Skip to Main Content

++
++
++
++
++
++
++

Portal decompression is indicated in patients who have portal hypertension complicated by gastrointestinal hemorrhage from esophageal varices that are not effectively controlled with sclerotherapy injections. Some procedures completely interrupt portal venous flow to the liver (end-to-side portacaval shunt), while others selectively decompress the portal system via a collateral shunt (side-to-side portacaval, splenorenal, and mesocaval). The procedure selected will depend upon the patency of the portal and splenic veins, the results of liver function studies, the amount of portal venous blood being shunted, and whether the patient is bleeding acutely.

++

Selection of patients should be based on their clinical status, results of liver function studies, and interpretation of hepatic hemodynamics as determined by radiologic studies. Patients considered for shunting procedures generally should be under 60 years of age. Ideally, there should be no evidence of encephalopathy, jaundice, ascites, or muscle wasting. Serum albumin should be above 3 g/dL, prothrombin time greater than 1.5 times normal, and sodium sulfobromophthalein below 30% at 30 minutes. Deviation from these criteria does not absolutely contraindicate surgery, but the surgical risk is directly proportional to the degree of hepatic decompensation. Finally, liver transplantation may be considered.

++

Shunting procedures for portal hypertension can be divided into three types: portacaval, splenorenal, and mesocaval. Figures A, B, C, D, E, and F show diagrammatically the basic surgical choices for diversion of the portal venous flow.

++

The primary indication for portacaval shunt is the control of massive upper-gastrointestinal hemorrhage from varices which cannot be controlled with endoscopic ablation or when transjugular intrahepatic portosystemic shunts (TIPS) are not available. Portacaval shunts are sometimes preferred when there has been prior splenectomy, splenic vein thrombosis, reversal of flow in the portal vein, thrombosed splenorenal shunt, ascites, or hepatic vein thrombosis. The selection of a direct portacaval shunt, of course, depends upon the demonstration of a patent portal vein preoperatively or at laparotomy.

++

The side-to-side anastomosis (Figure A) has been preferred by some in the presence of portal hypertension with no evidence of a rise in pressure on the hepatic end of the temporarily occluded portal vein. This suggests that the arterial blood supply is going through the liver and that lowering of the portal pressure by the side-to-side anastomosis with the vena cava ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.