Analysis Of The Relation Between Surgical Procedure And Prognosis Of Prehepatic Portal Hypertension

Background and ObjectivePrehepatie portal hypertension(PPH) is usually due to occlusion of the portal system,either by a congenital portal vein cavernous transformation (PVCT) or thrombosis of the portal system,leading to portal hypertension and the development of a collateral circulation.PPH has some similar clinical symptoms with cirrhotic portal hypertension,such as gastrointestinal bleeding and hypersplenism,but it has it's distinct clinical features:young,normal liver function,no hepatitis and good prognosis.PPH has high morbility in India,which mostly happens in the poor crowd,about 20%in total portal hypertension,range 30--35years.But in the west counties,it's morbility is low,about 3～4%,with no sex differences.Currently,in PPH'S treatment,because of the differences in regional socio-economic conditions,the health-care system,hospital's technology and equipment and doctor's clinical experience and technical level,there are different treatments for PPH.In developed countries,with good socio-economic conditions and well-equipped hospitals,majority doctors advocated conservative treatment for gastrointestinal hemorrhage firstly,such as varicose vein ligation or repeated endoscopic variceal sclerotherapy.Only when conservative treatment had failed,the management could be considered。But in developing countries,with poor socio-economic conditions and imperfect medicare system,most families unable to bear the huge economic burden for repeated selerotherapy,so surgical management as a one-time treatment of PPH is a more feasible alternative compared with repeated sclerotherapy and lifelong follow-up.Therefore,surgical management is still the main treatment of PPH in developing countries.Although there are several kind of surgical managements for PPH such as splenectomy,disconnection,various shunt and conjoined surgery of disconnection and shunt,it is difficult to select a kind of surgical management which has more advantages and better prognosis.This article aimed at further discuss the clinical characteristics and the relation between operative procedure and prognosis of PPH through a retrospective analysis of common conditions,clinical characteristics,diagnosis,treatments and results together with data of blood routine,liver function,coagulation function,the changes of free portal pressure(FPP) after operation.Object and Method79 patients with PPH,57 surgical management,22 conservative treatment,43 males,36 females,range 2～69 years,mean 35.47±4.19 years. Surgery group:57 cases,30 males and 27 females,range 6～70 years,mean 39.04±4.14 years,the time of onset to operation 2 weeks～10 years,mean 18.34±5.8 months.Conservative treatment group:22 cases,13 males and 9 females,range 17～68 years,mean 45.95±6.08 years,and there was no significant difference on age and sex with surgical group.Clinical characteristics.Splenomegaly or hypersplenism in all cases(100%).Bleeding esophagogastric varices in 49 cases(60.76%).The mean number of bleeding episodes per patient was 2.06±0.72.Anemia appearance in 31 cases(39%).Ascites in 15 cases(18.9%).Abdominal distension or pain in 30 cases(37.97%).Anorexia or inertia in 9 cases(11.39%).Gum hemorrhage and cutaneous purpura(3.8%) is seldom well as lower limb edema(2.53%).All patients have no hepatoencephalopathy.13 cases had undergone previous surgery of splenectomy or disconnection owing to splenomegaly,hypersplenism, gastrointestinal bleeding(16.46%).20 cases with other history of abdominal surgery(25.32%).7 cases with recurrent acute pancreatitis history(8.86%).The vast majority of cases with normal liver function:Child-Pugh A 69 cases (87.34%),Child-Pugh B 10 cases(12.66%),Child-Pugh C 0 case.There was no significant difference of surgical group and conservative group in the classification of liver function.All 79 patients had gastroesophageal varicosity through upper GI endoscopy:severe varicose 57 cases(72.15%),moderate varices 15 cases(18.99%),mild varicose 7 cases(8.86%).The surgical group and the conservative group had no significant difference in gastroesophageal varicosity. Surgical procedures:Total portosystemic shunt surgery(TPSS) was performed in 12 cases:mesocaval side-to-side shunt(MCS-SS) in 4 cases, mesocaval C shunt(MCS-C) in 5 eases,splenorenal shunt after splenectomy(CSS) in 3 cases.Distal splenorenal shunt(DSS)(Warren) in 5 cases.Disconnection was performed in 21 cases:splenectomy and gastroesophageal devascularization(SGD) in 17 cases,splenectomy and lower esophageal gastric resection(Phemister) in 4 cases.Conjoined surgery of disconnection and shunt(CSDS) was performed in in 5 cases.In addition,there were 11 cases of left portal hypertension performed splenectomy.Follow up:Telephone call and out-patient clinic follow-up was used.Statistical method:All data were processed with SPSS14.0 Software (a=0.05)ResultThe mean blood loss was statistically significant(p<0.05) in favor of DSS(285 cc,SD 93) versus other surgical groups,and there was no statistically significant difference between TPSS,Disconnection and CSDS (P>(0.05):DSS136±73ML,TPSS795±401ML,Disconnection 1340±860ML,CSD S 875±594ML.No statistically significant difference in operating time between all surgical groups:TPSS 3.46±0.57h,DSS 3.1±0.92h,Disconnection 3.07±0.50 h,CSDS 3.43±0.62h,splenectomy 3.54±0.85 h..There was statistically significant difference on the fall of portal pressure(FPP) in each group(P<0.05):highest for TPSS(10.8cmH₂O,SD 4.87),similar for DSS (10.6 cmH₂O,SD6.94) and CSDS(10.12 cmH₂O,SD4.96),next for splenectomy(8.18 cmH₂O,SD2.71),and last for Disconnection(4.93 cmH₂O,SD4.78).In the hypersplenism alleviation,except for DSS group,it had been resolved in other groups.In DSS group,leucocyte and platelet had no obvious amelioration with 3.71×10⁹/L(SD 0.56)and 85.8×10⁹/L(SD 12.87).There was no significant change on liver function between preoperative and postoperative in each group.In the surgery group 52 cases were followed up,5 cases were lost,follow- up priod ranges from 14 months to 15 years,mean 58±10.5 months.In conservative treatment group 20 cases were followed up,two cases were lost,16 cases re-blede after conservative treatment.The results showed that surgery group was superior to conservative treatment group in controling re-bleeding(P <0.05),and rebleeding rate of shunt groups(including TPSS group,DSS group and CSDS group) was significantly lower than disconnection group(P <0.05),and CSDS group had the best curative effect.There was no encephalopathy in any group.ConclusionPrehepatic portal hypertension(PPH) has its unique clinical characteristics,which has some differences with cirrhosis portal hypertension in clinical manifestation and treatment.The surgical management is still the best way to treat PPH.To patient with PPH,it should take surgical management when has appropriate opportunity as soon as possible.It has important relation between surgical procedure and prognosis of prehepatic portal hypertension.In the choice of surgery,if patients has serious splenomegaly or hypersplenism,with a patent splenic vein or superior mesenteric vein(SMV),it should take CSDS at first,then MCS or CSS.DSS is suitable when there is only mild splenomegaly,mild hypersplenism,and a shuntable splenic vein.Splenectomy and devascularization is the choice when there is no shuntable vein.