Devascularization in portal hypertension.dr quiyum

role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice

1. Role of devascularization in management of portal hypertension Presented by Dr Quiyum Phase B Hepatobiliary,pancreatic and liver Transplant surgery

2. Introduction Gastroesophageal varices are major source of morbidity and mortality among patients with portal hypertension. The reported 6-week mortality following each episode of variceal bleeding remains in the range of 15-20%.

3. Devascularization being a variceal-directed ablative surgery aims at obliteration of varices or disconnection of the esophagogastric veins from the hypertensive portal tributaries. The goal of the esophagogastric devascularization is to disconnect the esophagus and stomach from this collateral system while maintaining a portosystemic shunt in place via the adventitial plexus surrounding the esophagus

4. Relevant anatomy portal hypertension develops<<diversion of portal venous blood away << join the low-pressure systemic circulation via collateral pathways— natural portosystemic shunts (esophagogastric region is the main site of shunting.) The coronary vein and gastric veins are connected with the superior vena cava by collateral channels in the submucosa of the esophagus(mainly) between the two muscular layers, and in the periesophageal area (adventitial plexus). increased blood flow and resistance in the muscularis layer << increase in venous pressure<<formation of dilated and tortuous varices. in the esophageal wall , The intrinsic veins include the submucosal, subepithelial, and the intraepithelial veins the extrinsic vein - Periesophageal veins .

5. In portal hypertension, the increased venous pressure can produce varices throughout the length of the esophagus and down into the upper stomach; however, the bleeding from esophageal varices usually occurs in the lowest 5 cm of the esophagus. In the stomach, although varices are seen more often on the lesser curve, it is the less common fundal varices that are more dangerous and likely to lead to exsanguinating hemorrhage ( Mathur et al, 1990 ). Therefore a technique targeting this vulnerable area would help in controlling or preventing bleeding from esophageal varices. An ideal technique would be the permanent obliteration or interruption of varices in the lower periesophageal vessels and intraepithelial dilated vessels

6. Indication patients with underlying chronic liver disease 1. Acute VH when other method have failed 2.not candidates for transplantation and need varices-directed surgery or have symptomatic hypersplenism needing splenectomy, 3. bridge to liver transplantation when TIPPS unavailable. 4. a shunt is indicated but unshuntable vein in patients with extensive mesenteric venous thrombosis, including portal, splenic, and superior mesenteric vein thrombosis or an inadequate vein size to permit a shunt Not recommended if LT available, Not recommended in chronic or prophylactic setting

7. patients with healthy liver , extrahepatic portal vein obstruction (EHPVO) and noncirrhotic portal fibrosis (NCPF portal biliopathy in the absence of a shuntable vein ( Varma et al, 2014) and chronic pancreatitis with portal hypertension #good results in children with massive splenomegaly with hypersplenism secondary to EHPVO (Rao et al, 2004; Subhasis et al, 2007). Goyal and coworkers (2007 ##isolated splenectomy as a means of secondary prophylaxis for variceal bleeding has a 30% to 50% failure rate and hence is not advocated ( Coelho et al, 2014; Raia et al, 1984 ), except in the instance of left-sided portal hypertension.

8. contraindication CTP –C When LT indicated Prophylactic or chronic VH

9. Type of devascularization procedure HASSAB DEVASCULARIZATION PROCEDURE (1960-1970) SUGIURA AND FUTAGAWA DEVASCULARIZATION PROCEDURE(1970-1980) MODIFIED SUGIURA DEVASCULARIZATION PROCEDURE (later) Other modification Laparoscopic devascularization

10. Hassab’s procedure 1957 Dr. Mohammed Aboul-Fotouh Hassab , a professor of surgery at Alexandria University in Egypt. abdominal incision . Splenic artery ligation followed by splenectomy is performed. ligation of short gastric veins is followed by ligation of the vessels ascending through the hiatus and the diaphragm. The gastrohepatic ligament is incised, the left gastric vessel is divided between ligatures. abdominal esophagus is circumferentially dissected and looped with umbilical tape,ligation of vessels around the abdominal esophagus; this includes devascularization of 3 to 4 inches (7 to 10 cm) of lower esophagus and proximal stomach with sacrificing of vagus nerve and ligation of left gastric vessels The abdomen is closed after placement of a drain in the region. An important aspect of the Hassab procedure is the absence of esophageal transection and pyloroplasty

11. Result In Hassab’s series (1967), 174 patients operated during or after a bleed, with 39 patients operated under emergency conditions at the time of bleeding, and in 151 patients, devascularization was performed prophylactically (total 364 pt ) an in-hospital mortality of 9% for elective cases, an emergency setting, the mortality was 38.4% there was only one late rebleeding event during follow-up. varices disappeared completely or improved in 91% of patients. But the intramural connections, combination with sclerotherapy is necessary further.

12. literature modified gastroesophageal decongestion and splenectomy GEDS ( Hassab ) was performed on patients who need immediate surgical intervention for variceal bleeding. safe, simple and less time-consuming No esophageal transection was performed in this procedure; therefore no esophageal fistula, The rebleeding rate was 23%

13. Sugiura and fataura procedure transthoracic and an abdominal procedure performed through two separate incisions.( lt lateral thoracotomy and upper midline) The thoracic procedure involves extensive paraesophageal devascularization (30-50)up to the inferior pulmonary vein and esophageal transection. The abdominal procedure includes splenectomy, devascularization of the abdominal esophagus and cardia, and selective vagotomy and pyloroplasty

14. Sugiura and Futagawa (1973) reported the disappearance of varices ( 97%). The overall operative mortality was 4.6%, and postoperative hemorrhage occurred in two patients., patients who underwent the procedure, 203 (30%) had prophylactic, 363 (54%) had elective, and 105 (16%) had an emergency procedure. Portal hypertension etiology was cirrhotic in 495 cases, EHPVO in 39 cases, and from other causes in the remainder. Operative mortality was 4.9% overall, with 13.3% mortality in emergency cases and 3% in elective cases. In patients with cirrhosis, ChildPugh status–based mortality was 0% for 244 Child-Pugh class A patients, 2% for 251 class B patients, and 16% for 176 class C patients. Late deaths were due to hepatic failure and hepatocellular carcinoma and not due to variceal bleeding. the Sugiura procedure was believed to be technically complex and time consuming and was largely ignored or abandoned.

15. Modified Sugiura procedure Only abdominal approach with variations being inclusion or exclusion of esophageal transection splenectomy, vagal preservation, and anti reflux surgery The main vagal trunk is preserved; highly selective vagotomy is performed, and therefore no drainage procedure is necessary. Fundoplication is not performed. Esophageal transaction is performed by using an EEA stapler

16. When the esophagus is inflamed because of multiple sessions of sclerotherapy, especially in the acute setting, the stapling is done just below the gastroesophageal junction (Chaudhary & Aranya , 1991). Occasionally, fundic resection is needed for bleeding from large fundic varices the Sengstaken -Blakemore tube is used for temporary control of bleeding, we first perform the esophagogastric devascularization and splenic artery ligation without deflating the tube and later proceed to splenectomy Placement of a feeding jejunostomy in patients with esophageal transection or stapling permits early institution of enteral nutrition postoperatively. A gastrograffin swallow is done around the seventh postoperative day, after which oral alimentation is resumed.

17. Laparoscopic devascularization

18. the Hassab operation devascularizes only the extramural vessels ; intramural vessels are not treated. Only one study in the Chinese literature compared the Hassab and Sugiura procedures and found the Sugiura procedure to be more effective in terms of reduction of rebleeding and eradication of varices, with comparable operating time and morbidity ( Wen et al, 2008 Studies comparing devascularization alone with devascularization with esophageal transection have shown comparable rebleeding rates. The esophageal transection group has a higher incidence of esophageal stricturing ( Johnson et al, 2006 ; Zhang et al, 2014) comparing splenectomy with no splenectomy groups, both were comparable in rebleeding, operative time, and morbidity. The preservation of the spleen was associated with decreased perioperative blood transfusion requirement and the portal vein thrombosis rate. another modification included splenic artery ligation instead of performing a splenectomy.

19. Efficacy ability to control bleeding without the attendant liver dysfunction, as occurs with a shunt procedure. Overall, devascularization procedures have a rebleeding rate of 5% to 16% and mortality rate of 1% to 7%, without risk of encephalopathy Immediate control of bleeding is achieved in almost all cases: 95% to 100% The 5 year survival rate with the Hassab operation ranges from 73% to 85%, seemingly better than other devascularization procedures. The 5 year survival rate of the Sugiura and modified Sugiura operations is approximately 70% and dramatically decreases to approximately 30% in the emergency setting. Outcomes are much better in noncirrhotic portal hypertension. Approximately 10% to 15% of patients with EHPVO have no shuntable vein or a thrombosed splenoportal and mesentericoportal axis.

20. Shunt or devascularization ??? RCT showed , devascularization was found to have superior survival and less incidence of encephalopathy rate Rebleeding was less with shunting in another RCT A meta-analysis (2013(1716 patients, of which 770 underwent devascularization, and in 946, a shunt ). Although there was no significant difference in the mortality rate and overall survival, the recurrent bleeding rate was significantly higher in the devascularization group than shunt group; the rate of encephalopathy was lower in the devascularization group. Ascites control was better in the shunt group.

21. Complication Rebleeding Esophagial leak /stricture OPSI Post splenectomy sepsis

22. Summery : 16 cases were undertaken the splenectomy and esophagogastric devascularization. During the follow-up of 6-72 months, no esophageal and gastric varices were found.

23. The surgical treatment of 18 patients with PVCT was studied retrospectively. Eight patients underwent mesocaval shunt with artificial grafts, two patients had splenectomy and disconnection, three patients had a central splenorenal shunt, and six patients had a distal splenorenal shunt. There were no deaths or hepatic encephalopathy after operation. Bleeding recurred in two patients (disconnection in one, mesocaval shunt in one). The individualized choice of shunt is ideal for treating PVCT, and the combined procedures of shunt and disconnection are useful. The Rex shunt will be the focus of PVCT surgery in the future.

24. Surgical procedure selection was based on overall consideration of several factors, according to the severity of vascular dilation, the PC location, and the extent of liver dysfunction. Splenectomy was performed for 21 cases with apparent splenomegaly, but without obvious lumpy, tortuous dilation of the lower esophagus and gastric fundus veins. Surgical vascular disconnection in the gastric fundus and lower esophagus in combination with splenectomy was performed in 36 cases with severe tortuous dilation in the lower esophagus and gastric fundic mucosa. Among them, surgical thrombus removal and end-to-end anastomosis of the PV were performed in 8 cases with the main PV trunk occlusion In three children tortuous dilation of the intrahepatic portal vein, with severe damaged liver function, was detected. Living-donor liver transplantation was selected for these patients.

25. Five patients were symptomatic. Three patients had intermittent bleeding from esophageal and gastric varices, and all 5 had relative degrees of hypersplenism with enlarged spleens and thrombocytopenia (11,000 to 77,000) Postoperative complications included ascites in 2 patients that resolved within 1 month. There were no early shunt thromboses. Gastrointestinal bleeding did not recur in any patient, and ascites resolved in all. Spleen size decreased significantly ( P <.01) from 9.4 ± 4.0 cm to 5.0 ± 3.7 cm below the left costal margin. Mean platelet count and white blood cell count rose after shunting from 79 ± 42 to 176 ± 73 ( P <.02) and 5.4 ± 2.3 to 7.5 ± 3.9 ( P =.06), respectively. All shunts were studied at 1 and 7 days, and 3 and 6 months after the procedure. Shunt patency was documented in all cases. Subsequently, shunt blockage occurred in 2 patients . Conclusions: The Rex shunt has proven to be an effective method of resolving portal hypertension caused by EPVT including thrombosis after living donor transplantation. This shunt is preferable to other surgical procedures because it eliminates portal hypertension and its sequelae by restoring normal portal flow to the liver

26.   30 children with symptomatic CTPV that were treated by a Rex shunt between 2008 and 2015. All children were evaluated based on symptoms, complete blood count, portal system color-flow Doppler ultrasound or computed tomography angiography portography and gastroscopy for gastroesophageal varices pre- and postoperatively. Children were also evaluated during follow-up. Intraoperative evaluations included liver biopsy, portography and portal pressure. Rex was successful in 28 patients (93.3%). The portal pressure immediately decreased significantly after placing of the shunt (P < 0.01). During the clinical follow-up period within 2-82 months, transaminase levels were maintained in the normal range. Blood flow velocity and diameter of the left portal vein significantly increased after surgery (P < 0.01). In addition, leukocyte and platelet counts increased postoperatively and anemia improved significantly (P < 0.01). Gastroscopy results indicated that the degree of gastroesophageal varices significantly alleviated postoperatively within 3 months and 1 year (P < 0.01). In 2 patients who demonstrated nodular cirrhosis and chronic active hepatitis, success of the Rex shunt was not achieved after operation. We found that for Rex effectiveness hepatic pathology and patient age were major determinants. Conclusion:  Rex shunt is an effective approach for the treatment of children suffering from CTPV at an early stage that do not show additional liver lesions.

27. Operative vedio

28. Our patient Problem: Oesophagial varices Hypersplenism PVCT Cholelithiasis choledocholithiasis Proposed : Modified Sugiura plus cholecystectomy ,choledocholithotomy +_ rex shunt if expertise available

29. Thank you