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1. EVOLUTION OF SURGERY
EVOLUTION OF SURGERY
OF PORTAL HYPERTENSION
OF PORTAL HYPERTENSION
IN Egypt (last century)
IN Egypt (last century)
Prof. Mohamed Abd Elwahab
Prof. Mohamed Abd Elwahab
Gastroenterology Surgical Center
Gastroenterology Surgical Center
Mansoura University
Mansoura University
2. • Hitherto, portal hypertension in Egypt (and allover the
world) remains full of mysteries in its pathogenesis,
prevention and management.
• Eminent bleeding from varices remains the most
common problem faced by the medical profession in
Egypt.
• The “rightfor” and type management of such cases with
or without bleeding remains a battle ground between
physicians and surgeons.
3. The Story of Surgery of Portal
Hypertension.
•Nicolai Eck………. 1877
•Whipple……. 1935-1945
•Linton……………1961
•Warren…………. 1966
•Drapanase……… 1975
•Tips………. 1990-2002
4. • The story of the surgical treatment of
portal hypertension begins in 1877 in
Russia. At that time Nicolai Eck described
a portocaval shunt for treatment of portal
hypertension.
(Eck Nv. 1953)
5. • In 1893 Pavlov and his Co-workers refuted
ECK’s conclusion.
• Initial success in controlling variceal
bleeding was achieved in 1903 when Vidal
performed a portocaval anastomosis in
cirrhotic patients
6. • In 1935 Whipple et al. Studied the natural
history of portal hypertensive bleeding in
patients with cirrhosis, his initial success
published in 1945 triggered an explosion of
enthusiasm for portocaval shunt and its variants
• Controlled prophylactic and therapeutic trials
over the following 15 years however confirmed
the infectiveness of total shunt in prolonged
survival
7. • In an attempt to obviate or reduce the late
morbidity and improve survival following
portacaval shunt, several investigators looked
for a procedure that would achieve variceal
decompression without depriving the liver of its
portal blood supply.
• Linton et al for example advocated splenectomy
and central splenorenal shunt as a method
which could meet these criteria, however with
time, the shunt failed, either enlarged
sufficiently or thrombosed.
8. • After central splenorenal Drapanas popularized
the mescoval interposition shunt and calaimed
that this procedure succeeded in achieving
variceal decompression. This type of shunt
proved later on to be not effective in
management of variceal bleeding due to high
incidence of hepatic cell failure, encephalopathy
and shunt thrombosis.
9. Distal Spleno Renal 1967
Shunt (Rational)
• Selective decompression of gastro-esophageal
varices.
• This shunt leaves the spleen.
• Portal hypertension maintained for perfusion the
liver.
• Improvement of gastrointestinal congestion and
absorption.
11. The Nile Valley was Inhabited at Least as
Early as 20,000 Years Age
• Written document did not appear until the early
dynastic period 3500-3000 B.C.
• Schistosomasis in Egypt discovered 3000 years ago as a
written documents in the walls of the temple in upper
Egypt.
• They discovered the way of transmission, protection and
the treatment.
19. • Bleeding esophageal varices as a
complication of portal hypertension is the
most common causes of upper
gastrointestinal hemorrhage in Egypt. The
economic impact of this disease is
compounded by the fact that it affect
individuals at the peak of their productive
life.
21. Aetiopathology
•In 1928 sorour followed by Hashem 1947 laid
down the foundation of the pathological pattern
of liver periportal fibrosis as a cause of portal
hypertension.
• The pathology of liver cirrhosis changed in the
late 70s and early 80s duo to appearance of type
B. hepatitis, C-hepatitis and mixed pathology.
22.
23.
24. • During the first half of the last century, hepatic
schistosomiasis represent the cause of portal
hypertension replaced by hepatic cirrhosis due
to hepatitis B and C viruses as a causes of portal
hypertension in the last two decades.
25. Changes in liver pathology, last 20
years (1500 patients)
300
250
200
150
100
50
0
80-85 85-90 90-95 95-2000
Bil. Mixed Nonbil.
26. Homodynamic
• Intraoperative portal pressure (occluded
and free) was measured for the first time by
Khairy in 1960
• Study of splenic pulp in vivo by Badan
• Transplenic spleno portography
• Selective superior mesenteric angiography
27. Surgery has Evolved Widely During
the Last Century
DUE TO
1. Change of liver pathology
2. Development of new surgical techniques
3. Appearance of wide variety of alternative to the
patient and phyciation (pharmacological
endoscopic, interventional radiology)
28. Managment
1- Splenectom 1908
2- Total shunt 1950
3- Non shunt 1957
4- Mesocaval shunt 1974
5- Selective shunt 1978
6- Injection sclerotherapy 1980
7- Present status
29. Surgery for portal hypertension started early
in this century by splenectomy fot the first
time in 1908. (Aly pasha Ibrahim 1908)
30. However though splenectomy lowered portal
pressure (75-40%) this proved to be at most
temporary.
(Musa 1962-E-Sherif 1904)
31. In the Forties
• Total port-systemic shunts were introduced in
the west (Whipple 1945-Blackkemone 1947).
• In Egypt shunt surgery was practiced in late
fifties
32. Total Shunts
• In the 1950 portocaval shunts were applied to
schistosomal patients in Egypt. Up to 1970 this
type of surgery was criticized by many
surgeons. However because of the high
incidence of mortality and morbidity this
procedure was abandoned in this patients.
33. Non Shunts
• In the 1960 Hassab popularized splenectomy and
extensive devascualarization as a new surgical
aaproach for schistosomal portal hypertension.
• In the same period Khairy 1964 introdced the
operation of splenectomy and vasoligation of the
oesophagus and stomach
• Many modification tried after those two operation
in theforme of
• Suprediaphaogmatic devascualarization
• Trans gastric ligation
• Esophageal transection
34. Non shunt
• Lack of satisfaction of splenectomy in thatment of O.V.
Lack of satisfaction of splenectomy in thatment of O.V.
has led to the development of porto-azygos
has led to the development of porto-azygos
disconnection in it’s different forms including Hassabs
disconnection in it’s different forms including Hassabs
operation (1959) Which is still practiced till now.
operation (1959) Which is still practiced till now.
• Rational of Hassabs operation ..
Rational of Hassabs operation
1.Decongestion of variceal bearing area.
1.Decongestion of variceal bearing area.
2. Reduction of portal hypervolaemia.
2. Reduction of portal hypervolaemia.
3. Improvement of all blood elements.
3. Improvement of all blood elements.
4. Improvement of liver function
4. Improvement of liver function
35.
36.
37. Hassab’s operation
• Has the advantage of low operative mortality
low encephalopathy.
• However it faild to achieve its goal, with high
rebleeding rates.
39. Distal Spleno-Renal Shunts: DSRS
(Selective Shunt)
• In the early 1970, with the era of the
selective shunt. DSRS became popular in
Egypt around 1972 and it was adopted by
many Egyptian surgeons and still is
Over two decades later this type shunt was
practiced allover Egypt.
40.
41. Selective Shunts
•Science 1990 this type of shunt started to die out
– Change of pathology
– Loss of selectivity
– Sclerotherapy
42. • However with the passage of time
However with the passage of time
collateralization occurred turning it into
collateralization occurred turning it into
potentially total shunt with higher
potentially total
incidence of encephalopathy
incidence encephalopathy
43.
44.
45.
46. Selective Shunt
Corono-renal Shunt
• An alternative to selective shunt
• Not used due to high incidence of
thrombosis
47. Injection Sclerotherapy
• In Egypt injection sclerotherapy started around
1975, was done by surgeons and still in many center
using solid then flex scopes. Gradually it was taken
over by endoscopists, and became the first and
sometime the only line of treatment of bleeding
varices.
48. Transjuglar intra hepatic porto-
systemic shunts (TIPS)
1- To bridge to transplancation
II- Last resort in acute bleeding in child C
49. Present status
Sclerotherapy or band therapy are the treatment of
choice..
Is there is any place for surgey.
Is there is any place for surgey.
• Failure of sclerotherapy
Failure of sclerotherapy
•Gastric varices
Gastric varices
• Duodenal varices
Duodenal varices
• Young patients with good liver
Young patients with good liver
• Segmental portal hypertension
Segmental portal hypertension
50. • Failures of sclorotherapy
Failures of sclorotherapy
– Failure to clear the esophagus.
Failure to clear the esophagus.
– Recurrent massive bleeding during treatment
Recurrent massive bleeding during treatment
– Development of gastro-duodenal varices.
Development of gastro-duodenal varices.
– Congestive gastropathy.
Congestive gastropathy.
51. Gastric Varices
• Bleeding gastric varices are usually massive
Bleeding gastric varices are usually massive
difficult to diagnose and to control.
difficult to diagnose and to control.
• They are best controlled by surgery.
They are best controlled by surgery.
• Shunt surgery is more superior than non-shunt.
Shunt surgery is more superior than non-shunt.
52.
53.
54.
55. From 1975-2002
13377 patients
With bleeding varices managed in
gastroenterology center
Mansoura University
EYYPT
56. Management of bleeding varices in
gastroenterolgy center mansoura
University
• Surgery 1915
• Injection sclerotherpy 11467
57. Type of Treatment by Period
75-80 80-85 85-90 90-95 95-2000
Surgrey 108 374 454 468 387
Injection 0 560 1250 4500 5157
58. Type of Operation
No %
Slective shunt
Distal splenorenal 606 32
Coronorenal 40 2
Total shunt
Mesocaval 33 1.7
Small diameter 20 1
Central lieno- renal 26 1.3
Non shunt
Hassab 811 42.4
Splenectomy vasohigation
vasohigation 335 17.5
Stapler
Stapler 39 2
59. Hospital Mortality
No. %
DSRS 606 (19) 3%
Non shunt 1185 (23) 2%
Total shunt 79 (7) 9%
60. Rebleeding
No %
Selective shunt (606) 36 6%
Non shunt (1185) 272 23%
Total shunt (79) 6 8%
61.
62.
63. Hepatic pathology as prognostic factor
(after DSRS)
Bilharz. Non Mixed
Mortality late 8% 17% 22%
H.C.F. 4% 12% 16%
Portal perfusion 94% 75% 50%
Encephalopathy 4% 22% 26%
64. Schistosomal patients have
• A better survival rate with low incidence of
encepahalopathy after DSRS. Compared with
the cirrhatics and mixed population
(Annals of surgery 89)
65. Encephalopathy
No %
Selective shunt (606) 72 12%
Non shunt (1185) 35 3%
Total shunt (79) 79 40%
66. Late Mortality
F.U./y No %
Selective shunt (606) 15 88 14%
Non shunt (1185) 14 142 12%
Total shunt (79) 10 63 80%
67. conclusion
• The history of portal hypertension started in Egypt more
than 5000 y ago
• Evolution happened to many changes as etiopathology-
surgery and intervention radiology
• The present situation
- Pathology
N - Sclerotherapy is the first choice
O - Selective shunt or non shunt
W (according to many factors)
