, partial, or selective shunts based on their. The aim of this study was to compare the efficacy of surgical shunts and endoscopic sclerotherapy in treating variceal bleeding due to portal.
Second, it includes adult patients in an area that has been almost exclusively the domain of pediatric surgery. A total of 79 venous shunt operations were per formed. After the distal splenorenal shunt surgery is performed. Shunt surgery is considered to be the treatment of choice in patients with noncirrhotic portal hypertension. Patients with refractory hemorrhage frequently are referred for immediate surgical intervention usually emergency portacaval shunt. Abstractportalsystemic shunts are now recognized by most physicians as the most effective means of relieving portal hypertension complicated by bleeding esophageal varices or by medically resistant ascites. Aim portal hypertension is a common complication of chronic liver disease and can cause variceal bleeding which is associated with high mortality. Portosystemic shunt surgery in patients with idiopathic noncirrhotic portal hypertension. Transjugular intrahepatic portosystemic stent shunt in the management of portal hypertension dhiraj tripathi,1,2,3 adrian j stanley,4 peter c hayes,5 simon travis, 6 matthew j armstrong,1,2,3 emmanuel a tsochatzis,7 ian a rowe,8 nicholas roslund,9 hamish ireland,10 mandy lomax,11 joanne a. Portal hypertension suny downstate department of surgery.
They are done only in medical centers where the surgeon is experienced in doing the procedures. The rex shunt restores hepatopetal portal perfusion and is considered curative for portal hypertension in children with extrahepatic portal venous obstruction. The first patient presented with bleeding ev at 3 months postoperatively, which further progressed the patients portal hypertension following limited proportional portosystemic shunt. If you are experiencing this condition and are still maintaining good liver function, you may be a candidate for portal hypertension surgery where surgeons use a shunt to help relieve the pressure within the blood vessels. Portal decompression is indicated in patients who have portal hypertension complicated by gastrointestinal hemorrhage from esophageal varices that are not effectively controlled with sclerotherapy injections. Evaluation of venous shunt surgery in portal hypertension. These guidelines on transjugular intrahepatic portosystemic stent shunt tipss in the management of portal hypertension have been commissioned by the clinical services and standards committee cssc of the british society of gastroenterology bsg under the auspices of the liver section of the bsg.
Portal hypertension surgery jefferson university hospitals. Who have relatively good liver function and serious complications of portal hypertension, especially recurrent variceal bleeding. There is little data on the effect of sidetoside lienorenal sslr shunt on oesophageal variceal size, splenic size and splenic pulp pressure spp in. Shunts are rarely used because of the complications they may cause. Bambini da, superina r, almond ps, whitington pf, alonso e. Surgical shunts compared with endoscopic sclerotherapy for. Tobias portosystemic shunts university of illinois. Surgical management in portal hypertension international archives. Vidal performed the first portocaval shunt in man 26, and portal systemic shunts were reintroduced by whipple in 1945 27. Onethird of all patients 412 underwent a mesoportal bypass procedure rex shunt, while 58% 712 were managed with a distal splenorenal.
Portal hypertension, congestive splenomegaly, and portacaval shunt. The surgical treatment of portal hypertension has depended primarily on the use of portacaval or splenorenal shunts. Some procedures completely interrupt portal venous flow to the liver endtoside portacaval shunt. First, it draws attention to the benefits of the mesoportal bypass as a means of ameliorating the symptoms of portal hypertension in patients with portal vein thrombosis. Portosystemic shunts and portal hypertension the most frequently used experimental models for portal microsurgery are those achieved through portal systemic shunts. Your doctor will recommend it if you have severe liver problems. Portal hypertension is maintained in the splanchnic and portal venous system, and the shunt maintains portal flow to the liver. Portal hypertension may be caused by intrinsic liver disease, obstruction, or structural changes that result in increased portal venous flow or increased hepatic resistance. Varices develop across the esophagus and stomach from the pressure in the portal vein. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The term portal systemic shunt includes all types of surgical venovenous anastomoses that divert portal venous blood into the systemic circulation. Surgical management in portal hypertension intechopen. Portal hypertension surgical treatment ncbi bookshelf. Portal hypertension remains one of the most serious sequelae of chronic liver disease.
To shunt or not to prophylactically shunt is no longer the question. Portal hypertension boyoung song, md suny downstate. If suture ligation is used, the degree of vessel constriction is based on portal pressure. Who have relatively good liver function and serious complications of portal hypertension. Portal hypertension before the distal splenorenal shunt surgery is performed.
Portacaval shunts may lower blood pressure in the portal vein by diverting the flow of blood from the portal vein to the large vein that returns blood to the heart vena cava. Retrospective evaluation of all ct examinations of patients having portosystemic shunt pss was performed in a 4year time period. Pdf bleeding esophageal varices as a complication of portal hypertension is the most common cause of upper gastrointestinal haemorrhage in egypt, and. All included patients had portal obstruction due to any cause, resulting in increased blood flow and symptoms of portal hypertension. Treatment for portal hypertension pht has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Current role of surgery in portal hypertension ncbi. This type of shunt provides the best longterm maintenance of some portal flow and liver function, with a lower incidence of encephalopathy 1015% compared with total shunts. Options for treatment of intrahepatic shunts include surgical ligation of the hepatic vein.
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