Portal hypertension in liver cirrhosis, esophageal and fundal varices rupture bleeding accounts for about 20% of upper gastrointestinal hemorrhage, is one of the fatal complications in patients with liver cirrhosis. It is one of the fatal complications in cirrhotic patients. The bleeding volume is large and the morbidity and mortality rate is high, and the morbidity and mortality rate of the first bleeding is as high as more than 25%, and even if it is temporarily relieved by medical treatment, there is a possibility of recurrence of hemorrhage at any time after stopping the medication [1]. Although flow-disconnecting and shunt surgery can effectively control bleeding, for those with obvious insufficiency of hepatic reserve function, the surgical trauma and anesthesia on the liver and the whole body make some patients intolerable [2]. Therefore, minimally invasive treatment of portal hypertension in liver cirrhosis has become the focus of contemporary research, mainly for the treatment of ruptured esophageal variceal hemorrhage, intractable ascites, and Buga’s syndrome that cannot be controlled by medication or endoscopy, and to a lesser extent, for the treatment of patients awaiting liver transplantation, portal hypertensive gastropathy, etc.1. The Diagnosis of Portal Hypertension (PHT)The diagnosis of PHT consists of four aspects: ① clinical diagnosis; ② endoscopic diagnosis; ② endoscopic diagnosis; ② endoscopic diagnosis; ② endoscopic diagnosis; and ② diagnosis of portal hypertrophy. ① Clinical diagnosis; ② Endoscopic diagnosis; ③ Imaging diagnosis; ④ Portal vein and body circulation hemodynamic diagnosis.1.1 Clinical diagnosis:For patients with PHT, we should pay attention to ask whether there is chronic hepatitis, schistosomiasis, long-term heavy drinking and taking related drugs and other epidemiological history. Open portal collateral circulation, ascites and splenomegaly at the same time, is a typical triad of PHT, especially open collateral circulation is the most diagnostic specificity. Liver function abnormalities, liver fibrosis and peripheral blood cytopenia secondary to hypersplenism were common in laboratory tests. In addition, hepatitis virus markers and schistosome infection are also important in the clinical diagnosis of PHT.1.2 Endoscopic diagnosis: Author’s introduction: Guan Jianguo, male, deputy chief physician, research direction: hepatobiliary diseases, E-mail: [email protected]胃镜检查发现食管胃底曲张静脉是诊断PHT的直接证据,根据 Changes in the site, width and color of varicose veins can be used to estimate the risk of bleeding. The signs of bleeding risk are: ① EVII grade or above, diameter ≥5mm; ② vein is purple-blue; ③ red signs such as erythema, cherry red spot, blood bubble-like spot, etc. If the varices at the esophagogastric fundus junction are not in good condition, the risk of bleeding can be estimated. If the esophagogastric fundus junction varices sign, red sign and liver failure patients bleeding incidence is high [3]. Gastric varices (GV) were recorded by: ① varices in the gastric cardia (gastric cardia, Lg-c); ② varices in the gastric fundus of the gastric cardia (gastric cardia+fundus, Lg-cf); ③ isolated (or verrucous) varices in the gastric fundus (gastric Fundus (Lg-f).1.3 Imaging diagnosis:Ultrasound shows that the internal diameter of the portal vein trunk is >35px and the splenic vein is >25px, which is a reliable indicator for the diagnosis of PHT. Ultrasonography combined with color Doppler flow imaging can reveal evidence of opening of the portal-body collateral circulation, such as reopening of the umbilical vein and dilatation of the left gastric (coronary) vein. In addition, ultrasound can detect extrahepatic portal hypertension, including portal vein thrombosis, portal vein spongiform degeneration, and Budd-Chiari syndrome. CT scan can clearly show the triad signs of PHT, and has a high detection rate of most collateral vein openings; it can also accurately show the signs of portal vein thrombosis or tumor thrombus, as well as the signs of Budd-Chiari syndrome, which are also valuable in the diagnosis of extrahepatic PHT. After portal-ventricular vein shunt surgery, MRI can also make a non-invasive and effective judgment of anastomotic patency. Nuclear imaging can not only determine the presence or absence of shunts, but also differentiate and quantify intra- and extra-hepatic shunts, and distinguish between cirrhotic and non-cirrhotic portal hypertension. The heart/liver ratio of nuclear imaging can replace traumatic examination, directly reflecting the actual pressure of the portal vein, and has a good correlation with esophageal varices, and can also be used as a non-traumatic means of measuring portal pressure for prognostic assessment and evaluation of the efficacy of medications for lowering the portal pressure [4].1.4 Diagnostic angiography percutaneous percutaneous hepatic transection portal venography (PTP) PTP and arterial portal venography can be used to understand the precise nature of the main trunk of the portal vein and its branches. PTP and arterial portal venography can precisely understand the morphological changes of the portal vein trunk and its subordinate branches and the hemodynamic changes of the portal vein during PHT; clearly show the openness of the portal vein trunk and its subordinate branches and the portal collateral circulation, and understand the alignment of all levels of branches of the hepatic portal vein and the direction of blood flow, so as to provide a basis for the diagnosis of PHT.The measurement of hemodynamics of the corporal circulation in patients with PHT is an important reminder of the diagnostic value of PHT[5].2.2. Treatment of portal hypertension ( Treatment of PHT 2.1 Treatment of hypersplenism Partial splenic embolization (PSE) and radiofrequency ablation (RFA) of the spleen is a new technology developed in recent years, which has been widely used in the treatment of portal hypertension with hypersplenism. The theoretical basis lies in the fact that the embolizing agent embolizes the splenic red marrow, which is the main site of erythrocyte destruction, and preserves the white marrow, which contains a large number of lymphocytes, thus preserving the immune function of the spleen [6]. Currently, although the mechanisms by which PES improves liver function are not well understood, two mechanisms, immunologic and hemodynamic, are generally accepted. Radiofrequency ablation is the use of radiofrequency current (450-500 kHz) to make ions around the electrodes oscillate and friction to generate heat (>50-110°C) to get the purpose of destroying the lesion. From the viewpoint of immunological mechanism, spleen not only produces some inhibitory substances to inhibit the regeneration of hepatocytes, but also spleen regulates the inflammatory or fibrotic process, which causes inflammation of liver tissue. Reducing the inhibitory factors of the spleen on the liver by RFA leads to the improvement of liver function. Doppler ultrasound revealed a decrease in splenic artery blood flow and an increase in hepatic and superior mesenteric artery blood flow after PSE. Splenic vein blood flow was significantly reduced, but portal vein blood flow was not significantly altered, suggesting that the increase in hepatic nutrient blood supply may be one of the reasons for the improvement in liver function. Cirrhosis patients are mostly combined with different degrees of liver function damage; patients with low resistance are easy to be combined with infections, and PSE treatment can induce infections, hepatic failure, hepatic coma, gastrointestinal bleeding and so on. Therefore, we should not blindly pursue the embolization effect and increase the degree of embolization, and should carry out reasonable embolization based on individual differences [7-8].2 Treatment of esophagogastric fundal varices The pathological manifestations of the establishment of venous collateral circulation in different parts of the body due to portal hypertension caused by various reasons. When cirrhosis causes total portal hypertension, small longitudinal veins become collateral anastomoses between the portal vein and the body circulation. Gastric varices are formed by innominate veins in the proximal fenestrated zone (the 2-75px area at and above the esophagogastric junction, where submucosal blood vessels are arranged in longitudinal parallels and fenestrated), due to the fact that blood from the gastric veins is most resisted in this area as it flows into the esophagus. These deep innominate veins dilate markedly and move submucosally during portal hypertension, developing esophageal or gastric varices.Iwase H et al. analyzed the gastric vasculature using endoscopic ultrasound (EUS), angiography, and CT, and found that there were two types of gastric variceal anatomical structures: type I: there was only a single innominate or extramural variceal vein of the same diameter; and type II: there were a large number of complex variceal veins with side-branching connections. Type I usually presents with limited gastric varices, whereas type II usually presents with diffuse gastric varices.The treatment of gastric varices by EVL or EVS is often incomplete and fails to occlude all the varicose veins, especially in patients with type II gastric varices. In recent years, endoscopic sclerotherapy (ES) of esophagogastric varices (e.g., cyanoacrylate injection) has been advocated. Gastric varices (GV), like esophageal varices (EV), are one of the serious complications of portal hypertension. In the past, EV has been studied more frequently and in depth, whereas GV has been studied relatively less and the understanding of GV is much more superficial than that of EV. In the past decade, with the clinical application of endoscopic sclerotherapy and tissue adhesive therapy and the recognition of portal hypertensive gastropathy (PHG), the study of GV has begun to pay attention. Currently, tissue glue injection therapy is considered as the first choice for the treatment of active bleeding from gastric varices, and it is the only available and effective treatment, which is widely used both at home and abroad, but there are some debates about it in terms of technique, safety and long-term efficacy [9]. Endoscopic varicose vein ligation (EVL) is an effective treatment for ruptured esophageal varices bleeding in cirrhosis [10-11]. The mechanism of action is mainly to make the ligated vein ischemia, strangulation, venous occlusion, the formation of fibrosis, so as to make the esophageal variceal veins disappear, to achieve the purpose of hemostasis and prevention of rebleeding. Percutaneous transhepatic fundic vein embolization (PTVE) is a percutaneous transhepatic procedure in which the portal vein is penetrated through the liver, and a 5F catheter is inserted into the superior mesenteric vein or the splenic vein for imaging and measurement of portal pressure. Based on the results of portal venography, an appropriate arterial catheter is inserted into the gastric coronary vein or short gastric vein to perform selective venography and embolize the varicose vein. However, the recent rebleeding rate of this method is also as high as 15%, so it needs to be repeatedly administered to achieve the exact effect [12].2.3 Transjugular intrahepatic porto-systemic stent shunt (TIPSS) The earliest indication for TIPSS is that the patient’s general condition is not suitable for surgical shunt. The clinical use of TIPSS in surgical shunts dates back to 1982, but it suffers from a high rate of channel obstruction. Until 1988, Richer firstly applied the metal support frame to the clinic, TIPS reappeared, with a success rate of 93.3%, and the 30-day rebleeding rate was only 6.7%. 75%~90% of patients with persistent ascites disappeared after TIPSS or made the drug treatment effective. The main factors affecting the long-term efficacy of TIPSS are stenosis of shunt tract or stent obstruction, among which TIPSS still cannot replace the traditional shunt and shunt surgery to solve the problem of stenosis of hepatic venous segment caused by overgrowth of shunt tract endothelial membrane.The application of TIPSS in patients waiting for liver transplantation further expands the indications for TIPSS, which enables the patients to safely go through the waiting period and improves the post-transplantation recovery process. TIPSS technology has been quite mature, and the future development direction should be to improve its medium- and long-term efficacy: (1) to solve the problem of further damage to liver function by shunt, especially hepatic encephalopathy; (2) to study the mechanism of stenosis and obstruction of shunt, and seek for preventive and solution methods [13-14]; (3) to further expand the application of TIPSS before definitive surgery, and study the combination of TIPSS with other interventional or conventional treatments. interventional or traditional treatments.2.4 Application of laparoscopic technology in the treatment of portal hypertensionWhen the spleen is large in patients with hypersplenism, performing LS is not only technically difficult, with poor exposure of the surgical field, inappropriate for controlling bleeding, and difficult to deal with the splenic hilum, but also with high green of surgical complications, and a high rate of intermediate openings, and is therefore regarded as a relative contraindication to LS. The application of hand-assisted laparoscopic splenectomy (HLS) allows direct hand traction and separation via hand-assisted device, better exposure of the surgical field, shorter time than conventional surgery, less intraoperative bleeding, no other serious intraoperative and postoperative complications in patients, and no recurrence of varicose veins. It can be predicted that the application of laparoscopic technology in portal hypertension will have a very broad future [15].3. ProspectIn summary, there are various treatment methods for portal hypertension, and the most appropriate therapy must be carefully selected for specific cases based on careful mastery of their liver function and blood dynamics, and according to the specific conditions and feasibility [16]. Minimally invasive surgery is a new technology guided by a new concept, not an independent discipline or a new discipline. It is not in opposition to traditional surgery, but is a supplement and development of traditional surgery, and must follow the basic principles of traditional surgery.