Leading article
Surgical treatment for portal hypertension M. A. Mercado Surgical Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico, DF 14080 (e-mail: [email protected]) Based on the BJS lecture delivered at the Annual Meeting of the European Surgical Association, Warsaw, Poland, May 2015
Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9849
During the second half of the 20th century, one of the most interesting and thriving fields in surgery was the treatment of portal hypertension. A great number of surgical techniques were developed (shunts and devascularization procedures), with many publications supporting or rejecting their applications. Shunts and devascularization procedures had a parallel development, and both have been challenged by emerging treatment options. The interventional radiologist creates a portal– systemic shunt using a transjugular approach (transjugular intrahepatic portal–systemic shunt, TIPS) whereas the endoscopist has the option of injection sclerotherapy or, more recently, band ligation1 . Soon after the application of the portacaval shunt in 1948, several other options, such as central splenorenal and mesocaval shunts, were developed. They were all associated with low rebleeding rates, but often at the expense of hepatic encephalopathy and liver failure. The portacaval shunt is still used by Orloff’s group with good results, reflecting their extensive degree of experience with this procedure2 . No other group has confirmed their results; nor have they been refuted. The most studied shunt is the selective distal splenorenal shunt (DSRS) developed by W. Dean Warren. This shunt was designed to selectively decompress the oesophagogastric and splenic area while maintaining mesenteric portal blood flow to the liver. Its main disadvantage, however, was loss of selectivity and late function as a total shunt3 . In © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
the 1980s this shunt was compared with sclerotherapy, showing a lower rebleeding rate, but the same survival. In the 1990s the shunt was compared with liver transplantation; in general, the long-term results of shunting were inferior to those of transplantation, although in a highly selected population it had better results. In the late 1990s selective shunting was also compared with TIPS among patients with Child–Pugh A disease, with similar outcomes. Both the Warren procedure and TIPS were shown to be feasible as bridge therapies before liver transplantation4 . In the past 15 years, the widespread use of variceal band ligation and evidence-based supportive pharmacotherapy, however, seems to have relegated surgical shunts to a secondary treatment. This is exemplified at the author’s centre where some 30 years of surgical treatment for portal hypertension has been superseded by band ligation in the past decade. Three operations were used: the DSRS; extensive oesophagogastric devascularization with splenectomy, using a two-stage thoracic and abdominal approach (Sugiura–Futagawa procedure) that later evolved into a complete portoazygos disconnection without splenectomy and oesophageal transection; and the small-diameter portal–systemic shunt (thought to function similarly to TIPS)5 – 8 . Both DSRS and complete portoazygos disconnection were associated with good results. Mortality rates were low (2.7 per cent), long-term results acceptable (encephalopathy rate 6 per
cent, rebleeding rate 6 per cent) and survival was good9 . In the past decade, surgery for portal hypertension has been replaced at this centre by band ligation and, in selected patients, liver transplantation (about 45 patients per year). Very few patients are selected for surgical treatment: those refractory to endoscopic treatment with a Child–Pugh A classification, low Model for End-stage Liver Disease score, and good pulmonary and renal function. As in many parts of the world, donor livers are in short supply in Mexico and liver transplantation is not readily available. Surgical treatment should, however, still be considered in patients with ‘normal’ livers, for instance in those with schistosomiasis and other causes of prehepatic portal hypertension, but therein lies the problem. Few surgeons nowadays have been trained in, or are familiar with, the surgical treatment of portal hypertension, so the option of surgery is discounted. Interestingly, comparative studies have shown little difference in outcomes between surgical and nonsurgical approaches. A prospective controlled clinical trial4 at five centres in the USA involving 140 patients with Child–Pugh A or B disease randomized to DSRS or TIPS showed no significant difference in rebleeding (5.5 and 10.5 per cent respectively) or first encephalopathy event. Survival was also the same, despite the combined rate of thrombosis, stenosis and need for reintervention being much lower after patency for DSRS (11 per cent) compared with TIPS (82 per cent). BJS 2015; 102: 717–718
718
A Cochrane review10 in 2006 compared total surgical shunts, DSRS and TIPS with endoscopic therapy (sclerotherapy and/or banding). Some 22 trials involving 1409 patients were included. Shunts had less rebleeding at the expense of more acute and chronic encephalopathy. There were no differences in short-term mortality or long-term survival. The shunt occlusion rate was 3.1 per cent overall, 7.8 per cent for DSRS and 59 per cent for TIPS. In addition, individual series are informative regarding choice of procedure and factors that influence outcome. An assessment of a modified Sugiura procedure had an operative mortality rate of 7 per cent, with a rebleeding rate of 7 per cent11 . The authors proposed modified devascularization as rescue therapy for patients who are not candidates for selective shunt, TIPS and transplantation. A review of 34 years’ experience with selective shunt surgery in Miami demonstrated 5-, 10- and 20-year survival rates of 58.9, 34.4 and 12.5 per cent respectively. Recurrent bleeding occurred in 12 per cent and encephalopathy in 13.4 per cent of patients. Alcoholic recidivism was an independent predictor of poor prognosis3 . The author’s institution described an experience with 1000 operations over five decades at the beginning of the 21st century9 . Operations were classified as portal blood flowpreserving procedures (selective shunts and devascularization) or total shunts. In the past decade only lowrisk patients (Child–Pugh A) have been selected for surgery. A wide spectrum of results was originally seen in the total shunt group, with a high encephalopathy rate of 40 per cent. For portal blood flow-preserving procedures, the mortality rate was 2.7 per cent, with a postoperative
© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
M. A. Mercado
encephalopathy rate of 6 per cent in the shunt group. Devascularization had the lowest rate of encephalopathy (2 per cent) with a rebleeding rate of 6 per cent. The conclusion was that these operations should be done in highly selected patients (Child–Pugh A), with the type of operation (selective shunt or devascularization) chosen according to the individual characteristics of each patient. Surgery for portal hypertension had a leading role in the development of modern surgery. These procedures have disappeared this century because they ‘failed to win’ prospective multicentre randomized trials against less invasive strategies. The evolution of treatment of portal hypertension left the operations behind. The present generation of surgeons is destined to miss a set of wonderful operations. For those of us who were involved, it was a privilege to be part of that surgical generation12 .
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6
7
8
Disclosure
The author declares no conflict of interest.
9
References 1 Wolff M, Hirner A. [Surgical treatment of portal hypertension.] Zentralbl Chir 2005; 130: 238–245. 2 Orloff MJ. Fifty-three years’ experience with randomized clinical trials of emergency portocaval shunt for bleeding esophageal varices in cirrhosis: 1958–2011. JAMA Surg 2014; 149: 155–169. 3 Livingstone AS, Koniaris LG, Perez EA, Alvarez N, Levi JU, Hutson DG. 507 Warren–Zeppa distal splenorenal shunts: a 34-year experience. Ann Surg 2006; 243: 884–892. 4 Henderson JM, Boyer TD, Kutner MH, Galloway JR, Rikkers LF, Jeffers LJ et al; DIVERT Study Group. Distal splenorenal shunt versus
www.bjs.co.uk
10
11
12
transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial. Gastroenterology 2006; 130: 1643–1651. Orozco H, Mercado MA, Granados Garcia J, Hernandez-Ortiz J, Tielve M, Chan C et al. Selective shunts for portal hypertension: current role of a 21-year experience. Liver Transpl Surg 1997; 3: 475–480. Mercado MA, Morales-Linares JC, Granados-García J, Gómez-Méndez TJ, Chan C, Orozco H. Distal splenorenal shunt versus 10-mm low-diameter mesocaval shunt for variceal hemorrhage. Am J Surg 1996; 171: 591–595. Mercado MA, Orozco H, Chan C, Hinojosa C, Gálvez-Treviño R, Ramos-Gallardo G. Surgical treatment of non-cirrhotic presinusoidal portal hypertension. Hepatogastroenterology 2004; 51: 1757–1760. Mercado MA, Orozco H, Ramírez-Cisneros FJ, Hinojosa CA, Plata JJ, Alvarez-Tostado J. Diminished morbidity and mortality in portal hypertension surgery: relocation in the therapeutic armamentarium. J Gastrointest Surg 2001; 5: 499–502. Orozco H, Mercado MA. The evolution of portal hypertension surgery: lessons from 1000 operations and 50 years’ experience. Arch Surg 2000; 135: 1389–1393. Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev 2006; (4)CD000553. Selzner M, Tuttle-Newhall JE, Dahm F, Suhocki P, Clavien PA. Current indication of a modified Sugiura procedure in the management of variceal bleeding. J Am Coll Surg 2001; 193: 166–173. Orozco H, Mercado MA. Rise and downfall of the empire of portal hypertension surgery. Arch Surg 2007; 142: 219–221.
BJS 2015; 102: 717–718
Surgical treatment for portal hypertension M. A. Mercado Surgical Division, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico, DF 14080 (e-mail: [email protected]) Based on the BJS lecture delivered at the Annual Meeting of the European Surgical Association, Warsaw, Poland, May 2015
Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9849
During the second half of the 20th century, one of the most interesting and thriving fields in surgery was the treatment of portal hypertension. A great number of surgical techniques were developed (shunts and devascularization procedures), with many publications supporting or rejecting their applications. Shunts and devascularization procedures had a parallel development, and both have been challenged by emerging treatment options. The interventional radiologist creates a portal– systemic shunt using a transjugular approach (transjugular intrahepatic portal–systemic shunt, TIPS) whereas the endoscopist has the option of injection sclerotherapy or, more recently, band ligation1 . Soon after the application of the portacaval shunt in 1948, several other options, such as central splenorenal and mesocaval shunts, were developed. They were all associated with low rebleeding rates, but often at the expense of hepatic encephalopathy and liver failure. The portacaval shunt is still used by Orloff’s group with good results, reflecting their extensive degree of experience with this procedure2 . No other group has confirmed their results; nor have they been refuted. The most studied shunt is the selective distal splenorenal shunt (DSRS) developed by W. Dean Warren. This shunt was designed to selectively decompress the oesophagogastric and splenic area while maintaining mesenteric portal blood flow to the liver. Its main disadvantage, however, was loss of selectivity and late function as a total shunt3 . In © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
the 1980s this shunt was compared with sclerotherapy, showing a lower rebleeding rate, but the same survival. In the 1990s the shunt was compared with liver transplantation; in general, the long-term results of shunting were inferior to those of transplantation, although in a highly selected population it had better results. In the late 1990s selective shunting was also compared with TIPS among patients with Child–Pugh A disease, with similar outcomes. Both the Warren procedure and TIPS were shown to be feasible as bridge therapies before liver transplantation4 . In the past 15 years, the widespread use of variceal band ligation and evidence-based supportive pharmacotherapy, however, seems to have relegated surgical shunts to a secondary treatment. This is exemplified at the author’s centre where some 30 years of surgical treatment for portal hypertension has been superseded by band ligation in the past decade. Three operations were used: the DSRS; extensive oesophagogastric devascularization with splenectomy, using a two-stage thoracic and abdominal approach (Sugiura–Futagawa procedure) that later evolved into a complete portoazygos disconnection without splenectomy and oesophageal transection; and the small-diameter portal–systemic shunt (thought to function similarly to TIPS)5 – 8 . Both DSRS and complete portoazygos disconnection were associated with good results. Mortality rates were low (2.7 per cent), long-term results acceptable (encephalopathy rate 6 per
cent, rebleeding rate 6 per cent) and survival was good9 . In the past decade, surgery for portal hypertension has been replaced at this centre by band ligation and, in selected patients, liver transplantation (about 45 patients per year). Very few patients are selected for surgical treatment: those refractory to endoscopic treatment with a Child–Pugh A classification, low Model for End-stage Liver Disease score, and good pulmonary and renal function. As in many parts of the world, donor livers are in short supply in Mexico and liver transplantation is not readily available. Surgical treatment should, however, still be considered in patients with ‘normal’ livers, for instance in those with schistosomiasis and other causes of prehepatic portal hypertension, but therein lies the problem. Few surgeons nowadays have been trained in, or are familiar with, the surgical treatment of portal hypertension, so the option of surgery is discounted. Interestingly, comparative studies have shown little difference in outcomes between surgical and nonsurgical approaches. A prospective controlled clinical trial4 at five centres in the USA involving 140 patients with Child–Pugh A or B disease randomized to DSRS or TIPS showed no significant difference in rebleeding (5.5 and 10.5 per cent respectively) or first encephalopathy event. Survival was also the same, despite the combined rate of thrombosis, stenosis and need for reintervention being much lower after patency for DSRS (11 per cent) compared with TIPS (82 per cent). BJS 2015; 102: 717–718
718
A Cochrane review10 in 2006 compared total surgical shunts, DSRS and TIPS with endoscopic therapy (sclerotherapy and/or banding). Some 22 trials involving 1409 patients were included. Shunts had less rebleeding at the expense of more acute and chronic encephalopathy. There were no differences in short-term mortality or long-term survival. The shunt occlusion rate was 3.1 per cent overall, 7.8 per cent for DSRS and 59 per cent for TIPS. In addition, individual series are informative regarding choice of procedure and factors that influence outcome. An assessment of a modified Sugiura procedure had an operative mortality rate of 7 per cent, with a rebleeding rate of 7 per cent11 . The authors proposed modified devascularization as rescue therapy for patients who are not candidates for selective shunt, TIPS and transplantation. A review of 34 years’ experience with selective shunt surgery in Miami demonstrated 5-, 10- and 20-year survival rates of 58.9, 34.4 and 12.5 per cent respectively. Recurrent bleeding occurred in 12 per cent and encephalopathy in 13.4 per cent of patients. Alcoholic recidivism was an independent predictor of poor prognosis3 . The author’s institution described an experience with 1000 operations over five decades at the beginning of the 21st century9 . Operations were classified as portal blood flowpreserving procedures (selective shunts and devascularization) or total shunts. In the past decade only lowrisk patients (Child–Pugh A) have been selected for surgery. A wide spectrum of results was originally seen in the total shunt group, with a high encephalopathy rate of 40 per cent. For portal blood flow-preserving procedures, the mortality rate was 2.7 per cent, with a postoperative
© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
M. A. Mercado
encephalopathy rate of 6 per cent in the shunt group. Devascularization had the lowest rate of encephalopathy (2 per cent) with a rebleeding rate of 6 per cent. The conclusion was that these operations should be done in highly selected patients (Child–Pugh A), with the type of operation (selective shunt or devascularization) chosen according to the individual characteristics of each patient. Surgery for portal hypertension had a leading role in the development of modern surgery. These procedures have disappeared this century because they ‘failed to win’ prospective multicentre randomized trials against less invasive strategies. The evolution of treatment of portal hypertension left the operations behind. The present generation of surgeons is destined to miss a set of wonderful operations. For those of us who were involved, it was a privilege to be part of that surgical generation12 .
5
6
7
8
Disclosure
The author declares no conflict of interest.
9
References 1 Wolff M, Hirner A. [Surgical treatment of portal hypertension.] Zentralbl Chir 2005; 130: 238–245. 2 Orloff MJ. Fifty-three years’ experience with randomized clinical trials of emergency portocaval shunt for bleeding esophageal varices in cirrhosis: 1958–2011. JAMA Surg 2014; 149: 155–169. 3 Livingstone AS, Koniaris LG, Perez EA, Alvarez N, Levi JU, Hutson DG. 507 Warren–Zeppa distal splenorenal shunts: a 34-year experience. Ann Surg 2006; 243: 884–892. 4 Henderson JM, Boyer TD, Kutner MH, Galloway JR, Rikkers LF, Jeffers LJ et al; DIVERT Study Group. Distal splenorenal shunt versus
www.bjs.co.uk
10
11
12
transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial. Gastroenterology 2006; 130: 1643–1651. Orozco H, Mercado MA, Granados Garcia J, Hernandez-Ortiz J, Tielve M, Chan C et al. Selective shunts for portal hypertension: current role of a 21-year experience. Liver Transpl Surg 1997; 3: 475–480. Mercado MA, Morales-Linares JC, Granados-García J, Gómez-Méndez TJ, Chan C, Orozco H. Distal splenorenal shunt versus 10-mm low-diameter mesocaval shunt for variceal hemorrhage. Am J Surg 1996; 171: 591–595. Mercado MA, Orozco H, Chan C, Hinojosa C, Gálvez-Treviño R, Ramos-Gallardo G. Surgical treatment of non-cirrhotic presinusoidal portal hypertension. Hepatogastroenterology 2004; 51: 1757–1760. Mercado MA, Orozco H, Ramírez-Cisneros FJ, Hinojosa CA, Plata JJ, Alvarez-Tostado J. Diminished morbidity and mortality in portal hypertension surgery: relocation in the therapeutic armamentarium. J Gastrointest Surg 2001; 5: 499–502. Orozco H, Mercado MA. The evolution of portal hypertension surgery: lessons from 1000 operations and 50 years’ experience. Arch Surg 2000; 135: 1389–1393. Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev 2006; (4)CD000553. Selzner M, Tuttle-Newhall JE, Dahm F, Suhocki P, Clavien PA. Current indication of a modified Sugiura procedure in the management of variceal bleeding. J Am Coll Surg 2001; 193: 166–173. Orozco H, Mercado MA. Rise and downfall of the empire of portal hypertension surgery. Arch Surg 2007; 142: 219–221.
BJS 2015; 102: 717–718
