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SURGICAL TREATMENT of PORTAL HYPERTENSION by A 474 Postgrad Med J: first published as 10.1136/pgmj.32.372.474 on 1 October 1956. Downloaded from SURGICAL TREATMENT OF PORTAL HYPERTENSION By A. I. S. MACPHERSON, CH.M., F.R.C.S.E. Surgeon, Royal Infirmary, Edinburgh; Lecturer, Department of Surgery, University of Edinburgh When the flow of portal blood into or through anterior abdominal wall (' caput Medusae') or the liver is gradually obstructed the hydrostatic demonstrated as ' oesophageal varices' by oeso- pressure in the portal system of veins rises, the phagoscopy or radiography after barium swallow. spleen enlarges and a collateral venous circulation (5) In more than 80% of cases the obstruction is develops to return the portal blood to the general within the liver, secondary to chronic hepatic circulation. This syndrome is given the name of disease, and symptoms and signs of such a condi- Portal Hypertension. The site of the obstructing tion are also evident. lesion may be inside or outside the liver. Intra- hepatic obstruction is almost invariably caused by Indications for Surgical Treatment cirrhosis of the liver, the regeneration of the The prime indication for surgical treatment in parenchyma and the growth of fibrous tissue portal hypertension is the occurrence of haema- which constitute the "healing" phase of this temesis or melaena. Operation may also be called condition a distortion of the vascular for when an is and causing gross enlarged spleen causing pain Protected by copyright. tree and greatly increasing the resistance to portal discomfort as well as persistent gi'anulopenia and blood flow through it. Extra-hepatic obstructions thrombocytopenia or to prevent the onset of may be situated in the portal vein itself, in which severe bleeding when oesophageal varices can be case the hypertension and other changes affect demonstrated and other features of the syndrome the whole portal bed but the liver is normal, or are present. In assessing the suitability of a patient in' the splenic vein, when the changes will be for operation it is important to remember the localized to the splenic circulation and its connec- various ways in which the condition may present. tions with the greater curvature of the stomach. Most cases will be found to conform to one of Obstruction of the superior mesenteric vein three broad groups, each of which has a different does not cause portal hypertension. The effect prognosis: depends to a large extent upon the situation of (I) The block in the portal vein is extra-hepatic. the obstruction and may either be a massive The patient is often a young person and is usually intestinal infarction, which is usually rapidly fatal, in other respects normal. The progress without or a transient melaena with few other symptoms operation is characterized by repeated haema-http://pmj.bmj.com/ or signs. temesis from which recovery is generally rapid. Death may occur from an uncontrollable haemorr- Clinical Features hage or from intestinal infarction. The outlook The clinical features of portal hypertension are: after operation for these patients is good. (I) Splenomegaly, often with a feeling of (2) The block is intra-hepatic but there are fewif weight or recurring episodes of sharp pain in the any symptoms of hepatic disease, and the results left upper quadrant. of hepatic function tests are almost within normal (2) Changes in the circulating blood picture limits. The liver is moderately enlarged and on September 27, 2021 by guest. is (granulopenia and thrombocytopenia), which rubbery and smooth to palpation and the spleen is appear to be associated with the presence of an often very large. There is no previous history of enlarged and over-active spleen and together any serious hepatic disease. This group has been comprise the syndrome of Hypersplenism. called Hepatolienal fibrosis and it constitutes the (3) Episodes of alimentary bleeding which may greater proportion of cases of portal hypertension be slight in amount and detected only as ' occult in Great Britain. Operation should be done to blood' in the faeces or may be a profuse haema- prevent further haematemesis because with each temesis. This blood loss is the principal cause of episode of severe loss of blood further damage to the anaemia that is usually present. the liver occurs and its powers of recovery are (4) The presence of abnormal portal systemic reduced. In many instances the hepatic condition communications. These may be seen on the appears to be almost static so that the prognosis October 1956 MACPHERSON: Surgical Treatment of Portal Hypertension 475 Postgrad Med J: first published as 10.1136/pgmj.32.372.474 on 1 October 1956. Downloaded from of operation depends upon the degree of hepatic by oesophagotomy and suture of the enlarged veins damage already present and the successful pre- (Crile, 1953). The virtue of this latter procedure is vention of further bleeding. uncertain because further operation is always (3) The block is intra-hepatic. There is a necessary and because experience has shown that history of severe or protracted hepatic disease a bleeding from oesophageal varices frequently ceases few years previously from which there has been a after an operation such as exploratory laparotomy measure of clinical recovery, of exposure to has been performed on a mistaken diagnosis of hepatoxins or of prolonged overindulgence in bleeding peptic ulcer. alcoholic beverages. The liver is hard and irregular Definitive surgical treatment is usually under- and the results of function tests show grave hepatic taken when the patient's condition has been impairment. There may be such clinical signs of sufficiently restored by transfusion, diet, vitamins hepatic failure as weight-loss, jaundice, fluid and iron to make him a reasonable operation risk. retention or mental deterioration. The prognosis In patients with cirrhosis this process often takes in these patients is poor and from the very nature 4 weeks or more. Operation may then take one of of the condition cannot be much improved by three forms: operation. Indeed, the mortality after operations I. Splenectomy alone. In patients with proven on patients with cirrhosis and ascites is so high obstruction in the splenic vein splenectomy pro- that the presence of persistent fluid retention vides complete relief. The only satisfactory way should be considered a contra-indication to of demonstrating such a lesion is by preoperative surgery. trans-splenic portal phlebography. Splenectomy is also a valuable operation when there are present Treatment splenomegaly and such severe granulopenia that the From what has been said it is apparent that the effects of what should be minor infections are factors which largely determine the prognosis in magnified and prolonged and when it is not possi- most cases of are the func- ble to demonstrate collateral circulation in portal hypertension any the Protected by copyright. tional and pathological condition of the liver and cardio-oesophageal area. On the other hand, in its response to suitable treatment. Hence the basis patients who have already had episodes of haemate- of all treatment for this condition must be medical. mesis or melaena splenectomy is followed by The form this treatment may take is described recurrent bleeding so frequently that it cannot be elsewhere in this number. In most cases anaemia considered as anything more than a palliative is also present and is of an.iron-deficiency type. It procedure. responds to iron in full therapeutic doses. In some 2. Operations designed to divert the portal patients with chronic hepatic disease absorption of blood away from the varix-bearing area by means iron from the alimentary tract is defective and the of an anastomosis between a large portal and a response to iron by mouth is poor. However, there large systemic vein. The veins usually chosen are is almost invariably improvement if the iron is the portal vein and the inferior vena cava, and the given parenterally. splenic vein (after splenectomy) and the left renal The essential preliminary to the treatment of vein. In order to prevent of active is a correct The drainage hepatic bleeding diagnosis. pres- arterial blood back through the proximal end of the http://pmj.bmj.com/ ence of an enlarged spleen and a palpable cirrhotic portal vein it is advisable to ligate the portal vein liver is strong evidence in favour of portal hyper- close to the porta hepatis and to anastomose its tension, but when, because of a history suggestive distal end with the side of the inferior vena cava. of ulcer dyspepsia, bleeding from a peptic ulcer This operation diverts all the portal blood from the cannot be excluded, there should be no hesitation liver as well as from the varix-bearing area and for in passing an oesophagoscope to see whether the this reason there is the possibility that it may be blood is coming from the stomach or the oeso- more liable to be followed by neurological compli- phagus. If the bleeding is seen to be from oeso- cations (Sherlock et al., I954). When the spleen is on September 27, 2021 by guest. phageal varices treatment consists of (I) early res- so large or so active that splenectomy is essential it toration by transfusion of the lost blood; (2) suffi- is preferable to perform an anastomosis between the cient sedative to take the edge off the patient's end of the splenic vein and the side of the left renal anxiety but not so much as to make him unco-oper- vein. The blood supply to the kidney must be ative. Small doses of omnopon intravenously controlled by an arterial clamp while the suturing probably serve this purpose best; (3) control of any is being done. In our experience periods of bleeding tendency secondary to the hepatic disease occlusion up to 45 minutes have not resulted in any by intravenous injections of vitamin Kl-oxide; and damage to renal function.
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