The surgical treatment of portal hypertension, a syndrome characterized by abnormal hemodynamic changes in the portal venous system, has a history of more than 100 years, with Drummond and Morison (1896) being the first to report the use of a large omentum fixed to the peritoneal surface of the scars and the peritoneum of the liver and spleen to establish collateral circulation. Mayo (1910) used splenectomy to treat hepatic sclerosis, and Rowntree (1929) ligated the coronary vein of the stomach in one patient, pioneering the first dissection of flow. During the century of surgical treatment of portal hypertension, the etiology, disease manifestations, and treatment outcomes have led to a wide variety of treatment options. A wide variety of procedures have been designed and performed in both bypass and dissection, each attempting different avenues to address the fatal ruptured esophageal and fundic variceal bleeding in this syndrome. Dissection attempts to disconnect almost all vessels that could cause bleeding, while bypass attempts to create shunts between almost all accessible portal vessels. A century of technological innovation and maturation of surgical techniques for portal hypertension has eliminated the surgical no-go areas and technical barriers to bleeding in portal hypertension. However, the results of surgical treatment of portal hypertension have never been fully satisfactory. In the last 50 years, liver transplantation has flourished and the field of non-surgical treatment of portal hypertension has been broadened. Nowadays, the treatment of portal hypertension is not only about the diversification of surgical approaches and accumulation of cases, but also about the renewal and transformation of concepts and strategies. There are various means of treatment for portal hypertension, which can be broadly divided into several categories: medical drug therapy, endoscopic therapy, radio-interventional therapy, and surgical therapy. The choice of what is more reasonable for treatment has been a problem to be solved in the treatment of portal hypertension bleeding. The characteristics of patients with portal hypertension, such as systemic hemodynamic status, pathological type and course of the liver, and hepatic functional reserve, together with the limitations of current knowledge of these issues, determine that the treatment of portal hypertension should follow the principle of individualized selection of surgical modalities. The purpose of an individualized approach to the surgical treatment of portal hypertension is to select the surgical approach according to the different changes in the hemodynamics of the portal venous system, with the aim of addressing the hemodynamic abnormalities in a more rational manner and improving the outcome. However, our experience in the individualized treatment of portal hypertension is very limited due to insufficient understanding of portal hypertension, and there are few reports in this area in China. Based on our recent clinical treatment experience, we will make some preliminary discussion on this issue, taking into account the literature. In fact, many issues that have been debated in the surgical treatment of portal hypertension have been tested by medical practice for more than half a century, and a basic consensus or definitive conclusion has been achieved. For example, the problem of prophylactic surgery, the current opinion is relatively unanimous, is not to advocate the use of prophylactic surgery, because not only the surgery itself is risky, but also not all patients with varicose veins will bleed, only about 30% to 50% of them will bleed, so the surgery will bring additional blow to these patients, but make the survival rate decreased. Another example is emergency surgery in case of bleeding. In recent years, due to the great progress in non-surgical treatment, most patients with major bleeding can pass the dangerous period under non-surgical treatment such as medical medication and endoscopic ligation, creating conditions for the next surgical treatment or continuing non-surgical treatment to prevent re-bleeding. Therefore, it is currently advocated that emergency surgery should be avoided in acute bleeding in favor of drug and endoscopic-based non-surgical treatment. If the above treatment is not effective, surgery is indicated if the bleeding is too rapid or if the bleeding vein is in the endoscopic blind area of the fundus or if there is no condition for endoscopic treatment. Too much waiting for this group of patients can lead to shock, deterioration of liver function, jaundice, ascites, or even coma, and loss of time for surgery. Emergency surgery is advisable for the treatment of peripancreatic vascular dissection because of the patient’s severe condition, which makes it difficult to withstand a major surgical blow combined with inadequate preparation. Therefore, the main aspect of individualized surgical treatment of portal hypertension focuses on the choice of surgical approach for patients undergoing elective surgery. Traditional surgical approaches include two main categories of bypass and dissection, with a variety of specific surgical approaches. In the past, it has been suggested in general terms that the impact on liver function is relatively lower than that of bypass surgery due to the low impact of bypass on hepatic portal perfusion, which is suitable for patients with recurrent bleeding, elderly and frail patients and emergency patients, and is simple to perform and can be widely carried out in primary care units. In contrast, shunts are more complicated and time-consuming to perform and can be more devastating to the liver because of the reduced portal perfusion. It is generally accepted that for patients with fair liver function and a Child classification of A or B, either flow dissection or shunt can be performed. For patients with poor liver function and a Child grade C, surgery is risky and active medical therapy should be used to improve liver function, and if surgery is necessary, it is advisable to choose flow dissection. If the liver function is always in grade C with ascites, TIPS is a better alternative with the advantage of less trauma, although the long-term efficacy is not ideal and the stent is prone to embolism, but it can temporarily control the hemorrhage of ruptured esophageal varices. Obviously, the above statement only emphasizes the patient’s liver function status and fails to take into account the different conditions of the patient’s portal venous system, so it can be said that the individualization of surgical treatment of portal hypertension has not been taken into account. Since the understanding of the portal vein and systemic system in patients with portal hypertension is not yet clear, there are fewer specific criteria that are operable for the selection of specific surgical approaches. It has been proposed that if the patient is in poor condition, over 50 years of age, and has off-hepatic flow on ultrasound, to reduce the possibility of progressive liver damage, only a flow disconnection procedure should be performed; if the patient is in good general condition, under 50 years of age, and ultrasound shows hepatotropic flow, an appropriate shunt should be selected based on MRI showing the conditions of the relationship between the shunting vessels. The basis of the choice of surgical approach for portal hypertension should focus on the hemodynamic changes in the portal venous system. With recent advances in hemodynamic studies of the portal venous system and other aspects, the issue of individualizing surgical treatment of portal hypertension has received increasing attention. It is clear from hemodynamic studies of the liver that in liver lesions there is an increase in resistance of the portal venous system with a consequent increase in blood flow, the former being the initiating factor and the latter being an important factor in the development of a hyperdynamic circulatory state in the portal venous system. There are too many individual differences in the proportion of resistance and high blood flow in the portal venous system, the anatomical condition and shunting capacity of the collateral vessels, the location of the main shunting vessels, the amount of splenic filling and its role in the compensatory state of portal hypertension, the opening of the umbilical vein, the amount of compensatory blood flow increase in the hepatic artery, and the status of liver function in different patients. With so many individual differences, it is obvious that using the same treatment is biased. It has been suggested that the velocity and flow of the portal vein and splenic artery affect splenic venous blood flow. If splenic artery blood flow is greater than splenic vein, then the spleen is actively congested and the proportion of blood flow from the splenic vein supplying the portal venous system increases, indicating inadequate compensation of the collateral shunt; if splenic venous blood flow is higher than splenic artery blood flow or there is reverse blood flow, then the spleen is passively congested, indicating adequate compensation of the collateral shunt . Therefore, the direction of blood flow in the main side branches of the splenogastric region is considered to be an important reference for the selection of the surgical procedure. Some scholars have summarized the indications for each of several surgical procedures. The surgical indications for flow dissection are: (1) upper gastrointestinal hemorrhage for which non-surgical treatment is ineffective; (2) history of upper gastrointestinal hemorrhage with FPP 8-10 cm/s and FPP pressure difference >1.96 kPa after splenectomy; (3) anteroposterior splenic diameter of 10 mm and non-significant hypersplenism; (4) absence of chronic pancreatitis, splenic phlebitis and its peripheral inflammation; (5) absence of ascites or small amount of ascites and absence of retroperitoneal edema ; (6) history of severe esophageal varices or bleeding. Although flow dissection can be used in patients with relatively poor liver function, it should be performed with caution in patients with extensive portal system thrombosis, where failure to relieve portal system hypertension after flow dissection may result in intractable ascites, intestinal dysfunction, liver dysfunction or even early recurrent bleeding. These patients are also clearly not candidates for portosystemic shunts, and endoscopic interventions may be considered. Since the early years of academic cirrhosis, it has been recognized that once gastrointestinal bleeding occurs in patients with post-hepatitis cirrhosis portal hypertension, it indicates that the patient’s liver function has been impaired, and more than 70% of the patients’ liver function belongs to Child B or C. No matter what kind of surgical treatment is taken, it cannot fundamentally improve the liver function, and only by minimizing the blow to the liver reserve capacity can we strive for a better prognosis. In recent years, it has been found that the combination of shunt and dissection can not only maintain certain portal pressure and portal blood supply to the liver, but also unblock the high blood flow in the portal system, which has the characteristics of both dissection and peripheral shunt, and is an ideal procedure for treating portal hypertension because the advantages and disadvantages of both dissection and shunt complement each other. Tangdu Hospital of the Fourth Military Medical University summarized 40 cases of combined bypass and dissection surgery for the treatment of portal hypertension bleeding over the past 19 years, with an operative mortality rate of 3.6%, no recent rebleeding after surgery, a distant rebleeding rate of 8.3%, a postoperative encephalopathy rate of 5.0%, and postoperative survival rates of 83.4%, 64.5%, and 54.5% at 5, 10, and 15 years, respectively. The combined shunt-plus-dissection procedure is attracting great interest. However, it has also been suggested that the addition of a bypass after dissection is redundant and unhelpful. Especially for patients with poor liver function, this procedure is not suitable, while patients with good liver function can be treated satisfactorily with either dissection or bypass, so it is not necessary to add bypass to dissection. The combined procedure is bound to increase the difficulty and trauma of surgery, prolong the operation time, and aggravate the damage of liver function. Changes in portal pressure are the most prominent manifestation of hemodynamics in portal hypertension, and the main pathological changes in portal hypertension, such as esophagogastric fundic varices, splenomegaly and ascites, are closely related to elevated portal venous pressure. Elevated portal venous system pressure is an important factor in esophageal varices, and it is generally believed that bleeding may occur only when the portal venous pressure exceeds 30 cmH2O. At present, the level of portal venous pressure can be roughly estimated by hemodynamic testing of the portal venous system, which provides some guidance for the choice of surgery. From a clinical point of view, it is of some significance to use the portal venous pressure after flow dissection as an indicator for deciding the next surgical step. Some studies have reported intraoperative measurement of portal pressure, based on visceral portal pressure and hepatic portal pressure as an indicator of whether a portal shunt can be performed. The difference between FPP and HOPP is used as a marker of how much portal blood is perfused to the liver, and the change in the difference between SOPP and FPP represents the degree of opening of portal traffic branches in portal hypertension? The smaller the difference, the greater the extrahepatic portal shunt flow and the less perfusion into the portal vein, when shunt surgery should be carefully considered. The method of measuring portal vein pressure changes is simple and easy to perform, and it has some significance in estimating portal vein hemodynamic changes, making the choice of operation and judging the prognosis. In recent years, we have made some attempts to individualize the choice of surgical treatment for portal hypertension. We have analyzed the relationship between intraoperative portal venous pressure and postoperative rebleeding in portal hypertension using the simplest approach and the most direct indicators to explore when a shunt should be added to the standardized implementation of dissection. The survey followed up 112 cases of surgical cases of portal hypertension, and the portal venous pressure before and after dissection, the time from dissection surgery to the first bleeding, and the degree of rebleeding were measured and observed respectively after choosing to open the abdomen, and the corresponding conclusions were drawn: the rate of postoperative rebleeding was significantly lower in cases with liver function grade A and B than in cases with liver function grade C, and the occurrence time of rebleeding in the latter was significantly shorter than in the former, and the degree was mostly vomiting blood; before dissection There was no significant difference in the incidence, time and degree of postoperative rebleeding between cases with portal venous pressure lower than and higher than 35 cmH2O; the rate of postoperative rebleeding was significantly higher in cases with portal venous pressure higher than 35 cmH2O after disconnection than in cases with pressure lower than 35 cmH2O, and the time of rebleeding was significantly shorter and the degree of bleeding was also aggravated. Based on the above findings, we concluded that there is no positive relationship between preoperative portal venous pressure and postoperative esophageal variceal rupture rebleeding in patients with hepatic sclerosis portal hypertension, while the good or bad liver function determines the time and degree of postoperative rebleeding to a greater extent. If the portal pressure is still higher than 35 cmH2O after bypass surgery, bypass surgery should be added, that is, combined bypass surgery. The combined bypass operation was started in 1986, and there were some different opinions at that time. It was believed that the advantage of bypass operation was to remove the blood vessels in the bleeding area directly without affecting the portal blood supply to the liver, and the possibility of encephalopathy was less, and if bypass operation was added, although it was good for preventing rebleeding, it reduced the blood supply to the liver and increased the chance of encephalopathy, and performing two major operations at the same time. It is more than worthwhile to perform two major surgeries at the same time, unnecessarily increasing the impact on the patient. Nevertheless, there are some reports that show that the results of combined bypass surgery are better than bypass or dissection alone. It is believed that bypass surgery is valuable because it directly removes the variceal side branches from the bleeding area of the esophagus and fundus; relieves the increased portal vein pressure after removal of the side branches; reduces and prevents portal hypertensive gastropathy; and prevents the formation of splenic vein thrombosis. value. However, there are no clear clinical indications for when to use combined bypass surgery. In the case of portal hypertension, where the hemodynamic changes in the portal venous system are extremely complex, combined dissection and bypass surgery can take into account the complex and variable hemodynamic changes and help to correct and adjust the various hemodynamic changes in a more comprehensive manner. We performed 57 combined bypass and dissection procedures, and the operative mortality rate, encephalopathy rate, and rebleeding rate were lower than those of bypass and dissection alone, and the 5-year survival rate was higher than that of the separate procedures. Tangdu Hospital of the Fourth Military Medical University reported hemodynamic changes in the portal venous system after combined bypass surgery, and found that the splenorenal venous anastomosis was open, the portal veins were all hepatotropic, the portal pressure was reduced by 5 cmH2O, and the portal blood flow was reduced by about 30%. The management of ruptured esophageal variceal bleeding in portal hypertension as a serious complication of hepatic sclerosis has been treated with various methods over the years, but the treatment results vary greatly due to insufficient research on its hemodynamic mechanisms. More and more physicians are gradually recognizing the importance of indicators of hemodynamics in portal hypertension in the choice of surgical approach. In the above observations, we only analyzed the rebleeding after dissection based on the intraoperative portal pressure. The applied items are simple and may be used as a simple method for clinical procedures in the current situation where the hemodynamics of portal hypertension are not well understood, and more work needs to be done in conjunction with careful analysis of the hemodynamic indices of patients with portal hypertension. Regardless of whether flow dissection, bypass or even combined bypass surgery is symptomatic and cannot reverse hepatic sclerosis, the increasing maturity of liver transplantation technology in recent years has made the treatment of end-stage hepatic sclerosis portal hypertension see an attractive future. Liver transplantation has been recognized as the best treatment option for benign end-stage liver diseases, mainly hepatic sclerosis and liver failure. Its 1-year postoperative survival rate is around 90% and 5-year survival rate is 70%, and its efficacy is much better than various shunt or dissection procedures and long-term endoscopic treatment. According to the results of 46 liver transplantation cases of portal hypertension after hepatitis in Peking University People’s Hospital, the upper gastrointestinal tract barium meal was rechecked 1 month after transplantation, and the esophageal varices were significantly regressed. Patients with upper gastrointestinal bleeding in portal hypertension, which may eventually require liver transplantation, must be treated in a coordinated manner by the surgeon, with patients with Child grade A being treated with flow dissection and shunts, and patients with Child grade B and especially C being treated with bleeding control as a transitional measure to get them through the bleeding process. Awaiting decisive liver transplantation. Therefore, less invasive endoscopic treatment and TIPS interventional stenting can be preferred to avoid the blow of open surgery and abdominal adhesions that can add to the problems of later liver transplantation. For those who must undergo open surgery, distal splenorenal shunts are also preferred abroad to avoid operations in the hilar region. In conclusion, portal hypertension is a disease involving multiple organs and systems throughout the body, and surgical treatment is aimed at its most dangerous complication, upper gastrointestinal bleeding. Most of the evaluations on the choice of surgical procedure so far have remained at the level of “empirical medicine” and are far from “evidence-based medicine”. At present, we do not have a multicenter, randomized, prospective study comparing different treatments, and even long follow-ups comparing the efficacy of different treatments from the same hospital over the same period of time are rare.