Surgery for Portal Hypertension: Is it History?

S K Mathur MS,FACS Sr.Consultant Surgeon Surgical Gastroenterology HPB Surgery & Liver Transplantation Wockhardt Hospitals
(Associated Hospital of Harvard Medical International)

& JR Railway Hospital Mumbai

Evolution of Treatment for Portal Hypertension - Cleveland Clinic

100% 80% 60% 40% 20% 0% 19461964 19651980 19801990 19901994 TIPSS Sclerotherapy OLTx Devasc DSRS Total shunts

Modified from Hermann Ann Surg 1996

Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era.
Bismuth H, Adam R, Mathur S, Sherlock D. Am J Surg. 1990 Jul;160(1):105-10. Hepatobiliary Surgery and Liver Transplant Unit, Paul Brousse Hospital, Villejuif, France.

We propose that initial bleeding be controlled by endoscopic sclerotherapy, Grade A patients appear to be managed best by a reduced-size portacaval shunt (RPS) Grade B patients can be managed by either sclerotherapy, RPS, or OLT, depending upon individual circumstances. Grade C patients are best managed by liver transplantation

with prospects of good survival and few complications.

Historical trend in Management of Portal hypertension KEM hospital, Mumbai

Sclerotherapy Surgery

1983

Year

1950

1980

1990

2000

Long term results of chronic endoscopic variceal sclerotherapy

SKM
Variceal obliteration Mean no. EVS sessions Variceal recurrence rate Recurrent variceal bleed - Prior to obliteration - Post obliteration 30 day mortality 84% 5.1+/-2.2 28% 35% 5% 3% World literature 62 - 95% 4 - 6.8 19 - 62% 22 - 58% 3 - 23% 1 - 12%

Mathur et.al Gastrointest. Endoscopy 1990

% rebleeders needing Surgical rescue

59 60 50 40 30 20 10 0
Teres et al 1987 Rikkers et al 1989 Henderson et al 1990

Trials of Long term Sclerotherapy V/s Splenornal shunt

10-59% required surgery for failed EVS

28 17 10 Shunt

Spina et al 1990

No. of patients : 112

60

72

66

Surgery for Portal Hypertension

Personal Series:1983 - 2007

n=608 Sx 190
23% Surgery in EVS Gr. 10%Primary Sx
66 124

EVS 542
Mathur SK

542

Portal Hypertension In India: Etiology 1983-2007 N=608*

277 CIRRHOSIS

45%
14%

39%

EHPVO 236

NCPF

87

8 Budd-Chiari
*Personal series

Clinical Manifestations
Variceal bleeding Ascitis Liver cell failure Cirrhosis

Non-Cirrhotic portal hypertension Symptomatic Splenomegaly Hypersplenism Growth retardation EHPVO Biliary Obstruction Menorrhagia

Surgery for Portal Hypertension

Indications for Surgery

for variceal Bleed: - Esophageal - Gastric fundic - Ectopic varices Other Indications: *Symptomatic Splenomegaly *Symptomatic Hypersplenism *Growth retardation *Portal Biliopathy * Menorrhagia

Portal Hypertension Current Surgical Options Indications for Surgery

Primary Therapy Rescue therapy - Emergency Surgery - Elective Surgery

Indications for Primary Surgery Sinistral PHT (Left sided)

n=3 Isolated Splenic vein thrombosis

bleed from fundal varices

Splenectomy : curative

PHT:Indications for Surgery Primary therapy

Ectopic variceal bleed n=1 Jejunal / Ileal / stomal / Colonic / Rectal

- Biliary variceal bleed - Ruptured retropeitoneal varices

PHT: Indications for Surgery

Bleeding Diffuse Fundal Gastric varices

Classification of Gastric Varices

Hoskings
BJS 1988

Baveno Am J Gastroenterol Hepatol 1988 J Gastro 1989 Consensus 96 Gv with Mathurs Sarins

GOV1 GOV2

OV Type1 Type2

IGV1

Isolated GV Type1

IGV2

ENDOSCOPIC AND RADIOLOGICAL APPRAISAL OF GASTRIC VARICES

Mathur SK et al. B.J.S. 1990

FGV Incidence : 25% FGV Bleed : 100%

Fundic Gastric Varices Results of Glue Injection

Initial Control Early rebleed Late rebleed Fatal Complications Mortality from bleed 87 - 100% 12.5 27% 54% 1 3% 6 8.5%

(Endoscopy 1993, 1994, 2002)

Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience
Akahoshi T et al. Surgery. 2002 Jan; 131(1 Suppl): S176-81.

n=52 , active bleeding 32 and recent bleeding 20 mean Follw-up : 28.1 months RESULTS: Initial hemostasis was 96.2%. (no bleeding occurred for 48 hours after sclerotherapy) Cumulative non-bleeding rates at : 1 5 10 years 64.7% 52.7% 48.2%
CONCLUSIONS:

Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.

FGV: Post Glue Injection Complications

Effect of TIPS on Fundal Gastric Varices & Congestive Gastropathy

FGV fails to resolve & Rebleed in 20 - 50 % of cases Cause : presence of spontaneous splenorenal shunt which competes with TIPS for preferential flow Portal gastropathy does not disappear completely
Sanyal et al Ann Intern Med 1997 Murphy et al J Vasc Interven Radial 1995

TIPS for FGV

Rebleed 20% (Mean F-U 36.7months) 30 day Mortality 15%
(Tripathi D et al GUT 2002)

Actuarial rebleed 36% over 12 months

( Hepatology 1999)

Indications for Primary Surgery

Bleeding Fundal gastric varices : n = 71

Post Shunt

Rebleed 2%

Bleeding Fundal gastric varices Results of Surgery

n=71 Procedurs: -Shunts 20 -Modified Sugiura 48 -Splenectomy 03 Rebleed: 2%
(mean FU 48.4months SD27.3, range 3-124) (personal unpublished series)

Portal Hypertension Primary Elective Surgery Spleen related Indications

Symptomatic Hypersplenism Symptomatic Splenomegaly Growth Retardation

Portal Hypertension Indications for Surgery

Hypersplenism : - WBC - Platelets 33% < 4000/Cu mm. <1,00000

Symptomatic hypersplenism: Incidence : 7%

- WBC < 2000 - Platelets < 50,000 Recurrent sepsis Spontaneous bleeding Anaemia in absence of GI bleeding

Portal Hypertension Indications for Surgery

Symptomatic Splenomegaly : 1.5% - dragging pain & visible lump

Extra hepatic Portal Hypertension in Children Indications for Surgery

Growth retardation in EHPVO : Incidence * Sarin et.al. 51% * Mathur et.al. 5%

Surgery For growth retardation : 1%

Extra hepatic Portal Hypertension

INDICATIONS FOR PRIMARY ELECTIVE SURGERY
Other indicaions Portal billiopathy Menorrhagia
Spleen related Indications Symptomatic Hypersplenism Symptomatic Splenomegaly Growth Retardation

EHPVO:Portal Biliopathy
Bile duct abnormalities: 85 100% Symptomatic: 1%

ERCP

MRCP

MR Cholangiogram + Superimposed Portogram

MRCP

Portal Biliopathy Cholangitis

CBD obstruction

Endo Sono Peri dochal Varices

O.V.

Fundal G.V.

MRCP+MR ANGIOGRAPHY

Large calculi in Rt hep duct, CHD and prox CBD with marked IHBR diln. CBD prominent but N. E/o EHPVO with portal cavernoma with hepatopetal and hepatofugal collaterals and splenomegaly.

Portal Biliopathy Therapeutic Options

Sphincterotomy with endoscopic stone extraction. Biliary stenting Shunt Surgery: - to relieve biliary obstruction - to facilitate subsequent bile duct surgery

Biliary Surgery in presence of Portal Hypertension

Bile duct obstruction due to portal biliopathy In EHPVO: Direct bile duct surgery is hazardous : it can lead to profuse uncontrollable bleeding from collaterals around bile duct Can result in to mortality Recommendation : Porta-systemic shunt 6week interval Biliary Surgery
A Chaudhary BJS 1998

Portal Biliopathy in EHPVO Results of Porto Systemic Shunt

Personal : n=10 ( 9 failed prior Endotherapy) - Shunt alone Success 7(70%) - Subsequent Biliary surgery 3(30%) Literature*: n=40 - Shunt alone success: 70-80% - Subsequent biliary surgery: 20-50%
*Vibert E, Azoulay D et al. Ann Surg 2007 *A Chaudhary BJS 1998

Portal Hypertension Indications for Surgery

for variceal Bleed

Rescue therapy - Emergency Intervention *Acute Variceal bleed - Elective Intervention * Recurrent Variceal bleed Etiology of PHT: - Cirrhotic - Non-cirrhotic

Q. What to do for refractory bleeding ?

Incidence : 20%30% of

patients

TIPS

TIPS

Case # 5

Distal-spleno-renal shunt
Splenic vein

SHUNT

Renal vein

TIPS Vs Surgery
Evidence based Medicine :
U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments : Level I: Evidence obtained from at least one properly designed randomized controlled trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

TIPS for control of acute variceal bleeding

Control of bleeding: 93 - 95 % 1-month actuarial probability of rebleeding : 22% Operative mortality (30 days) : 28%.- 37% Complications : 13% - massive hemoperitoneum - cardiorespiratory arrest & cardiac failure - acute renal failure - bacteremia
Banares R, Am J Gastroenterol. 1998 Bosch J. J Hepatol 2001

Rescue Therapy Emergency TIPS vs Surgery Good risk patients

Solitary RCT in good risk patients active bleed failing first line Rx n = 70 TIPS vs small diameter P-C shunt Failure of therapy: 56% TIPS vs 26% Surgery (P < 0.02)
Rosemurgy Ann Surg 1996

Elective Rescue Therapy TIPS v/s Surgical shunts

Ten years' follow-up of 472 patients following TIPSS insertion at a single centre Procedure-related mortality : 1.2%. Rebleed: 13.7% (within 2 years of TIPS) (principally from gastric and ectopic varices) Shunt patency rates: need for reinterventions - Primary 45.4% & 26.0% at 1 and 2 years
- Secondary assisted patency rate was 72.2%.

hepatic encephalopathy: 29.9% (de novo encephalopathy: 11.5%)

Tripathi D et al, Edinburgh,UK, Eur J Gastroenterol Hepatol. 2004;16:9-18.

TIPS: PTFE covered V/s Uncoverd Stents long-term results of a randomized multicentre study
N = 80 (follow-up for 2 yrs) TIPS Stent Covered Uncovered Primary patency 76% 36% (P=0.001) Rebleed 10% 29% (P<0.05) Encephalopathy 33% 49% (P<0.05) Probability of survival 58% 45% (NS) (2 years)
Bureau C et al Liver Int. 2007 Aug;27:742-7.

DSRS v/s TIPS

(Retrospective Case Control Study) Good risk patients n=40 Conclusion : TIPS - Significantly higher incidence v/s DSRS
* Rebleed episodes (p < 0.001) * Rehospitalization (p < 0.05) * Shunt revision (p < 0.001)

* More expensive (p<0.005) 30 day mortality : 20% v/s 0%

(Helton et al Arch surg 2001)

Distal splenorenal shunt versus TIPS for variceal bleeding : a randomised trial
73 DSRS & 67 TIPS (Child Pugh A and B patients) Follow-up: 2-8yrs (mean46+/-26 months) DSRS and TIPS similar in efficacy in the control of refractory variceal bleeding
(rebleeding DSRS, 5.5%; TIPS, 10.5%; P = .29)

Re-intervention: significantly greater for TIPS compared with DSRS

(DSRS, 11% v/s TIPS, 82%, p<0.001)

No difference in need for LT The choice is dependent on available expertise.

Henderson JM, et al, Gastroenterology, May 2006

H-Graft Portacaval Shunts Versus TIPS H-Graft Portacaval Shunts VersusWith TIPS Ten-Year Follow-up of a Randomized Trial Ten-Year Follow-up Predicted Survivals Comparison to of a Randomized Trial Rosemurgy AS et al, to Predicted Survivals With ComparisonAnn Surg. 2005; 241: 238246. .

TIPS 66 HGPCS 66 10(15%) 13(20%) (Post procedure) Child-Pugh C 70% 84% Rebleed: 20(30%) 5(7.6%) Shunt stenosis 32(48.5%) 7(10.6%) significantly higher after TIPS (P <0.001) Encephalopathy: 30% 10%
Rosemurgy AS et al, Ann Surg. 2005; 241: 238246

N=132 Mortality

H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals TIPS (N = 66) HGPCS (N = 66) Through 24 months, actual survival was superior after HGPCS v/s TIPS (P = 0.04). Survival at 5 to 10 years was superior after HGPCS compared with TIPS for : - Child's class A and B (P = 0.07) - MELD scores less than 13 (P = 0.04)
Rosemurgy AS et al, Ann Surg. 2005; 241: 238246.

Rescue Therapy in Cirrhotics TIPS v/s Surgical shunt

Evidence based Conclusions for Child A & B & MELD < 13: * Surgical shunt has a role - DSRS or HGPCS for high risk Child C: TIPS

Portal Hypertension

Rescue Therapy TIPS Vs Surgical Shunt

According to the Centre for EvidenceBased Medicine:

"Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

Surgery for Portal Hypertension Is it History? CONCLUSIONS: No Rescue Therapy: 10-20%

* Cirrhotics: - Good risk patients: : Surgical Shunt not TIPS - Poor risk patients: TIPS * Non-Cirrhotic: Surgical Shunt or Devasc.

Surgery for Portal Hypertension Is it History? CONCLUSIONS: No

Surgery is the Therapy of choice: *Bleed from: - Diffuse Fundal Gastric Varices - Ectopic varices * Symptomatic Splenomegaly * Symptomatic Hypersplenism * Growth retardation * Billiary obstruction * Menorrhagia

Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. Orloff MJ J Am Coll Surg. 2009 July
BACKGROUND: The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN: A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death. RESULTS: The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS: EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).

Natural history in EHPVO

Hepatopetal blood flow in portal cavernoma

Adequate hepatic portal perfusion

Preservation of hepatocyte function

Normal life span

Acute Variceal Bleeding Indications for Em. Rescue Therapy

Failure to control variceal hemorrhage : Continued bleed inspite of: Vasoactive drugs + Endotherapy + Tamponade Recurrent bleed within 72 hours: inspite of 2 attempts at EVS / EVL - fresh blood in NG tube, - fall in HB> 2gm%, - need for more than 6 units of blood in 24 hours Life threatening hemorrhage even after one session : Hypotension, Bp < 80 mmHg.

INDICATIONS FOR ELECTIVE SURGERY

Failure of chronic EVS
Single life threatening rebleed Two significant rebleeds - Hb fall > 2 gm% - 2 units blood Persistence of large varices after 6-10 sessions of EVS Development of Fundal varices

Rebleed in defaulter of EVS

Inability to follow up - absence from work travel expense / distance

Surgery for PHT

Indications for Primary surgery Emergency n=15 -Bleeding Fundal Gastric Varices -Bleeding Oesophageal Varices Elective n= 51 Fundal Gastric Variceal bleed Hypersplenism Growth retardation Inability to follow up Biliary Obstruction Menorrhagia 11 4

22 19 2 7 3 2

EVS:Indications for Elective Surgery

Gastric Varices Oesophageal Varices ( failure of EVS) Inability to Follow up Hypersplenism Splenomegaly Growth retardation Bile duct obstruction Gastropathy bleed Ectopic Varices bleed 37 24 15 24 3 5 3 1 2

Surgical Options in PHT

Devascularisation ( Modified Sugiura ) Emergency 73 Elective 37 Shunts : ( elective) * DSRS 31 * Proximal leinorenal 39 * Side to side leinorenal 4 * Spleno- Adrenal 3 * End renal-side splenic 1 * Mesocaval (PTFE graft) 1 * Modified Spleno-renal shunt 1 ( Y Shunt) 110

80

Surgery: Long term results

Overall 6%
18 16 14 12 EHO NC PF Cirr

6%

12%

8%

6%

5%

% 10
8 6 4 2 0

Recurrence Rebleed Stricture Block DEVASCULARISATION 53 SD 34 months (4-143 months)

Rebleed

Enceph

SHUNT SURGERY 25 SD 29 months (4-107months)

No single surgical procedure is

ideal for all patients or all circumstances

Choice of Surgery
Timing : Emergency vs elective

Experience of surgeon with shunt surgery Portal venous anatomy Indication for surgery Site of bleed

Distal-spleno-renal shunt