Portal hypertension is a group of clinical syndromes characterized by increased portal venous pressure, obstructed blood flow and/or increased blood flow in the portal venous system with the formation of collateral circulation. There are many causes of portal hypertension, mainly cirrhosis from various causes, accounting for 80% to 90% of the cases. According to statistics, 30% of cirrhotic patients can eventually develop portal hypertension, while 30% of cirrhotic patients can cause bleeding within 2 years of the discovery of varices, and if the bleeding stops without treatment, their recurrent bleeding rate is 70% within a year, and the morbidity and mortality rate can be 33%. The most common and dangerous complication of portal hypertension is death due to rupture of the varices of the esophagogastric fundus, which is the main indication for surgical treatment.
The complexity and importance of developing a universally applicable surgical treatment for portal hypertension cannot be overstated due to the complex pathogenesis of portal hypertension, the numerous etiologies of cirrhosis, and the great individual variability in liver function status and portal hemodynamics. Moreover, the clinical management of portal hypertension involves multiple disciplines, including gastroenterology, endoscopy, imaging, interventional medicine, surgery, and transplantation, and there is an urgent need for close collaboration among all clinical disciplines. To date, we have not seen any evidence-based medical research on portal hypertension in China, and most of the literature is retrospective. The World Gastrointestinal Organization (WGO) developed guidelines for the treatment of esophageal varices in 2008 and introduced the WGO methodology for developing guidelines for esophageal varices. Our literature lacks high-quality evidence on the choice of surgical treatment for portal hypertension, and clinical pathways are the implementation of diagnostic and treatment standards, guidelines, or protocols. Therefore, it is very difficult to develop clinical pathways. Here we present our surgical procedures for the treatment of portal hypertension in cirrhosis, which can only be used to draw inspiration and expect clinical workers in portal hypertension nationwide to actively participate in research and continuous modification and improvement, with the aim of establishing standardized treatment procedures (pathways) for the surgical treatment of portal hypertension in accordance with our national conditions and improving the efficiency, quality and service level of diagnosis and treatment.
A. Diagnostic and treatment procedures for acute hemorrhage of ruptured esophagogastric fundic varices
(A) patients with previously diagnosed portal hypertension, once acute hemorrhage occurs, need to race against time, rapid and orderly rescue.
1. Closely monitor the patient’s vital signs and hemodynamic changes, heart rate and blood pressure monitoring, central venous line pressure measurement and indwelling catheter.
2. Rapidly replenish blood volume to maintain hemodynamic stability, and maintain erythrocyte pressure volume of 25%-30% is appropriate.
3.Place nasogastric tube, ice saline gastric lavage, closely observe the flow and nature of drainage.
4. Complete medical history taking and physical examination rapidly.
5.Medication to reduce portal pressure and control bleeding, such as growth inhibitor, terlipressin (terlipressin) or posterior pituitary hormone combined with nitroglycerin, etc.
6, Endoscopy and treatment: In addition to further clarifying the diagnosis as well as assessing the degree of varicose veins, bleeding can be controlled by ligature and/or injection of sclerosing agents and spraying of hemostatic drugs. This measure is the preferred method to diagnose and treat acute bleeding in portal hypertension and can effectively stop the bleeding, but it is technically demanding and many primary hospitals have not yet carried out this program.
7.If the above treatment cannot control bleeding or units without endoscopic hemostatic techniques, a three-chambered two-bag tube can be used to stop bleeding by compression. This measure can temporarily control bleeding, but the rate of recurrent bleeding is high, and patient compliance is poor, the incidence of comorbidities is high, and intensive care is required during treatment. This treatment is rarely used in western countries, but it is still a good emergency treatment measure in emergency situations in China, especially in primary hospitals and remote areas.
8.Laboratory and auxiliary tests
(1) Routine blood test: It can roughly understand the degree of hypersplenism, and also determine the amount of bleeding according to the changes of hemoglobin concentration and red blood cell pressure, and estimate whether to continue bleeding or need blood transfusion.
(2) Blood liver function and coagulation function tests: to understand the degree of liver function damage.
(3) Arterial blood gas analysis and electrolyte measurement: to understand whether there is acid-base balance and electrolyte disorder.
(4) Blood renal function measurement.
(5) Ultrasound and Doppler ultrasound (DUS) examination: to understand the degree and size of cirrhosis, whether the spleen is enlarged and its degree, and whether there is ascites and how much; DUS can detect the diameter of portal vein, blood flow velocity and the direction of blood flow.
(b) If the cause of bleeding is unknown, in addition to the above-mentioned active resuscitation measures, the cause of bleeding needs to be quickly identified.
1.Detail medical history for viral, alcoholic and schistosomiasis liver disease.
2.Physical examination especially needs to pay attention to whether there is splenomegaly, ascites, liver palm and spider nevus, etc.
3.Endoscopic examination for the presence of esophagogastric fundic varices, while other lesions of the stomach and duodenum can be excluded.
4.B ultrasound and DUS: whether there are manifestations of portal hypertension such as cirrhosis, splenomegaly, ascites, increased portal vein diameter and/or collateral vessels, etc. If the internal diameter of portal vein is ≥1.3cm, portal hypertension needs to be considered.
The above four points are extremely valuable to confirm the diagnosis of bleeding due to portal hypertension in liver cirrhosis.
（If the bleeding is not controlled after 24 to 48 hours of non-surgical treatment, or if the bleeding has stopped and recurred, patients with jaundice and ascites who are not eligible for emergency surgery should be treated with intrajugular intrahepatic portosystemic shunt (TIPS) if the hospital conditions permit; for those with Child-Pugh A/B liver function, emergency surgery should be performed immediately to save life.
(D) The choice of emergency surgery procedure
1, combined with the specific conditions in China, as long as there is blood flow to the liver, the main use of dissection, such as peripancreatic vascular dissection or selective dissection. In Europe and the United States, shunts are often used, especially distal splenic and renal vein shunts (Warren procedure), so that patients have the opportunity to receive liver transplantation later.
2. For those who are critically ill and have poor liver function, the spleen may not be cut, but only the ligation of the beginning of the splenic artery and the suture of the gastric coronary vessels and the lateral branch veins of the lesser curvature may be performed.
3.If rupture of esophagogastric fundic varices bleeds during the hospitalization waiting for surgery, dissection or combined surgery of shunt and dissection can be performed according to the established surgical plan.
II. Surgical procedures to prevent rebleeding
Since the recurrence rate of bleeding after the first bleeding in portal hypertension can be as high as 70% within one year if left untreated, after the bleeding stops, liver preservation therapy should be actively performed, and the indications for and tolerance of surgery should be comprehensively evaluated, especially the liver reserve function, the degree of portal hypertension, the risk of bleeding, and the hepatic and portal vein hemodynamic status, in addition to the routine major surgery to assess the function of important organs such as heart, lung, kidney, and cardiovascular and cerebrovascular. Hemodynamic status.
(a) Comprehensive and systematic assessment of the patient’s general condition, hepatic reserve function and degree of portal hypertension
(1) History taking: (1) History of upper gastrointestinal bleeding as vomiting blood or blood in stool, and whether there is a combination of clinical manifestations of peripheral circulation failure. ② Hemorrhage triggers such as violent cough, emotional excitement or history of eating rough food. ③ If there is a history of multiple bleeding episodes, the number of episodes and intervals should be asked. ④ Whether there is a history of chronic liver disease, cirrhosis, etc.
2. Physical examination: ① Any abdominal wall varices. ② Whether the enlarged spleen can be palpated. (③) Whether there are mobile turbid sounds in the abdomen. ④ Any yellowing of sclera and petechiae of skin and mucous membrane. ⑤ Whether there are liver palms and spider nevus, etc.
3. Laboratory examination
(1) Routine blood tests.
(2) Blood and liver function, coagulation function test.
(3) Arterial blood gas analysis and electrolyte measurement.
(4) Blood and kidney function measurement.
(5) Tumor marker tests: such as AFP, CEA, CA199, CA125, CA50, etc. to rule out the possibility of combined tumors such as primary liver cancer.
(6) Hepatitis virus serological examination: such as hepatitis A, B, C, E and other types of hepatitis virus antibody test. It can discern the cause of cirrhosis. If it is caused by post-hepatitis B cirrhosis (most common in China), the HBV-DNA value should also be measured.
(7) Immunological examination: If the serological examination of hepatitis virus is negative, immunological examination is required. Positive immunological examination of schistosomes may suggest schistosomal liver disease; if anti-nuclear antibody (ANA), anti-smooth muscle antibody (SMA), anti-hepatic and renal microsomes, anti-soluble liver antigen/hepatopancreatic antigen (SLA/L P) and other indicators are positive, autoimmune liver disease should be suspected; positive anti-mitochondrial antibody (AMA) should be considered cholestatic liver disease.
4, Endoscopic examination is the gold standard for diagnosing esophagogastric fundic varices to understand the site, number, diameter of varices and the presence or absence of red signs, to determine the degree of varices and bleeding tendency, and to exclude the presence or absence of associated ulcers, erosions and tumors in the stomach and duodenum (6).
(5) Imaging examination (1) ultrasound and DUS: to understand the size of the liver and spleen, the degree of cirrhosis and atrophy, and the amount of abdominal water; to obtain accurate hemodynamic information of the portal system, including the diameter, flow speed and direction of the portal vein, superior mesenteric vein and splenic vein, and also to find out whether there is thrombosis in the portal system, etc.
(2) Spiral CT angiography (CTA) and/or magnetic resonance portal venous system angiography (MRPVG): to understand the morphology and size of the liver and spleen, to determine the volume of the liver, the presence or absence of ascites, and the anatomical images of the portal venous system, such as the diameter of the trunk branches of the portal venous system, patency (presence or absence of thrombus), the location, size and number of side branches, and the perfusion status of the hepatic artery and portal vein, and to understand the hepatic and inferior vena cava patency (to exclude Budd-Chiari syndrome), and also provides a good indication of the complex spatial relationships and anatomical patterns among the vessels and between the vessels and adjacent organs (7). Because of the continuous development of CT scanning technology, especially 64- or 128-row spiral CT can obtain very clear vascular imaging information, and because ascites affects magnetic resonance angiography, we apply CTA examination except for contrast-allergic patients.
(3) Transarterial portal venography: Because it is an invasive test, and because of the development of CT technology, it is basically not used. However, it has a unique value in confirming whether the portal vein has become an outflow tract. when DUS suspects that the portal vein has left the hepatic blood flow, if the main trunk and side branches of the portal vein are visualized by transarterial portography, it proves that the portal vein has become an outflow tract, which restricts the application of many surgical methods, and only portal and intestinal lateral venous shunts or traditional splenorenal venous shunts and other total portal venous shunts can be used, but not end-lateral portal or intestinal lumen venous shunts, selective shunts, and portal odd vein dissection.
All of the above tests need to be completed within 3~4 days after admission.
(B) The significance of the test results
1, etiological diagnosis Hepatitis virus serology test helps to diagnose the etiology of cirrhosis, such as hepatitis B and C virus. Unless emergency surgery, it is best to control HBV-DNA value below 103 copies/ml before surgery and continue antiviral treatment for 2~3 years after surgery to maintain liver function and prevent deterioration or even failure of liver function. If the viral test is negative, immunological tests need to be considered to help diagnose liver diseases such as schistosomiasis, autoimmune and cholestasis. Etiological diagnosis is also extremely important in guiding the selection of the procedure. Different etiologies of cirrhosis lead to different results of the same treatment. For example, for portal hypertension caused by schistosomiasis cirrhosis, various surgical approaches can achieve better results and fewer postoperative complications.
2. Assessment of liver reserve function Liver reserve function mainly reflects the patient’s tolerance to surgery, and Child-Pugh classification is commonly used at present (see Table 1). Those with liver function grade A have good tolerance for surgery; those with liver function grade B have higher surgical risk; those with liver function grade C, in principle, cannot undergo traditional surgery and can only be candidates for liver transplantation. Since Child-Pugh classification sometimes does not accurately reflect liver reserve function, it must be combined with liver volume measurement. Hepatic spiral CT has become the most commonly used method for clinical measurement of liver volume at home and abroad. A liver with insignificant shrinkage is better tolerated for surgery, even though liver function is poor. On the contrary, if the liver volume is significantly reduced, even if the liver function is better, it means that the liver function is already in a critical state and cannot withstand the surgical blow, and the risk of surgery is extremely high.
3. Assessment of the degree of portal hypertension The assessment of the degree of portal hypertension includes determining the degree of hypersplenism and the degree of varices.