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Key Points

  1. Etiology of portal hypertension may be classified as prehepatic, intrahepatic, or posthepatic.

  2. Extrahepatic portal vein obstruction (EPVO) is the most common type of prehepatic obstruction.

  3. Most cases of acute variceal bleeding can be controlled with fluid resuscitation, correction of coagulopathy, and pharmacologic support.

  4. Octreotide is the most commonly used pharmacologic intervention in the management of acute variceal bleeding.

  5. Upper endoscopy is an important intervention for both diagnostic and therapeutic purposes in acute variceal bleeding.

  6. Endoscopic sclerotherapy or band ligation can be used to control refractory variceal bleeding.

  7. Classification of portosystemic shunts: nonselective shunt, selective shunt, direct reconstruction of portal circulation.

  8. H-type mesocaval shunt is the most commonly used nonselective shunt.

  9. The most common selective shunt is the distal splenorenal shunt.

  10. EPVO is optimally managed by the mesentericoportal shunt (Rex shunt).

  11. Transjugular intrahepatic portosystemic shunt (TIPS) may be used as a bridge for liver transplantation in patients with intrinsic liver disease who have acute unresponsive variceal bleeding.

  12. If significant portal hypertensive complications are accompanied by progressive hepatic synthetic failure, liver transplantation is preferred.

Technical Points Summary: Surgical Shunts

  1. Intraoperative mesentericoportal venography and measurement of portal pressures.

  2. Use of autologous venous conduit (internal jugular vein), if conduit is necessary.

  3. Adequate mobilization of inflow and outflow vessels.

  4. Fine monofilament suture for anastomoses.

  5. Postreconstructive venography is critical.

  6. Selective postoperative intravenous anticoagulation in high-risk patients.

  7. Antiplatelet therapy for 30 to 90 postoperative days.

Portal Hypertension in Children

The management of children with portal hypertension has evolved significantly over the past 2 decades. Improved survival in such patients has resulted secondary to both medical therapies and surgical interventions, including: (a) progress in the pharmacologic control of acute portal hypertensive hemorrhage; (b) improved efficacy and safety of endoscopic methods to treat acute esophageal variceal hemorrhage, which may also reduce the risk of rebleeding; (c) recognition of the role for traditional or innovative surgical therapy (portocaval shunts or reconstruction); and (d) improved outcomes following pediatric liver transplantation as a definitive treatment for children with end-stage liver disease/life-threatening complications of portal hypertension.

Historical Overview

The principle of the surgical treatment of portal hypertension began with the work of Nikolai Eck in 1877. In dogs, he fashioned a side-to-side portal vein–inferior vena cava anastomosis following which he ligated the hepatic limb of the portal vein, thus creating a functional end-to-side shunt. In 1898, Benti described the portal hypertensive state, a syndrome of splenomegaly and gastrointestinal bleeding. Five years later, Eugene Vidal performed the first successful shunt in humans, an end-to-side shunt that successfully controlled bleeding, but which eventually was complicated by recurrent ascites, encephalopathy, and death. In pediatric surgery, Marion, in 1953, and Clatworthy, in 1955, described a mesocaval shunt in which a divided common iliac vein was turned up and connected to the side of the superior mesenteric vein (SMV). In 1972, Drapanas popularized the ...

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