The surgical treatment for portal hypertension: a systematic review and meta-analysis

Early Experience with Surgical Management of Non-Cirrhotic Portal Hypertension in Nigeria: Report from a Single Centre

Introduction

Portal hypertension is characterised by an increase in portal pressure. It may be a result of cirrhosis of the liver or non-cirrhotic hepatic and portal vein diseases. Non-cirrhotic portal hypertension (NCPH) is caused by a heterogeneous group of diseases affecting the liver and extrahepatic locations. In our setting, the most common cause of NCPH is schistosomiasis. We describe our experience in the surgical management of NCPH.

Materials and Methods

This is a single centre retrospective study of all patients who had surgery for NCPH from January 2015 to December 2023 was retrieved for data collection. Data collected included the cause of portal hypertension, age, gender, indication for surgery, type of surgery, and outcome of surgery. Data were analysed using SPSS version 26.

Results

A total of 13 patients had surgery for NCPH. The most common cause of NCPH was hepatosplenic schistosomiasis in 10 patients, whereas the remaining 3 patients had idiopathic NCPH. The indication for surgery was upper gastrointestinal bleeding secondary to oesophageal varices refractory to endoscopic therapy. The surgical intervention of choice includes the modified Sugiura procedure in five patients and the Hassab procedure in eight patients. Variceal rebleeding was seen in two patients within 1 year of surgery (15%) and in only three patients within 3 years of surgery (23%).

Conclusion

Surgical treatment of NCPH is associated with good outcomes in patients with failed endoscopic therapy.

Decompensated portal hypertension complicated by bleeding

Despite the fact that the risk of death from esophagogastric variceal bleeding caused by portal hypertension is highest in patients with gastrointestinal bleeding, the diagnosis and treatment need to be further improved. This study is based on the analysis of scientific and practical data about the diagnosis and treatment of patients with complicated portal hypertension, which allows us to understand the complexity of the pathological process, the causes of unsatisfactory diagnostic and treatment results, and the possibility of providing routine and emergency care. Management of portal hypertension includes prevention of the first bleeding, treatment of acute variceal bleeding, and prevention of recurrent bleeding. The literature review based on sources from PubMed, MEDLINE aims to demonstrate the methods of diagnosing and treating bleeding from the esophageal and gastric veins in medical institutions with different levels of capacity.

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.

Clinical factors that influence the outcome of selective devascularization in the treatment of portal hypertension

There is a high incidence of death due to variceal hemorrhage in patients with portal hypertension. Factors to consider when choosing selective devascularization in the treatment of variceal hemorrhage remain a controversy. This study aims to generate the prevalent clinical risk factors that affect the outcomes of selective devascularization procedures. Elucidating these features may guide future treatment of esophageal varices in patients with portal hypertension. We retrospectively analyzed medical records of 455 patients who underwent selective devascularization procedures in our center. Patients were subject to splenectomy, selective devascularization with or without esophageal transection. The mode of surgery recurred in comparable rates in both the group with major complications postoperatively (high-risk group which consisted of 63 patients) or the group without major postoperative complications (low-risk group, 392). Risk factors that negatively influenced outcomes of surgery include severe symptoms (89% in high risk group and 71% in low risk group), large volume of blood loss in the hemorrhage before surgery (81% in high risk group and 16% in low risk group), sever liver cirrhosis (83% in high risk group and 67% in low risk group), previous endotherapy, prolonged prothrombin time, and poor liver function. Selective devascularization is a feasible option to treat variceal hemorrhage in patients with portal hypertension.

Microwave ablation versus hepatic resection for the treatment of hepatocellular carcinoma and oesophageal variceal bleeding in cirrhotic patients

PURPOSE

The aim of this study was to compare the results of microwave ablation (MWA) and hepatic resection (HR) when combined with pericardial devascularisation plus splenectomy (PCDV) for the treatment of patients with cirrhosis complicated by small hepatocellular carcinoma (HCC) and oesophageal variceal bleeding (EVB).

MATERIALS AND METHODS

Between 2001 and 2013, 73 patients (median age 53.2 years, 67% male) with small HCC and concomitant EVB who underwent MWA or HR for HCC and PCDV for cirrhotic portal hypertension were selected retrospectively for inclusion in this study. The overall survival curves and recurrence-free survival curves were calculated using the Kaplan-Meier method and compared using log-rank tests. Multivariate analysis was performed using the Cox regression model.

RESULTS

The 1-, 3- and 5-year overall survival rates were 95.2%, 71.4% and 38.1% and 96.7%, 53.3% and 43.3% for the HR and MWA groups, respectively; these did not differ significantly between the two groups. However, patients in the HR group had more post-operative complications (52.3% vs. 13.7%; p = 0.002). Multivariate analysis identified albumin and bilirubin levels and tumour size to be statistically significant and independent prognostic factors for overall survival, while BCLC stage was associated with poor recurrence-free survival. Furthermore, albumin levels were shown to be an independent predictive factor for post-operative complications.

CONCLUSIONS

For patients with small HCC and concomitant EVB, MWA plus PCDV may reduce the incidence of post-operative complications relative to and provide similar therapeutic benefits as HR plus PCDV, especially for patients with low albumin levels.

Hypersplenism is correlated with increased risk of hepatocellular carcinoma in patients with post-hepatitis cirrhosis

Several risk factors exist for hepatocellular carcinoma in patients with post-hepatitis cirrhosis (PHC), including hypersplenism. Splenectomy is a common but controversial procedure in the management of hypersplenism, but its impact on hepatocellular carcinoma (HCC) remains uncertain. We conducted a hospital-based study of PHC patients to identify potential risk factors, including a history of splenectomy, which has been associated with progression from PHC to HCC. From 2002 to 2012, 2678 patients developed hypersplenism secondary to PHC. Of these patients, 828 developed HCC and 1850 did not. Potential risk factors of HCC were determined by univariate and multivariate analyses to exclude confounding variables. Odds ratios (ORs) and 95 % confidence intervals (95 % CIs) were determined for each factor. Many factors, such as liver function, platelet (PLT) counts, Child-Pugh class, and history of hepatitis, were associated with progression to HCC. PHC patients with hypersplenism who displayed elevated levels of alanine transaminase (ALT), aspartate transaminase (AST), γ-glutamyltransferase (GGT), ALK, phosphatase, and prolonged prothrombin time (PT) had a significantly increased risk of HCC. However, the patients who had splenectomy showed better liver function test results and less progression to HCC. In patients with PHC and hypersplenism, abnormal levels of ALT, AST, ALP, and GGT and prolonged PT are risk factors of HCC. Splenectomy, as the intervention method of hypersplenism, is performed less frequently in patients who developed HCC than in patients who did not develop HCC. Therefore, splenectomy may act as an independent factor that is significantly associated with HCC development.

Radiofrequency ablation plus devascularization is the preferred treatment of hepatocellular carcinoma with esophageal varices

BACKGROUND

Most hepatocellular carcinomas (HCCs) are associated with cirrhosis. Portal hypertension (PHT) and esophageal variceal bleeding (EVB) can limit the patient's treatment options. Surgical therapy in such patients is challenging. We performed devascularization plus liver resection or radiofrequency ablation (RFA) to treat HCC patients with concomitant EVB resulting from PHT secondary to cirrhosis. Such combined operations have never been reported for the management of HCC patients with variceal esophageal bleeding.

AIM

To evaluate two different treatment regimens for patients with HCC and EVB.

METHODS

We evaluated 35 BCLC stage 0/A patients with HCC and EVB who underwent either devascularization plus liver resection (Group A) or devascularization plus RFA (Group B). We reviewed the safety and outcomes of the two groups and assessed risk factors for patient survival and tumor recurrence.

RESULTS

Significant factors for overall survival were surgical approach and Child-Pugh classification. Child-Pugh classification was the only independent risk factor for overall postoperative survival [hazard ratio (HR) 8.320, 95 % confidence interval (CI) 1.739-39.799, P = 0.008]. Age was the only independent risk factor for tumor recurrence (HR 4.025, 95 % CI 1.343-12.062, P = 0.013).

CONCLUSIONS

RFA plus devascularization is the preferred treatment of HCC with EVB. RFA plus devascularization should be considered in Child-Pugh class A patients below 50 years of age.