Is there still a role for surgery in bleeding portal hypertension?

Diagnosis and management of ectopic varices in portal hypertension

Ectopic variceal bleeding is a rare cause of gastrointestinal bleeding that can occur in settings of cirrhotic and non-cirrhotic portal hypertension and is characterised by its development at locations remote from the oesophagus and stomach. Ectopic varices can be difficult to identify and access, and, although a relatively uncommon cause of portal hypertensive bleeding, can represent a difficult diagnostic and therapeutic challenge associated with considerable mortality. Low incidence and variance in variceal anatomy preclude large randomised controlled trials, and clinical practice is based on experience from case reports, case series, and specialist centre expertise. Optimisation of survival outcomes relies on understanding a patient's portal venous anatomy and functional hepatic reserve to guide timely and targeted endoscopic and endovascular interventions to facilitate the rapid control of ectopic variceal bleeding.

Surgical portosystemic shunts versus devascularisation procedures for prevention of variceal rebleeding in people with hepatosplenic schistosomiasis

BACKGROUND

Hepatosplenic schistosomiasis is an important cause of variceal bleeding in low-income countries. Randomised clinical trials have evaluated the outcomes of two categories of surgical interventions, shunts and devascularisation procedures, for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. The comparative overall benefits and harms of these two interventions are unclear.

OBJECTIVES

To assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, LILACS, reference lists of articles, and proceedings of relevant associations for trials that met the inclusion criteria (date of search 11 January 2018).

SELECTION CRITERIA

Randomised clinical trials comparing surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with GRADE and Trial Sequential Analysis. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We found two randomised clinical trials including 154 adult participants, aged between 18 years and 65 years, diagnosed with hepatosplenic schistosomiasis. One of the trials randomised participants to proximal splenorenal shunt versus distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy, and the other randomised participants to distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy. In both trials the diagnosis of hepatosplenic schistosomiasis was made based on clinical and biochemical assessments. The trials were conducted in Brazil and Egypt. Both trials were at high risk of bias.We are uncertain as to whether surgical portosystemic shunts improved all-cause mortality compared with oesophagogastric devascularisation with splenectomy due to imprecision in the trials (risk ratio (RR) 2.35, 95% confidence interval (CI) 0.55 to 9.92; participants = 154; studies = 2). We are uncertain whether serious adverse events differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 2.26, 95% CI 0.44 to 11.70; participants = 154; studies = 2). None of the trials reported on health-related quality of life. We are uncertain whether variceal rebleeding differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 0.39, 95% CI 0.13 to 1.23; participants = 154; studies = 2). We found evidence suggesting an increase in encephalopathy in the shunts group versus the devascularisation with splenectomy group (RR 7.51, 95% CI 1.45 to 38.89; participants = 154; studies = 2). We are uncertain whether ascites and re-interventions differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy. We computed Trial Sequential Analysis for all outcomes, but the trial sequential monitoring boundaries could not be drawn because of insufficient sample size and events. We downgraded the overall certainty of the body of evidence for all outcomes to very low due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

Given the very low certainty of the available body of evidence and the low number of clinical trials, we could not determine an overall benefit or harm of surgical portosystemic shunts compared with oesophagogastric devascularisation with splenectomy. Future randomised clinical trials should be designed with sufficient statistical power to assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisations with or without splenectomy and with or without oesophageal transection.

Outcomes of surgical shunts and transjugular intrahepatic portasystemic stent shunts for complicated portal hypertension

Background

Transjugular intrahepatic portasystemic stent shunt (TIPSS), instead of surgical shunt, has become the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPSS or surgical shunting for complicated portal hypertension.

Methods

This was a retrospective study of all consecutive patients who received portasystemic shunts from 1994 to 2014 at a single institution. Patients who underwent surgical shunting were compared with those who had a TIPSS procedure following one-to-one propensity score matching. The primary study endpoints were overall survival and shunt failure, defined as major variceal rebleeding, relapse of refractory ascites, irreversible shunt occlusion, liver failure requiring liver transplantation, or death.

Results

A total of 471 patients received either a surgical shunt or TIPSS. Of these, 334 consecutive patients with cirrhosis who underwent elective surgical shunting (34) or TIPSS (300) for repeated variceal bleeding or refractory ascites were evaluated. Propensity score matching yielded 31 pairs of patients. There were no between-group differences in morbidity and 30-day mortality rates. However, shunt failure was less frequent after surgical shunting than TIPSS (6 of 31 versus 16 of 31; P = 0·016). The 5-year shunt failure-free survival (77 versus 15 per cent; P = 0·008) and overall survival (93 versus 42 per cent; P = 0·037) rates were higher for patients with surgical shunts. Multivariable analysis revealed that a Model for End-Stage Liver Disease (MELD) score exceeding14 and TIPSS were independently associated with shunt failure. In patients with MELD scores of 14 or less, the 5-year overall survival rate remained higher after surgical shunting than TIPSS (100 versus 40 per cent; P < 0·001).

Conclusion

Surgical shunting achieved better results than TIPSS in patients with complicated portal hypertension and low MELD scores.

Surgery as primary prophylaxis from variceal bleeding in patients with extrahepatic portal venous obstruction

BACKGROUND AND AIM

In patients with extrahepatic portal venous obstruction (EHO), death is usually due to variceal bleeding. This is more so in developing countries where there is a lack of tertiary health-care facilities and blood banks. Prophylactic operations in cirrhotics have been found to be deleterious. In contrast, patients with EHO have well-preserved liver function, and we therefore investigated the role of prophylactic surgery to prevent variceal bleeding.

METHODS

Between 1976 and 2010, we operated on selected patients with EHO, who had no history of variceal bleeding but had "high-risk" esophagogastric varices or severe portal hypertensive gastropathy and/or hypersplenism, and came from remote areas with poor access to tertiary health care. Following surgery, these patients were prospectively followed up with regard to mortality, variceal bleeding, encephalopathy, and liver function.

RESULTS

A total of 114 patients (67 males; mean age 19 years) underwent prophylactic operations (proximal splenorenal shunts 98 [86%]; esophagogastric devascularization 16). Postoperative mortality was 0.9%. Among 89(79%) patients who were followed up (mean 60 months), hypersplenism was cured, and six (6.7%) developed variceal bleeding. The latter were managed successfully by endoscopic sclerotherapy. No patient developed overwhelming post-splenectomy sepsis or encephalopathy, and 90% were free of symptoms.

CONCLUSION

In patients with EHO, prophylactic surgery is fairly safe and prevents variceal bleeding in ∼ 94% of patients with no occurrence of portosystemic encephalopathy. Patients with EHO who have not bled but have high-risk varices and/or hypersplenism, and poor access to medical facilities should be offered prophylactic operations.

[Portosystemic shunt surgery between TIPS and liver transplantation]

Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease.This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies.

Current role of surgery in portal hypertension

Treatment for portal hypertension (PHT) has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The present review primarily focuses on the role of surgery in tackling patients with PHT and varices with regard to the Indian scenario and also looks at its relevance, given the availability of a host of other therapeutic options.

The evaluation of liver dysfunction: when to suspect portal hypertension

Portal hypertension, as a result of cirrhosis or other cause of liver dysfunction, is a life-threatening disease process. The risk of bleeding varices is high. Treatment options have much better outcomes when administered early on. The role of the PA in treating portal hypertension centers on recognizing the complications and understanding the medical management of those problems. Familiarity with the available treatment options can facilitate initiation of the most appropriate therapy for each patient. The best plan of action is to stabilize the patient and refer him or her to a tertiary center with clinicians who have experience in managing this uncommon problem.

Current Management of Sinusoidal Portal Hypertension

Portal hypertension resulting from cirrhosis was one of the biggest challenges faced by general surgeons up until the past two decades. The management of portal hypertensive variceal hemorrhage has undergone dramatic changes during this period. Endoscopic variceal ligation and transjugular intrahepatic portosystemic shunts are currently used with great success. The degree of liver dysfunction remains the most important determinant of outcome in these patients. Patients with cirrhosis who have good liver function and recurrent variceal bleed remain candidates for shunt surgery. However, the need for surgical intervention has become a rarity. The success of liver transplantation has ensured that portal hypertension is cured permanently and one does not often see the critically ill and decompensated patient with cirrhosis on the surgical service. A review of the current treatment options in this very ill patient population is the primary focus of this article.