Portal Hypertension. Boyoung Song, MD SUNY Downstate Department of Surgery

Transcription

1 Portal Hypertension Boyoung Song, MD SUNY Downstate Department of Surgery

2 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)

3 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

4 Case Presentation Vital Signs: /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

5 Case Presentation Laboratory Studies MELD Score: 19 [3.8 x log (e) (bilirubin mg/dl) x log (e) (INR) log (e) (creatinine mg/dl)]

6 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.

7 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

8 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

9 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

10 Questions?

11 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.

12 Causes of Portal Hypertension 90% in USA and Europe Most common cause worldwide

13 Variceal bleeding Ascites Encephalopathy Portal gastropathy Complications

14 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%

15 Non-Surgical Management of Portal Hypertension

16 Surgical Management of Portal Hypertension

17 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

18 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

19 Total Shunts Side-to-side portocaval shunt Hepatofugal portal flow effectively decompressing splanchnic system and obstructed sinusoids Control BOTH variceal bleeding and ascites

20 Mesocaval Shunt Total Shunts

21 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

22 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

23 Devascularization Procedures Hassab Procedure (1967) Gastroesophageal decongestion and splenctomy Low rebleed rate reported with use of endoscopic sclerotherapy (3.1% within 2 years)

24 Devascularization Procedure Sugiura and Futagawa (1973) Thoracoabdominal procedure for complete devascularization of thoracic esophagus and stomach with esophageal transection Include splenectomy, vagotomy and pyloroplasty

25 Devascularization Procedure Modified Sugiura Procedure Entirely abdominal approach with reanastomosis of the esophagus Data regarding rebleeding is variable. <10% from original surgeons ~30% from Europe and US

26 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.

27 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

28 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)

29 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

30 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: Collins JC, Sarfeg IJ: Surgical Management of Portal Hypertension. West J Med 1995, 162: 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. 5 th ed Knechtle SJ, Galloway JR. Chapter 76A. Location of portosystemic Shunting. In: Blumgart LH, Jarnagin WR. Surgery of the Liver, Biliary Tract and Pancreas. 5 th ed. 2011

31 Q U E S T I O N S?