SURGICAL TREATMENT

FOR BLEEDING
ESOPHAGEAL VARICES
◦ Surgical management outline:

Transjugular Intrahepatic
Portosystemic Shunts (TIPSS)

Surgical Shunts

Hepatic Transplantation
 Transjugular Intrahepatic Portosystemic
Shunts (TIPSS)

◦ TIPSS has become the main treatment of variceal hemorrhage that has not responded to
drug treatment and endoscopic therapy.

◦ COMPLICATIONS: ◦ CONTRAINDICATIONS:
◦ Perforation of the liver capsule ◦ Portal vein occlusion
associated with fatal intraperitoneal ◦ Encephalopathy
hemorrhage.
◦ Tumors
◦ Post-shunt encephalopathy
◦ Shunt stenosis, may present as further ◦ Liver cysts
variceal hemorrhage.
 Shunts are inserted under local
anesthetic, analgesia and sedation using
fluoroscopic guidance and
ultrasonography

Via the internal jugular vein and SVC, a

guidewire is inserted into a hepatic
parenchyma into a branch of the portal
vein

The track through the parenchyma is then

dilated with a balloon catheter to allow insertion
of a metallic stent, which is expanded once a
satisfactory position is achieved.

This forms a channel between the systemic and

portal venous systems
https://www.uclahealth.org/radiology/ir/transjugular-intrahepatic-portosystemic-shunt-tips
 Surgical Shunts
◦ Effective method of preventing
recurrent bleeding from esophageal
varices.
◦ Reduces the pressure in the portal
circulation by diverting the blood
into the low-pressure systemic
circulation
◦ Commonly used shunts are:
◦ Selective
◦ Non-selective
◦ Indications:
◦ CHILD’S grades A and B
◦ In whom the initial bleed has been
controlled by sclerotherapy
◦ Limited access to TIPSS
◦ Not a candidate for hepatic
transplantation.
◦ Alternatives
◦ Long term beta-blockers (Propanolol)
◦ Chronic sclerotherapy or banding
 Non-
Selective Selective

• Portocaval shunt
• Side-to-side
• Distal splenorenal shunt (Warren)
• End-to-side
• Preserve blood flow to the liver while
• High incidence of hepatic
decompressing the left side of the
encephalopathy, decreased liver
portal circulation
function.
• Lower rate of hepatic
• Mesocaval shunt encephalopathy
• uses an 8 or 10mm PTFE graft to connect
• Does not interfere with subsequent
the superior mesenteric vein to the IVC
liver transplantation
• easier to perform, can be easily ligated
during subsequent hepatic
transplantation
• small diameter portosystemic shunts - low
risk of encephalopathy, higher risk of shunt
thrombosis and rebleeding
 Sugiura
Non-Shunt Surgical Management
Procedure

Useful when patients have extensive portal & splenic vein thrombosis & no
other operative or radiologic options are available.

It is a transthoracoabdominal esophageal transection, consists in

paraoesophageal devascularization, esophageal transection and
reanastomosis, splenectomy, and pyloroplasty.

This decreases the arterial blood supply to the stomach and lower
esophagus, which decreases the bleeding.
 Variceal bleeding and orthotopic liver
transplantation
• Liver transplantation is the only therapy that will treat both
portal hypertension and the underlying liver disease
• The management of variceal bleeding should always take
into account the possibility of liver transplantation when this is
available.
• Considered in patients with variceal bleeding refractory to all
other forms of management.
• Previous surgical shunts greatly increase the morbidity
associated with orthotopic liver transplantation.
• TIPSS would be the preferred management for bleeds
resistant to sclerotherapy, as long as placement is optimal.
REFERENCES
1. Russell, R., Williams, N., & Bulstrode, C. J. K. (2007). Bailey and Love’s Short
Practice of Surgery 24e. pp 1074-1076. (International, Student ed.) [E-book].
Hodder Education Publishers.
2. Sriram, B. M. (2019). Srb’s Manual of Surgery. pp 611-617. (6th edition) [E-
book]. Jaypee Brothers Medical Pub.
3. Stein, D. E., MD. (2021, July 22). Esophagogastric Devascularization
Technique: Sugiura Procedure, Modified Sugiura Procedure, Modified Hassab
Procedure. Emedicine.Medscape.
https://emedicine.medscape.com/article/1895379-technique
4. CPG Management of Acute Variceal Bleeding. Malaysia. May 2007.