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General Surgery
Portal Hypertension
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 120 slides
Overview
- Definition of portal hypertension
- Scope of the problem
- Initial approach to the patient
History and pathophysiology
How the field developed, and what actually happens in the splanchnic and systemic circulations
- Early history of portal hypertension
- The surgical era of portal decompression
- Development of endoscopic therapy
- Advances led by non-surgeons
- Sequence of events in portal hypertension
- The splanchnic vascular response
- Sites where collateral veins appear
- 10-15 L/min
- Management implications of the hyperdynamic state
- Major complications of portal hypertension
- Distinguishing advanced from early liver disease
- Causes grouped by the site of the block
- Sites of obstruction in portal hypertension
- Relative frequency of the causes
- Causes of cirrhosis
Evaluating the patient
Assess the liver, the portal circulation and the varices at the first presentation
- Three essential components of the evaluation
- Clinical assessment of the liver
- Laboratory assessment of liver disease
- Scoring the severity of liver disease
- Child-Pugh score
- MELD score equation
- Finding the cause when the first tests do not fit
- Imaging the liver itself
- Doppler ultrasound of the portal circulation
- Cross-sectional imaging of the liver circulation
- Hepatic venous pressure gradient
- Direct portal pressure measurement
- 30%
- Endoscopic assessment of varices
- Grading systems and gastric findings
Treating variceal bleeding
Drugs, endoscopy, decompressive shunts, devascularization and transplantation
- Therapies available for variceal bleeding
- Management algorithm for variceal bleeding
- Following the treatment algorithm
- Roles of pharmacologic therapy
- Beta-blockers for portal hypertension
- Beta-blockers to prevent rebleeding
- Drug therapy for the acute variceal bleed
- Endoscopic band ligation of esophageal varices
- A course of banding treatment
- Banding compared with sclerotherapy
- First-line treatment after an acute bleed
- Current place of decompressive shunts
- Classification of surgical shunts
- End-to-side portacaval shunt
- Side-to-side portal systemic shunts
- The portoprival syndrome debate
- Technique of the side-to-side portacaval shunt
- Remaining indication for a total portal systemic shunt
- Partial shunts
- Distal splenorenal shunt
- Results of the distal splenorenal shunt
- Technique of the distal splenorenal shunt
- Postoperative care after shunt surgery
- Transjugular intrahepatic portal systemic shunt
- Technique of TIPS placement
- Early outcome and monitoring after TIPS
- Restenosis and thrombosis of a TIPS
- Reintervention, rebleeding and encephalopathy after TIPS
- Gastroesophageal devascularization
- Results of devascularization procedures
- Technique of devascularization
- Indications and follow-up after devascularization
- Liver transplantation in portal hypertension
- Patient selection for liver transplant
- Timing of transplant and organ allocation
- Expanding the donor pool
- <10%
- Interpreting the transplant outcome data
- Technical and follow-up advances in transplantation
Management strategies
Putting the treatments together for prophylaxis, the acute bleed and the prevention of rebleeding
- Three strategies for variceal bleeding
- Prophylaxis before the first bleed
- Resuscitation in acute variceal bleeding
- Drug and endoscopic therapy in the acute bleed
- Balloon tamponade
- Emergency TIPS in acute bleeding
- First-line prevention of rebleeding
- Full reassessment after a variceal bleed
- Good-risk patients after a bleed
- Indeterminate patients after a bleed
- End-stage liver disease after a bleed
- Failure of first-line treatment
- Randomised trial of TIPS versus the H-graft shunt
- Randomised trial of the distal splenorenal shunt versus TIPS
- Reintervention in the DSRS versus TIPS trial
- Covered stents as the current standard
Ascites
Medical management first; refractory ascites signals end-stage liver disease
- Medical management of ascites
- Refractory ascites
- Surgical options for ascites
- Peritoneovenous shunts
- The surgeon's role in ascites
Pulmonary syndromes in liver disease
Two opposite vascular disorders of the lung, with opposite implications for transplant
- Two distinct pulmonary vascular disorders
- Hepatopulmonary syndrome and portopulmonary hypertension
- Comparison of the two pulmonary syndromes
- Contributions of liver dysfunction and portal hypertension
- Clinical presentation of the pulmonary syndromes
- Diagnosis and treatment of hepatopulmonary syndrome
- Diagnosis of portopulmonary hypertension
- Portopulmonary hypertension and transplant eligibility
The multidisciplinary team
Who is involved, what each contributes, and who holds it together
- Members of the multidisciplinary team
- Roles of the core team members
- Supporting specialties and coordination
- Key points: definition and evaluation
- Key points: treatment
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- Maingot's Abdominal Operations, 12th Edition