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[Surgery in portal hypertension. Which patient and which operation?]
M A Mercado1, T Takahashi, G Rojas
1División de Cirugía y Clínica de Hipertensión Portal, Instituto Nacional de la Nutrición Salvador Zubirán, México, D.F.
Insights
Portal blood flow preserving surgeries effectively treat bleeding in patients with portal hypertension and good liver function. Procedures are chosen based on individual patient anatomy, showing an 85% survival rate.
Area of Science:
- Hepatology
- Surgical Gastroenterology
- Vascular Surgery
Context:
- Portal hypertension is a serious condition often leading to gastrointestinal bleeding.
- Effective surgical management is crucial for patients with good liver function (Child-Pugh A) and no pulmonary hypertension.
Purpose:
- To evaluate the outcomes of portal blood flow preserving surgical procedures in patients with hemorrhagic portal hypertension.
- To assess operative mortality, rebleeding rates, postoperative complications, and long-term survival.
Summary:
- A prospective trial included 94 patients with portal hypertension and bleeding history, treated with selective shunts, low diameter mesocaval shunts, or esophagogastric devascularization.
- Operative mortality was 8%, rebleeding occurred in 5%, and 5.6% experienced postoperative encephalopathy.
- Kaplan-Meier survival was 85% at 60 months, indicating the efficacy of these procedures.
Impact:
- Portal blood flow preserving procedures are recommended as the primary treatment for selected patients with hemorrhagic portal hypertension.
- Individualized surgical approach based on patient anatomy optimizes outcomes and survival.
Abstract:
A prospective trial of a cohort of patients (N = 94) with portal hypertension and history of bleeding was selected for surgery based on strict clinical and laboratory criteria. All of them were treated with portal blood flow preserving procedures. The following selection criteria were used: good cardiopulmonary function without pulmonary hypertension and good liver function (Child-Pugh A). All patients were operated in an elective fashion and the operations performed were: selective shunts (N = 38) (distal splenorenal and splenocaval), low diameter mesocaval shunts (N = 13) and the esophagogastric devascularization with esophageal transection (Sugiura-Futagawa) (N = 43). Patients were selected for each operation according to their anatomical conditions. Sixty-one of the patients were cirrhotics. Operative mortality was 8% and rebleeding was observed in 5% of the cases. Postoperative encephalopathy was seen in seven patients (three selective shunts, two low diameter mesocaval shunts and two devascularizations). In 13 of 62 patients postoperatively evaluated by means of angiography, portal vein thrombosis was shown (seven selective shunts, two low diameter shunts and four devascularizations). Twenty-two patients with preoperative portal vein thrombosis (and treated with a Sugiura-Futagawa operation) were excluded from postoperative angiographic evaluation. Survival (Kaplan-Meier) was 85% at 60 months. Portal blood flow preserving procedures are the treatment of choice for patients with hemorrhagic portal hypertension and good liver function. The kind of operation is selected according to the individual anatomical status of the patient.