EVOLUTION OF SURGERY OF PORTAL HYPERTENSION

IN Egypt (last century)

EVOLUTION OF SURGERY OF PORTAL HYPERTENSION

IN Egypt (last century)

Prof. Mohamed Abd ElwahabProf. Mohamed Abd ElwahabGastroenterology Surgical Center Gastroenterology Surgical Center

Mansoura UniversityMansoura University

Prof. Mohamed Abd ElwahabProf. Mohamed Abd ElwahabGastroenterology Surgical Center Gastroenterology Surgical Center

Mansoura UniversityMansoura University

• Hitherto, portal hypertension in Egypt (and allover the Hitherto, portal hypertension in Egypt (and allover the world) remains full of mysteries in its pathogenesis, world) remains full of mysteries in its pathogenesis, prevention and management. prevention and management.

• Eminent bleeding from varices remains the most Eminent bleeding from varices remains the most common problem faced by the medical profession in common problem faced by the medical profession in Egypt.Egypt.

• The “rightfor” and type management of such cases with The “rightfor” and type management of such cases with or without bleeding remains a battle ground between or without bleeding remains a battle ground between physicians and surgeons.physicians and surgeons.

• Hitherto, portal hypertension in Egypt (and allover the Hitherto, portal hypertension in Egypt (and allover the world) remains full of mysteries in its pathogenesis, world) remains full of mysteries in its pathogenesis, prevention and management. prevention and management.

• Eminent bleeding from varices remains the most Eminent bleeding from varices remains the most common problem faced by the medical profession in common problem faced by the medical profession in Egypt.Egypt.

• The “rightfor” and type management of such cases with The “rightfor” and type management of such cases with or without bleeding remains a battle ground between or without bleeding remains a battle ground between physicians and surgeons.physicians and surgeons.

The Story of Surgery of Portal The Story of Surgery of Portal Hypertension. Hypertension.

The Story of Surgery of Portal The Story of Surgery of Portal Hypertension. Hypertension.

•Nicolai Eck………. 1877Nicolai Eck………. 1877•Whipple……. 1935-1945Whipple……. 1935-1945•Linton……………1961 Linton……………1961 •Warren…………. 1966Warren…………. 1966•Drapanase……… 1975Drapanase……… 1975•Tips………. 1990-2002Tips………. 1990-2002

•Nicolai Eck………. 1877Nicolai Eck………. 1877•Whipple……. 1935-1945Whipple……. 1935-1945•Linton……………1961 Linton……………1961 •Warren…………. 1966Warren…………. 1966•Drapanase……… 1975Drapanase……… 1975•Tips………. 1990-2002Tips………. 1990-2002

• The story of the surgical treatment of The story of the surgical treatment of portal hypertension begins in 1877 in portal hypertension begins in 1877 in Russia. At that time Nicolai Eck described Russia. At that time Nicolai Eck described a portocaval shunt for treatment of portal a portocaval shunt for treatment of portal hypertension.hypertension.

((Eck Nv. 1953)Eck Nv. 1953)

• The story of the surgical treatment of The story of the surgical treatment of portal hypertension begins in 1877 in portal hypertension begins in 1877 in Russia. At that time Nicolai Eck described Russia. At that time Nicolai Eck described a portocaval shunt for treatment of portal a portocaval shunt for treatment of portal hypertension.hypertension.

((Eck Nv. 1953)Eck Nv. 1953)

• In In 1893 Pavlov1893 Pavlov and his Co-workers refuted and his Co-workers refuted ECK’s conclusion.ECK’s conclusion.

• Initial success in controlling variceal Initial success in controlling variceal bleeding was achieved in 1903 when Vidal bleeding was achieved in 1903 when Vidal performed a portocaval anastomosis in performed a portocaval anastomosis in cirrhotic patientscirrhotic patients

• In In 1893 Pavlov1893 Pavlov and his Co-workers refuted and his Co-workers refuted ECK’s conclusion.ECK’s conclusion.

• Initial success in controlling variceal Initial success in controlling variceal bleeding was achieved in 1903 when Vidal bleeding was achieved in 1903 when Vidal performed a portocaval anastomosis in performed a portocaval anastomosis in cirrhotic patientscirrhotic patients

• In 1935 Whipple et al. Studied the natural In 1935 Whipple et al. Studied the natural history of portal hypertensive bleeding in history of portal hypertensive bleeding in patients with cirrhosis, his initial success patients with cirrhosis, his initial success published in 1945 triggered an explosion of published in 1945 triggered an explosion of enthusiasm for portocaval shunt and its variantsenthusiasm for portocaval shunt and its variants

• Controlled prophylactic and therapeutic trials Controlled prophylactic and therapeutic trials over the following 15 years however confirmed over the following 15 years however confirmed the infectiveness of total shunt in prolonged the infectiveness of total shunt in prolonged survivalsurvival

• In 1935 Whipple et al. Studied the natural In 1935 Whipple et al. Studied the natural history of portal hypertensive bleeding in history of portal hypertensive bleeding in patients with cirrhosis, his initial success patients with cirrhosis, his initial success published in 1945 triggered an explosion of published in 1945 triggered an explosion of enthusiasm for portocaval shunt and its variantsenthusiasm for portocaval shunt and its variants

• Controlled prophylactic and therapeutic trials Controlled prophylactic and therapeutic trials over the following 15 years however confirmed over the following 15 years however confirmed the infectiveness of total shunt in prolonged the infectiveness of total shunt in prolonged survivalsurvival

• In an attempt to obviate or reduce the late morbidity and improve survival following portacaval shunt, several investigators looked for a procedure that would achieve variceal decompression without depriving the liver of its portal blood supply.

• Linton et al for example advocated splenectomy and central splenorenal shunt as a method which could meet these criteria, however with time, the shunt failed, either enlarged sufficiently or thrombosed.

• In an attempt to obviate or reduce the late morbidity and improve survival following portacaval shunt, several investigators looked for a procedure that would achieve variceal decompression without depriving the liver of its portal blood supply.

• Linton et al for example advocated splenectomy and central splenorenal shunt as a method which could meet these criteria, however with time, the shunt failed, either enlarged sufficiently or thrombosed.

• After central splenorenal Drapanas popularized After central splenorenal Drapanas popularized the mescoval interposition shunt and calaimed the mescoval interposition shunt and calaimed that this procedure succeeded in achieving that this procedure succeeded in achieving variceal decompression. This type of shunt variceal decompression. This type of shunt proved later on to be not effective in proved later on to be not effective in management of variceal bleeding due to high management of variceal bleeding due to high incidence of hepatic cell failure, encephalopathy incidence of hepatic cell failure, encephalopathy and shunt thrombosis.and shunt thrombosis.

• After central splenorenal Drapanas popularized After central splenorenal Drapanas popularized the mescoval interposition shunt and calaimed the mescoval interposition shunt and calaimed that this procedure succeeded in achieving that this procedure succeeded in achieving variceal decompression. This type of shunt variceal decompression. This type of shunt proved later on to be not effective in proved later on to be not effective in management of variceal bleeding due to high management of variceal bleeding due to high incidence of hepatic cell failure, encephalopathy incidence of hepatic cell failure, encephalopathy and shunt thrombosis.and shunt thrombosis.

• Selective decompression of gastro-esophageal Selective decompression of gastro-esophageal varices.varices.

• This shunt leaves the spleen.This shunt leaves the spleen.• Portal hypertension maintained for perfusion the Portal hypertension maintained for perfusion the

liver.liver.• Improvement of gastrointestinal congestion and Improvement of gastrointestinal congestion and

absorption.absorption.

• Selective decompression of gastro-esophageal Selective decompression of gastro-esophageal varices.varices.

• This shunt leaves the spleen.This shunt leaves the spleen.• Portal hypertension maintained for perfusion the Portal hypertension maintained for perfusion the

liver.liver.• Improvement of gastrointestinal congestion and Improvement of gastrointestinal congestion and

absorption.absorption.

Distal Spleno Renal 1967Shunt (Rational)

Distal Spleno Renal 1967Shunt (Rational)

IINN EEGGYYPPTT Ancient HistoryIINN EEGGYYPPTT

Ancient History

The Nile Valley was Inhabited at Least as The Nile Valley was Inhabited at Least as Early as 20,000 Years AgeEarly as 20,000 Years Age

The Nile Valley was Inhabited at Least as The Nile Valley was Inhabited at Least as Early as 20,000 Years AgeEarly as 20,000 Years Age

• Written document did not appear until the early Written document did not appear until the early dynastic period 3500-3000 B.C.dynastic period 3500-3000 B.C.

• Schistosomasis in EgyptSchistosomasis in Egypt discovered 3000 years ago as a discovered 3000 years ago as a written documents in the walls of the temple in upper written documents in the walls of the temple in upper Egypt.Egypt.

• They discovered the way of transmission, protection and They discovered the way of transmission, protection and the treatment.the treatment.

• Written document did not appear until the early Written document did not appear until the early dynastic period 3500-3000 B.C.dynastic period 3500-3000 B.C.

• Schistosomasis in EgyptSchistosomasis in Egypt discovered 3000 years ago as a discovered 3000 years ago as a written documents in the walls of the temple in upper written documents in the walls of the temple in upper Egypt.Egypt.

• They discovered the way of transmission, protection and They discovered the way of transmission, protection and the treatment.the treatment.

Two Ancient Egyptian Farmers wearing penile sheathTwo Ancient Egyptian Farmers wearing penile sheath

Circumcision , operation , Ankh . ma Hor’s tomb. Saqqara The operator rubs the organ by a stone (Right ) then cuts

by a shaped flint (left)

Abdominal distension and umbilical hernia in boatman ptah-Hetep’s tomb , Saqqara.

Hearst papyrus, case 83 which antimony (inset) is mentioned for first time to treat schistosomiasis.

In recent history. Dr. Theodor In recent history. Dr. Theodor Bilharz.Bilharz. in in Cairo, in 1851 discovered human Cairo, in 1851 discovered human

schistosomasis. schistosomasis.

In recent history. Dr. Theodor In recent history. Dr. Theodor Bilharz.Bilharz. in in Cairo, in 1851 discovered human Cairo, in 1851 discovered human

schistosomasis. schistosomasis.

In last century In last century

• Bleeding esophageal varices as a Bleeding esophageal varices as a complication of portal hypertension is the complication of portal hypertension is the most common causes of upper most common causes of upper gastrointestinal hemorrhage in Egypt. The gastrointestinal hemorrhage in Egypt. The economic impact of this disease is economic impact of this disease is compounded by the fact that it affect compounded by the fact that it affect individuals at the peak of their productive individuals at the peak of their productive life.life.

• Bleeding esophageal varices as a Bleeding esophageal varices as a complication of portal hypertension is the complication of portal hypertension is the most common causes of upper most common causes of upper gastrointestinal hemorrhage in Egypt. The gastrointestinal hemorrhage in Egypt. The economic impact of this disease is economic impact of this disease is compounded by the fact that it affect compounded by the fact that it affect individuals at the peak of their productive individuals at the peak of their productive life.life.

IN EGYPTIN EGYPTPORTAL HYPERTENSIONPORTAL HYPERTENSION

Evoluted in different waysEvoluted in different ways

11-Aetiopathology-Aetiopathology2- Haemodynamic2- Haemodynamic3- Managment3- Managment

11-Aetiopathology-Aetiopathology2- Haemodynamic2- Haemodynamic3- Managment3- Managment

AetiopathologyAetiopathology

•In 1928 sorourIn 1928 sorour followed by Hashem 1947 laid followed by Hashem 1947 laid down the foundation of the pathological pattern down the foundation of the pathological pattern of liver periportal fibrosis as a cause of portal of liver periportal fibrosis as a cause of portal hypertension.hypertension.

• The pathology of liver cirrhosis changed in the The pathology of liver cirrhosis changed in the late 70s and early 80s duo to appearance of type late 70s and early 80s duo to appearance of type B. hepatitis, C-hepatitis and mixed pathology.B. hepatitis, C-hepatitis and mixed pathology.

•In 1928 sorourIn 1928 sorour followed by Hashem 1947 laid followed by Hashem 1947 laid down the foundation of the pathological pattern down the foundation of the pathological pattern of liver periportal fibrosis as a cause of portal of liver periportal fibrosis as a cause of portal hypertension.hypertension.

• The pathology of liver cirrhosis changed in the The pathology of liver cirrhosis changed in the late 70s and early 80s duo to appearance of type late 70s and early 80s duo to appearance of type B. hepatitis, C-hepatitis and mixed pathology.B. hepatitis, C-hepatitis and mixed pathology.

• During the first half of the last century, hepatic During the first half of the last century, hepatic schistosomiasis represent the cause of portal schistosomiasis represent the cause of portal hypertension replaced by hepatic cirrhosis due hypertension replaced by hepatic cirrhosis due to hepatitis B and C viruses as a causes of portal to hepatitis B and C viruses as a causes of portal hypertension in the last two decades.hypertension in the last two decades.

• During the first half of the last century, hepatic During the first half of the last century, hepatic schistosomiasis represent the cause of portal schistosomiasis represent the cause of portal hypertension replaced by hepatic cirrhosis due hypertension replaced by hepatic cirrhosis due to hepatitis B and C viruses as a causes of portal to hepatitis B and C viruses as a causes of portal hypertension in the last two decades.hypertension in the last two decades.

Changes in liver pathology, last 20 Changes in liver pathology, last 20 years (1500 patients)years (1500 patients)

0

50

100

150

200

250

300

80-85 85-90 90-95 95-2000

Bil. Mixed Nonbil.

HomodynamicHomodynamic

• Intraoperative portal pressure Intraoperative portal pressure (occluded (occluded and free)and free) was measured for the first time by was measured for the first time by Khairy in 1960Khairy in 1960

• Study of splenic pulp in vivo by BadanStudy of splenic pulp in vivo by Badan

• Transplenic spleno portographyTransplenic spleno portography

• Selective superior mesenteric angiography Selective superior mesenteric angiography

• Intraoperative portal pressure Intraoperative portal pressure (occluded (occluded and free)and free) was measured for the first time by was measured for the first time by Khairy in 1960Khairy in 1960

• Study of splenic pulp in vivo by BadanStudy of splenic pulp in vivo by Badan

• Transplenic spleno portographyTransplenic spleno portography

• Selective superior mesenteric angiography Selective superior mesenteric angiography

Surgery has Evolved Widely DuringSurgery has Evolved Widely During the Last Century the Last Century

Surgery has Evolved Widely DuringSurgery has Evolved Widely During the Last Century the Last Century

DUE TODUE TO1.1. Change of liver pathologyChange of liver pathology2.2. Development of new surgical techniquesDevelopment of new surgical techniques3.3. Appearance of wide variety of alternative to the Appearance of wide variety of alternative to the

patient and phyciation patient and phyciation (pharmacological (pharmacological endoscopic, interventional radiology)endoscopic, interventional radiology)

DUE TODUE TO1.1. Change of liver pathologyChange of liver pathology2.2. Development of new surgical techniquesDevelopment of new surgical techniques3.3. Appearance of wide variety of alternative to the Appearance of wide variety of alternative to the

patient and phyciation patient and phyciation (pharmacological (pharmacological endoscopic, interventional radiology)endoscopic, interventional radiology)

ManagmentManagmentManagmentManagment

1- Splenectom1- Splenectom 190819082- Total shunt2- Total shunt 195019503- Non shunt 3- Non shunt 195719574- Mesocaval shunt4- Mesocaval shunt 197419745- Selective shunt5- Selective shunt 197819786- Injection sclerotherapy6- Injection sclerotherapy 198019807- Present status7- Present status

1- Splenectom1- Splenectom 190819082- Total shunt2- Total shunt 195019503- Non shunt 3- Non shunt 195719574- Mesocaval shunt4- Mesocaval shunt 197419745- Selective shunt5- Selective shunt 197819786- Injection sclerotherapy6- Injection sclerotherapy 198019807- Present status7- Present status

Surgery for portal hypertension started early in this century by splenectomy fot the first time in 1908. (Aly pasha Ibrahim 1908)

Surgery for portal hypertension started early in this century by splenectomy fot the first time in 1908. (Aly pasha Ibrahim 1908)

HoweverHowever though splenectomy lowered portal though splenectomy lowered portal pressure (75-40%) this proved to be at most pressure (75-40%) this proved to be at most temporary. temporary.

(Musa 1962-E-Sherif 1904))

HoweverHowever though splenectomy lowered portal though splenectomy lowered portal pressure (75-40%) this proved to be at most pressure (75-40%) this proved to be at most temporary. temporary.

(Musa 1962-E-Sherif 1904))

In the FortiesIn the FortiesIn the FortiesIn the Forties

• Total port-systemic shunts were introduced in Total port-systemic shunts were introduced in the west the west ((Whipple 1945-Blackkemone 1947).Whipple 1945-Blackkemone 1947).

• In Egypt shunt surgery was practiced in late In Egypt shunt surgery was practiced in late fiftiesfifties

• Total port-systemic shunts were introduced in Total port-systemic shunts were introduced in the west the west ((Whipple 1945-Blackkemone 1947).Whipple 1945-Blackkemone 1947).

• In Egypt shunt surgery was practiced in late In Egypt shunt surgery was practiced in late fiftiesfifties

Total ShuntsTotal ShuntsTotal ShuntsTotal Shunts

• In the 1950 portocaval shunts were applied to In the 1950 portocaval shunts were applied to schistosomal patients in Egypt. Up to 1970 this schistosomal patients in Egypt. Up to 1970 this type of surgery was criticized by many type of surgery was criticized by many surgeons. However because of the high surgeons. However because of the high incidence of mortality and morbidity this incidence of mortality and morbidity this procedure was abandoned in this patients.procedure was abandoned in this patients.

• In the 1950 portocaval shunts were applied to In the 1950 portocaval shunts were applied to schistosomal patients in Egypt. Up to 1970 this schistosomal patients in Egypt. Up to 1970 this type of surgery was criticized by many type of surgery was criticized by many surgeons. However because of the high surgeons. However because of the high incidence of mortality and morbidity this incidence of mortality and morbidity this procedure was abandoned in this patients.procedure was abandoned in this patients.

Non ShuntsNon Shunts

• In the 1960 Hassab popularized splenectomy and extensive devascualarization as a new surgical aaproach for schistosomal portal hypertension.

• In the same period Khairy 1964 introdced the operation of splenectomy and vasoligation of the oesophagus and stomach

• Many modification tried after those two operation in theforme of

• Suprediaphaogmatic devascualarization • Trans gastric ligation• Esophageal transection

• In the 1960 Hassab popularized splenectomy and extensive devascualarization as a new surgical aaproach for schistosomal portal hypertension.

• In the same period Khairy 1964 introdced the operation of splenectomy and vasoligation of the oesophagus and stomach

• Many modification tried after those two operation in theforme of

• Suprediaphaogmatic devascualarization • Trans gastric ligation• Esophageal transection

• Lack of satisfaction of splenectomy in thatment of O.V. Lack of satisfaction of splenectomy in thatment of O.V. has led to the development of porto-azygos has led to the development of porto-azygos disconnection in it’s different forms including Hassabs disconnection in it’s different forms including Hassabs operation (1959) Which is still practiced till now.operation (1959) Which is still practiced till now.

• Rational of Hassabs operation .Rational of Hassabs operation .

1.1.Decongestion of variceal bearing area.Decongestion of variceal bearing area.

2.2. Reduction of portal hypervolaemia.Reduction of portal hypervolaemia.

3.3. Improvement of all blood elements.Improvement of all blood elements.

4.4. Improvement of liver functionImprovement of liver function

• Lack of satisfaction of splenectomy in thatment of O.V. Lack of satisfaction of splenectomy in thatment of O.V. has led to the development of porto-azygos has led to the development of porto-azygos disconnection in it’s different forms including Hassabs disconnection in it’s different forms including Hassabs operation (1959) Which is still practiced till now.operation (1959) Which is still practiced till now.

• Rational of Hassabs operation .Rational of Hassabs operation .

1.1.Decongestion of variceal bearing area.Decongestion of variceal bearing area.

2.2. Reduction of portal hypervolaemia.Reduction of portal hypervolaemia.

3.3. Improvement of all blood elements.Improvement of all blood elements.

4.4. Improvement of liver functionImprovement of liver function

Non shuntNon shuntNon shuntNon shunt

Hassab’s operationHassab’s operation Hassab’s operationHassab’s operation

• Has the advantage of low operative mortality Has the advantage of low operative mortality low encephalopathy.low encephalopathy.

• However it faild to achieve its goal, with high However it faild to achieve its goal, with high rebleeding rates.rebleeding rates.

• Has the advantage of low operative mortality Has the advantage of low operative mortality low encephalopathy.low encephalopathy.

• However it faild to achieve its goal, with high However it faild to achieve its goal, with high rebleeding rates.rebleeding rates.

Mesocaval Graft In EGYPT (1976)Mesocaval Graft In EGYPT (1976)

1- Mortality1- Mortality 43%43%2- Encephalopathy2- Encephalopathy 30%30%3- Hepatic failure3- Hepatic failure 30%30%

1- Mortality1- Mortality 43%43%2- Encephalopathy2- Encephalopathy 30%30%3- Hepatic failure3- Hepatic failure 30%30%

Distal Spleno-Renal Shunts: DSRS(Selective Shunt)

Distal Spleno-Renal Shunts: DSRS(Selective Shunt)

• In the early 1970, with the era of the selective shunt. DSRS became popular in Egypt around 1972 and it was adopted by many Egyptian surgeons and still is

Over two decades later this type shunt was practiced allover Egypt.

• In the early 1970, with the era of the selective shunt. DSRS became popular in Egypt around 1972 and it was adopted by many Egyptian surgeons and still is

Over two decades later this type shunt was practiced allover Egypt.

Selective ShuntsSelective Shunts

•Science 1990 this type of shunt started to die out – Change of pathology

– Loss of selectivity

– Sclerotherapy

•Science 1990 this type of shunt started to die out – Change of pathology

– Loss of selectivity

– Sclerotherapy

• However with the passage of time However with the passage of time collateralization occurred turning it into collateralization occurred turning it into potentially total shunt with higher potentially total shunt with higher incidence of encephalopathy incidence of encephalopathy

• However with the passage of time However with the passage of time collateralization occurred turning it into collateralization occurred turning it into potentially total shunt with higher potentially total shunt with higher incidence of encephalopathy incidence of encephalopathy

Selective Shunt

Corono-renal ShuntCorono-renal ShuntSelective Shunt

Corono-renal ShuntCorono-renal Shunt

• An alternative to selective shuntAn alternative to selective shunt• Not used due to high incidence of Not used due to high incidence of

thrombosisthrombosis

• An alternative to selective shuntAn alternative to selective shunt• Not used due to high incidence of Not used due to high incidence of

thrombosisthrombosis

Injection SclerotherapyInjection Sclerotherapy

• In Egypt injection sclerotherapy started around 1975, was done by surgeons and still in many center using solid then flex scopes. Gradually it was taken over by endoscopists, and became the first and sometime the only line of treatment of bleeding varices.

• In Egypt injection sclerotherapy started around 1975, was done by surgeons and still in many center using solid then flex scopes. Gradually it was taken over by endoscopists, and became the first and sometime the only line of treatment of bleeding varices.

Transjuglar intra hepatic porto-Transjuglar intra hepatic porto-systemic shunts (TIPS)systemic shunts (TIPS)

Transjuglar intra hepatic porto-Transjuglar intra hepatic porto-systemic shunts (TIPS)systemic shunts (TIPS)

1- To bridge to transplancation1- To bridge to transplancationII- Last resort in acute bleeding in child CII- Last resort in acute bleeding in child C1- To bridge to transplancation1- To bridge to transplancationII- Last resort in acute bleeding in child CII- Last resort in acute bleeding in child C

Present statusPresent statusPresent statusPresent status

Sclerotherapy or band therapy are the treatment of choice. .

Is there is any place for surgey. Is there is any place for surgey. • Failure of sclerotherapy Failure of sclerotherapy •Gastric varices Gastric varices • Duodenal varicesDuodenal varices• Young patients with good liverYoung patients with good liver• Segmental portal hypertension Segmental portal hypertension

Sclerotherapy or band therapy are the treatment of choice. .

Is there is any place for surgey. Is there is any place for surgey. • Failure of sclerotherapy Failure of sclerotherapy •Gastric varices Gastric varices • Duodenal varicesDuodenal varices• Young patients with good liverYoung patients with good liver• Segmental portal hypertension Segmental portal hypertension

• Failures of sclorotherapyFailures of sclorotherapy – Failure to clear the esophagus.Failure to clear the esophagus.– Recurrent massive bleeding during treatment Recurrent massive bleeding during treatment – Development of gastro-duodenal varices.Development of gastro-duodenal varices.– Congestive gastropathy.Congestive gastropathy.

• Failures of sclorotherapyFailures of sclorotherapy – Failure to clear the esophagus.Failure to clear the esophagus.– Recurrent massive bleeding during treatment Recurrent massive bleeding during treatment – Development of gastro-duodenal varices.Development of gastro-duodenal varices.– Congestive gastropathy.Congestive gastropathy.

Gastric VaricesGastric VaricesGastric VaricesGastric Varices

• Bleeding gastric varices are usually massive Bleeding gastric varices are usually massive difficult to diagnose and to control.difficult to diagnose and to control.

• They are best controlled by surgery.They are best controlled by surgery.

• Shunt surgery is more superior than non-shunt.Shunt surgery is more superior than non-shunt.

• Bleeding gastric varices are usually massive Bleeding gastric varices are usually massive difficult to diagnose and to control.difficult to diagnose and to control.

• They are best controlled by surgery.They are best controlled by surgery.

• Shunt surgery is more superior than non-shunt.Shunt surgery is more superior than non-shunt.

From 1975-2002From 1975-20021337713377 patients patients

With bleeding varices managed in With bleeding varices managed in gastroenterology centergastroenterology centerMansoura UniversityMansoura University

EYYPTEYYPT

From 1975-2002From 1975-20021337713377 patients patients

With bleeding varices managed in With bleeding varices managed in gastroenterology centergastroenterology centerMansoura UniversityMansoura University

EYYPTEYYPT

Management of bleeding varices in Management of bleeding varices in gastroenterolgy center mansoura gastroenterolgy center mansoura

UniversityUniversity

• SurgerySurgery 19151915• Injection sclerotherpyInjection sclerotherpy 1146711467• SurgerySurgery 19151915• Injection sclerotherpyInjection sclerotherpy 1146711467

Type of Treatment by PeriodType of Treatment by PeriodType of Treatment by PeriodType of Treatment by Period

75-8075-80 80-8580-85 85-9085-90 90-9590-95 95-200095-2000

SurgreySurgrey 108108 374374 454454 468468 387387InjectionInjection 00 560560 12501250 45004500 51575157

75-8075-80 80-8580-85 85-9085-90 90-9590-95 95-200095-2000

SurgreySurgrey 108108 374374 454454 468468 387387InjectionInjection 00 560560 12501250 45004500 51575157

Type of OperationType of OperationType of OperationType of Operation

NoNo %%

Slective shuntSlective shuntDistal splenorenalDistal splenorenal 606606 3232CoronorenalCoronorenal 4040 22

Total shuntTotal shuntMesocavalMesocaval 3333 1.71.7Small diameterSmall diameter 2020 11Central lieno- renalCentral lieno- renal 2626 1.31.3

Non shuntNon shuntHassabHassab 811811 42.442.4Splenectomy vasohigationSplenectomy vasohigation 335335 17.517.5StaplerStapler 3939 22

NoNo %%

Slective shuntSlective shuntDistal splenorenalDistal splenorenal 606606 3232CoronorenalCoronorenal 4040 22

Total shuntTotal shuntMesocavalMesocaval 3333 1.71.7Small diameterSmall diameter 2020 11Central lieno- renalCentral lieno- renal 2626 1.31.3

Non shuntNon shuntHassabHassab 811811 42.442.4Splenectomy vasohigationSplenectomy vasohigation 335335 17.517.5StaplerStapler 3939 22

Hospital MortalityHospital Mortality

No.No. %%

DSRSDSRS 606 (19)606 (19) 3%3%Non shuntNon shunt 1185 (23)1185 (23) 2%2%Total shunt Total shunt 79 (7)79 (7) 9%9%

RebleedingRebleeding

NoNo %%

Selective shunt (606)Selective shunt (606) 3636 6%6%Non shuntNon shunt (1185)(1185) 272272 23%23%Total shuntTotal shunt (79) (79) 66 8%8%

Hepatic pathology as prognostic factorHepatic pathology as prognostic factor(after DSRS)(after DSRS)

Bilharz.Bilharz. NonNon MixedMixed

Mortality lateMortality late 8% 8% 17%17% 22%22%H.C.F.H.C.F. 4% 4% 12%12% 16%16%Portal perfusion Portal perfusion 94%94% 75%75% 50%50%Encephalopathy Encephalopathy 4%4% 22%22% 26%26%

Schistosomal patients haveSchistosomal patients haveSchistosomal patients haveSchistosomal patients have

• A better survival rate with low incidence of A better survival rate with low incidence of encepahalopathy after DSRS. Compared with encepahalopathy after DSRS. Compared with the cirrhatics and mixed populationthe cirrhatics and mixed population

(Annals of surgery 89)(Annals of surgery 89)

• A better survival rate with low incidence of A better survival rate with low incidence of encepahalopathy after DSRS. Compared with encepahalopathy after DSRS. Compared with the cirrhatics and mixed populationthe cirrhatics and mixed population

(Annals of surgery 89)(Annals of surgery 89)

EncephalopathyEncephalopathy

NoNo %%

Selective shunt (606)Selective shunt (606) 7272 12%12%Non shuntNon shunt (1185)(1185) 3535 3%3%Total shuntTotal shunt (79) (79) 7979 40%40%

Late MortalityLate Mortality

F.U./yF.U./y NoNo %%

Selective shunt (606)Selective shunt (606) 15 15 8888 14%14%Non shuntNon shunt (1185)(1185) 14 14 142142 12%12%Total shuntTotal shunt (79) (79) 10 10 6363 80%80%

conclusionconclusion

• The history of portal hypertension started in Egypt more The history of portal hypertension started in Egypt more than 5000 y agothan 5000 y ago

• Evolution happened to many changes as etiopathology-Evolution happened to many changes as etiopathology-surgery and intervention radiologysurgery and intervention radiology

• The present situation The present situation - - Pathology Pathology - Sclerotherapy is the first choice- Sclerotherapy is the first choice- Selective shunt or non shunt- Selective shunt or non shunt (according to many factors)(according to many factors)

NNOOWW

NNOOWW

ThankThank YOUYOU