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BENIGN CONDITIONS
183
or dramatically reduced. Some people do not inflate the oesophageal balloon
due to the risk of oesophageal ulceration but we believe if this is not done in
some patients, re-bleeding is more rapid and difficult to control. In addition,
careful use of the oesophageal balloon will prevent oesophageal damage. Our
preferred method of holding the tube in the correct position with gentle trac-
tion uses a tennis ball which is cut half way across and used to grip the tube
after tape is placed around the outside ( Fig. 3.80 ).
This is simple, inexpensive, and avoids ulceration of the corner of the mouth,
which occurs when traction is applied by hanging weights (bags of saline etc.)
over some form of pulley. The tension can easily be checked by regular gentle
traction on the tube.
The oesophageal balloon is then inflated. There is no standard volume that
will achieve the correct pressure with any consistency. The pressure in the bal-
loon should be half way between the systolic and diastolic blood pressure and
can be measured by a transducer in the ICU setting or simply with a three-way
Fig. 3.80 A new tennis ball is cut halfway across and used to secure the tube and
provides a simple method of adjusting the tension while preventing ulceration.
Gastric and oesophageal secretions are collected and the oesophageal balloon
pressure is monitored hourly.
LIVER
184
Fig. 3.81 Surgery in patients with cirrhosis.
Child–Pugh
B+C
Child–Pugh
Class A
Inadequate
Marginal
Cirrhotic patients
needing major
liver resections
Poor response
inadequate
Portal vein
Embolization
and reassessment
Resection
Adequate
Adequate
Major
hepatectomy
contraindicated
Assess liver function
ICG excretion
3D reconstruction and
estimation of remnant
volume
BENIGN CONDITIONS
185
tap and pressure monitor (sphygmomanometer etc). There are risks associated
with the use of these tubes even without sclerotherapy and all concerned in the
care of these patients must be aware of these ( Table 3.5 ).
Devascularization procedures ( Figs. 3.81 , 3.82 , and 3.83 )
Devascularization procedures have been mostly abandoned following trials
that demonstrated that sclerotherapy was as effective as, and safer than, gastric
surgery (Hosking and Johnson, 1987 ). Nevertheless, there remain some situa-
tions when these procedures are still the treatment of choice and produce good
long-term results with low re-bleed rates (Sugiura and Futagawa, 1984 ; Shah
et al ., 1999 ; Selzner et al ., 2001 ). This is particularly true when patients are
unshuntable due to portal vein thrombosis; a situation which is not rare.
Probably the most common cause worldwide of portal hypertension is
schistosomiasis which causes hepatic fibrosis with a characteristic lesion
described as ‘pipestem fibrosis’ (Okuda, 2002 ). This produces intrahepatic
presinusoidal obstruction where the raised portal pressure is necessary to
Table 3.5 Protocol for management of a Minneapolis tube
Oesophageal ulceration
is avoided by attention
to the oesophageal
balloon.
◆
The balloon is maintained between systolic and diastolic
pressure but is let down for 5 minutes every hour. This is
checked and recorded (on the specially designed charts)
before reinflating. Careful traction ensures the gastric
balloon is correctly positioned
◆
Tubes are removed between 12–16 hours after insertion.
At that time the endoscopist is waiting to repeat the
sclerotherapy
Continued (occult)
bleeding is avoided,
by the careful
management of the
gastric and oesophageal
balloons. If despite this
bleeding appears to
continue then either:
◆
The bleeding is from another (additional) source such
as gastritis or peptic ulceration
◆
The gastric balloon has deflated
◆
Care of the oesophageal balloon is imperfect
Recurrent bleeding
after removal of the
tube is very unusual.
If this does occur
◆
The balloon pressure may have been too high or it may
have been left in for too long producing a friable
oesophagus
◆
Sclerotherapy can be difficult under these circumstances
and will require an experienced endoscopist
◆
The replacement of the balloon is almost never required
and undesirable. If bleeding continues other options will
have to be considered (see following section)
LIVER
186
Fig. 3.82 Circular stapler
positioned in the lower
oesophagus.
Fig. 3.83 Oesophagus is
drawn into the stapler by
tying the purse-string
sutures. The gun is closed
and fired. This transects
and re-anastomoses the
oesophagus.
BENIGN CONDITIONS
187
ensure liver perfusion. Reducing the portal pressure by surgical shunt or TIPS
(Bureau et al ., 2004 ) in these patients decreases the perfusion pressure to a
level where encephalopathy is almost inevitable (although it may be intermit-
tent) and disabling (Helton et al ., 2001 ). In these patients, where recurrent
bleeding from oesophageal varices cannot be controlled by sclerotherapy,
devascularization is very valuable. We favour the modified Sugiura procedure
and have been impressed by the low long-term re-bleed rates and the relatively
low morbidity (Selzner et al ., 2001 ; Ma et al ., 2004 ). The major problem we
have experienced has been oesophageal stricturing following stapling. This is
not surprising in a devascularized oesophagus which has generally been sub-
jected to extensive sclerotherapy. Perhaps more surprising is that these
oesophageal strictures have so far responded to simple dilatation.
The procedure itself is based on the premise that one should attempt to pre-
serve all the collateral channels, and that if this can be achieved then there is less
need for them to reform. It is for this reason that the surgery is performed on
the stomach wall and all variceal branches are divided very close to the wall as
for highly selective vagotomy (except on both lesser and greater curve). In this
fashion the upper half of the body of the stomach and 8–10cm of the oesopha-
gus is cleared. The length of the oesophagus cleared is less than was originally
described (Shah et al ., 1999 ; Selzner et al ., 2001 ) but avoids entering the chest,
which we feel is important. After devascularization with careful preservation of
the collateral channels and the vagus, a large oesophageal stapler (preferably
32mm) is introduced in to the lower oesophagus just above the cardia.
The device is opened, two Prolene ties are used, and then the device is closed
and fired.
This produces complete transection of the oesophagus and simultaneous
reanastomosis, interrupting all the vessels in the wall. Postoperatively, care is as
for oesophagectomy patients. We organize a contrast swallow at day 6 prior to
starting oral intake if there is any doubt about the integrity of the anastomosis.
Portosystemic shunts
Portosystemic (mesocaval) shunts are used infrequently today because of the
problems with encephalopathy and the development of liver transplant pro-
grammes. The remaining indications are consequently few and one must be
certain that all other pharmacological, medical, and endoscopic options have
been appropriately employed. In a small number of patients, however, intrac-
table bleeding, particularly from a non-oesophageal cause (gastric, GI tract,
rectum) can be effectively treated by portosystemic shunts (but not gastric
devascularization). They are also particularly valuable when bleeding from
gastric varices is associated with refractory oesophageal varices.
LIVER
188
Like other treatments in these patients, the aim should be not only to man-
age the acute problem but also not to prejudice subsequent necessary interven-
tion such as transplantation. Our policy is now to only use a PTFE H-graft for
these reasons (Henderson et al . 2000 ; Smyrniotis et al ., 2003 ):
◆
These procedures are increasingly uncommon, the H-graft is technically
relatively straightforward and all hepatobiliary surgeons are familiar with
the anatomy. We generally perform these procedures with a vascular sur-
gical colleague
◆
The synthetic graft (if the correct calibre is used) maintains some portal
fl ow while reducing the pressure minimizing the risk of encephalopathy.
This risk does not change with time as unlike other shunts there is no dila-
tion and increased fl ow
◆
An H-graft does not prejudice the performance of subsequent surgery.
Portocaval H-graft technique ( Figs. 3.84 – 3.88 )
Our favoured prosthetic material for the performance of the H-graft is an
8-mm ring PTFE graft. This involves a senior colleague as an assistant and
ensures that the vascular anastomosis is performed to the highest standard.
This is crucial to avoid early postoperative problems, particularly thrombosis
in the graft.
Fig. 3.84 The inferior vena
cava is mobilized.
BENIGN CONDITIONS
189
A transverse incision is employed, usually only just crossing the midline to
the left. Previous surgery in the right upper quadrant is the main cause of dif-
ficulty and mobilization of the right colon and duodenum requires patience
and care. If the gall bladder is present we usually remove it and then retract the
liver upwards exposing the operative field. Occasionally at this stage it is neces-
sary to divide the falciform ligament to allow mobility. Further mobilization of
the duodenum posteriorly will encounter thicker oedematous tissue with
many collaterals and additional care must be taken otherwise continued ooze
Fig. 3.86 The graft is
anastomosed to the inferior
vena cava.
Fig. 3.85 A ‘side-biting’
clamp is applied.
LIVER
190
Fig. 3.87 The portal end of
the graft is anastomosed.
Fig. 3.88 Final position of
the H-graft which lies in
an oblique position.
BENIGN CONDITIONS
191
can hamper the view and performance of the shunt. The IVC is then mobilized
and cleared and again the peritoneum is much more vascular than normal.
This exposure must be wide and one should not be tempted to anastomose in
an area which is poorly exposed. At least the anterior 180 degrees must be
cleared for 4–5cm before attention can be turned to the portal vein.
The portal vein is accessed in the right free border of the lesser omentum
after ascertaining the position of the bile duct and hepatic artery by palpation.
Similar problems may be encountered with fatty tissue that would normally be
relatively avascular but again, sufficient length and exposure are essential and
meticulous slow dissection will allow the portal vein to be freed for almost its
whole length (between the upper border of the pancreas and its bifurcation).
Once mobilized sufficiently, vascular clamps can be used to isolate a seg-
ment of the wall of the IVC and portal vein and the anastomosis performed
with the graft really forming the central limb of a reversed Z rather than H as
it must lie obliquely from IVC below to the portal vein above.
The IVC anastomosis is performed first and the end of the graft is bevelled
and a 5/0 Prolene suture used. Removing some of the rings of the graft at either
end can facilitate the anastomosis and does not prejudice the integrity.
The portal vein anastomosis is then completed, again with a continuous
suture after bevelling the end of the graft to ensure it lies in a good position.
Full mobility of the portal vein facilitates the continuous suture.
Before the final suture is tied the graft is flushed with heparinized saline.
After clamp removal (IVC first), a thrill should become palpable.
Postoperatively the function of the graft is easy to check with the duplex
ultrasonography or angiography and a patency rate of 90% is usually
achieved.
Transjugular intrahepatic portosystemic shunt (TIPS)
TIPS is a radiological procedure where an intrahepatic portosystemic shunt is
created. It was first performed in 1988 (Richter et al ., 1989 ) and has been
widely available since the early 1990s (Banares et al ., 1998 ). It was initially wel-
comed as a minimally invasive procedure which may be useful for intractable
complications of portal hypertension (Burroughs and Vangeli, 2002 ). While
initial results were encouraging the encephalopathy rates beyond six and par-
ticularly twelve months are high and shunt malfunction and thrombosis is
common. Improvements in sclerotherapy and the availability of other treat-
ments for ascites have limited its indications (although it remains a rescue
procedure for refractory bleeding or ascites and hepatic hydrothorax) (Azoulay
et al ., 2001 ). In addition, in some patients we have seen haemolysis (which can
be a significant problem) and embolization of a TIPS that had been in situ for
LIVER
192
a prolonged period to prevent this is extremely difficult. We feel that the main
indication for TIPS is bleeding in patients awaiting a liver transplant, but this
should only be used in this context by the team who are working up the patient
(Henderson et al ., 2004 ; Saab et al ., 2004 ; Rosemungy et al . 2000 ; Gazzera et al .,
2009 ).
Splenic vein thrombosis
Splenic vein thrombosis in portal hypertension, or secondary to pancreatitis,
produces localized left-sided portal hypertension or worsens the effect of pre-
existing raised portal pressure. This, together with the long-term increase in
size of the spleen, can produce hypersplenism, anaemia, and thrombocytope-
nia (Agarwal et al ., 2008 ). The combination of these haematological abnor-
malities and oesophageal varices is very dangerous. In patients with no portal
hypertension per se (i.e. those secondary to pancreatitis), the outlook can be
dramatically improved or potential problems even abolished completely by
splenectomy. This procedure is less valuable in the patients with portal hyper-
tension and a patent splenic vein. It carries the additional risk of suddenly
reducing the flow in the portal vein and precipitating portal vein thrombosis.
This would prejudice the opportunities for liver transplantation which is a
better option in this patient cohort.
For splenic vein thrombosis however, splenectomy is well tolerated and pro-
duces excellent long-term results. Patients are immunized 3 weeks prior to the
procedure against Streptococcus pneumoniae, Haemophilis influenzae , and
Neisseria meningitidis and informed of the need for postoperative antibiotics.
A predominantly left-sided transverse incision is used and generally problems
with venous congestion are localized and produce less technical difficulty than
with raised portal vein pressure. These spleens are enlarged but not massive
and mobilization, if done with care, should be uneventful.
The splenic flexure and distal transverse colon are initially mobilized by
dividing the gastrocolic omentum and entering the lesser sac. Congenital adhe-
sions to the back of the stomach are divided exposing the anterior portion of
the body and tail of the pancreas and the splenic hilum. The splenic artery is
identified and slung at this point but we prefer to divide it in the splenic hilum.
The spleen is then displaced forwards after division of the lienophrenic liga-
ment and any adhesions to the abdominal wall and diaphragm. Packing behind
the spleen enables the position of the splenic hilum to be comfortably seen and
the extent of the tail of the pancreas assessed.
Occasionally the splenic artery and vein can be easily seen if the tail of the
pancreas is short, but generally it is necessary to start inferiorly dividing the
short gastric vessels and working towards the hilum. At the hilum, the vessels