Interposition left gastric-caval shunt using internal jugular vein autograft in the treatment of portal hypertension

[Surgical treatment of portal hypertension in schistosomiasis mansoni]

Portal hypertension is defined by an hepatic venous pressure gradient greater than 5mmHg. It is usually caused by an increase in resistance in the portal-hepatic vascular bed due to obstruction to flow. The severe forms of schistosomiasis usually evolve with portal hypertension, esophageal, intraabdominal, retroperitoneal and abdominal wall varices. Massive bleeding due to esophageal or gastric variceal rupture is the major complication of portal hypertension in schistosomiasis. In regard to treatment, clinical (propranolol, somatostain, octreotide), endoscopic (sclerotherapy, clips and ligature of varices), vascular (TIPS - transjugular intrahepatic portosystemic shunt) and surgical (portosystemic shunts and portovariceal disconnection) approaches have been tried to decrease portal hypertension and prevent bleeding. In the present review the author discusses the subject emphasizing the surgical procedures.

Treatment of portal hypertension by subtotal splenectomy and central splenorenal shunt

A method is proposed to reduce portal hypertension utilizing subtotal splenectomy and a central splenorenal shunt. The advantages of this method are: diversion of the splenic component of the portal circulation, creation of a shunt for the portal blood into the systemic circulation, preservation of the splenic function and correction of the manifestations of the hypersplenism. Two cases are presented who remain well four years after surgery.

Bleeding esophageal varices

The unresolved issue of the optimal treatment of portal hypertension attests to the disappointments in present treatment. In reality, the disappointments are a result of progressive liver disease, which is not helped and probably deteriorates more rapidly after shunting operations. This dissatisfaction has led some to abandon shunts and to accept a higher incidence or potential for recurrent bleeding after nonshunting operations. The long-term results of splenic artery ligation and perhaps embolization are awaited with interest. Until then, as Conn has said, "We must learn to select better who should be shunted or to shunt better those we select".