Surgery in Patients with Hepatic Cirrhosis: Management of Portal Hypertension

  • Kareem Abu-Elmagd
  • Basem Soliman
  • Ajai Khanna
  • Masato Fujiki
  • Bijan Eghtesad
  • Guilherme Costa


The inherent development of portal hypertension (PH) in patients with hepatic cirrhosis and portomesenteric venous thrombosis commonly influences the outcome of any required major surgical intervention. Accordingly, a thorough assessment is often required to define status of hepatic reserve, spectrum of PH, and complexity of the coexisted pathology. This includes comprehensive clinical, biochemical, endoscopic, radiologic, and histopathologic evaluation. In candidates with preserved synthetic liver functions, optimization of nutritional and global health status is imperative to reduce overall morbidity and mortality. With the diagnosis of gut varices and demonstration of portomesenteric abdominal collaterals, directed management strategy is required to avoid the potential risk of provoking life-threatening complications including variceal hemorrhage and surgical bleeding with subsequent development of hepatic failure. With the initial recognition of marginal hepatic reserve or subsequent development of liver failure, organ transplantation should be seriously considered. Accordingly, patients with portal hypertension who are in need for major surgical procedures should be managed at tertiary medical centers. The availability of a multidisciplinary team with expertise in the relevant fields improves the overall outcomes measures including survival and value of health care.


Hepatic cirrhosis Portal hypertension Portomesenteric venous thrombosis Portosystemic collaterals Gastroesophageal varices Intestinal and colonic varices Variceal hemorrhage Transjugular intrahepatic portosystemic shunt (TIPS) Splenic and collateral embolization Surgical shunts Gastric devascularization 





  1. 1.
    Balducci G, Sterpetti AV, Ventura M. A short history of portal hypertension and of its management. J Gastroenterol Hepatol. 2016;31(3):541–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Gilbert DA-N. Les Fonctions hépatiques, par MM. A. Gilbert,... et P. Carnot. Paris: C. Naud; 1902.Google Scholar
  3. 3.
    Thompson WP, et al. Splenic vein pressure in congestive splenomegaly (Banti’s syndrome). J Clin Invest. 1937;16(4):571.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Sandblom P. The history of portal hypertension. J R Soc Med. 1993;86(9):544–6.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Orrego-Matte H, et al. Measurement of intrahepatic pressure as index of portal pressure. Am J Med Sci. 1964;247:278–82.CrossRefPubMedGoogle Scholar
  6. 6.
    Pillai AK, et al. Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions. Clin Radiol. 2015;70(10):1047–59.CrossRefPubMedGoogle Scholar
  7. 7.
    Gentilini P, Laffi G. Pathophysiology and treatment of ascites and the hepatorenal syndrome. Baillieres Clin Gastroenterol. 1992;6(3):581–607.CrossRefPubMedGoogle Scholar
  8. 8.
    Vargas HE, Gerber D, Abu-Elmagd K. Management of portal hypertension-related bleeding. Surg Clin North Am. 1999;79(1):1–22.CrossRefPubMedGoogle Scholar
  9. 9.
    Cadranel JF, et al. Hepatic hydrothorax. Presse Med. 2016;45(10):815–823.Google Scholar
  10. 10.
    Bhutta AQ, Garcia-Tsao G. The role of medical therapy for variceal bleeding. Gastrointest Endosc Clin N Am. 2015;25(3):479–90.CrossRefPubMedGoogle Scholar
  11. 11.
    Garbuzenko DV. Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. Curr Med Res Opin. 2016;32(3):467–75.CrossRefPubMedGoogle Scholar
  12. 12.
    Cabrera L, Tandon P, Abraldes JG. An update on the management of acute esophageal variceal bleeding. Gastroenterol Hepatol. 2017;40(1):34–40.Google Scholar
  13. 13.
    Kapoor A, Dharel N, Sanyal AJ. Endoscopic diagnosis and therapy in gastroesophageal variceal bleeding. Gastrointest Endosc Clin N Am. 2015;25(3):491–507.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Bosch J, et al. Effects of vasopressin on the intravariceal pressure in patients with cirrhosis: comparison with the effects on portal pressure. Hepatology. 1988;8(4):861–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Groszmann RJ, et al. Nitroglycerin improves the hemodynamic response to vasopressin in portal hypertension. Hepatology. 1982;2(6):757–62.CrossRefPubMedGoogle Scholar
  16. 16.
    Azam Z, et al. Short course adjuvant terlipressin in acute variceal bleeding: a randomized double blind dummy controlled trial. J Hepatol. 2012;56(4):819–24.CrossRefPubMedGoogle Scholar
  17. 17.
    Rahimi RS, Guntipalli P, Rockey DC. Worldwide practices for pharmacologic therapy in esophageal variceal hemorrhage. Scand J Gastroenterol. 2014;49(2):131–7.CrossRefPubMedGoogle Scholar
  18. 18.
    D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995;22(1):332–54.PubMedGoogle Scholar
  19. 19.
    Patch D, Burroughs AK. Advances in drug therapy for acute variceal haemorrhage. Baillieres Clin Gastroenterol. 1997;11(2):311–26.CrossRefPubMedGoogle Scholar
  20. 20.
    Berreta J, et al. Endoscopic versus endoscopic plus octreotide treatment for acute variceal bleeding. Benefit according to severity at admission. Acta Gastroenterol Latinoam. 2013;43(2):89–97.PubMedGoogle Scholar
  21. 21.
    Qi XS, et al. Nonselective beta-blockers in cirrhotic patients with no or small varices: a meta-analysis. World J Gastroenterol. 2015;21(10):3100–8.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Li T, et al. Carvedilol for portal hypertension in cirrhosis: systematic review with meta-analysis. BMJ Open. 2016;6(5):e010902.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Albillos A, et al. Propranolol plus prazosin compared with propranolol plus isosorbide-5-mononitrate in the treatment of portal hypertension. Gastroenterology. 1998;115(1):116–23.CrossRefPubMedGoogle Scholar
  24. 24.
    Abraldes JG, et al. Simvastatin lowers portal pressure in patients with cirrhosis and portal hypertension: a randomized controlled trial. Gastroenterology. 2009;136(5):1651–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Abraldes JG, et al. Addition of simvastatin to standard therapy for the prevention of variceal rebleeding does not reduce rebleeding but increases survival in patients with cirrhosis. Gastroenterology. 2016;150(5):1160–1170.e3.CrossRefPubMedGoogle Scholar
  26. 26.
    Paquet KJ, Oberhammer E. Sclerotherapy of bleeding oesophageal varices by means of endoscopy. Endoscopy. 1978;10(1):7–12.CrossRefPubMedGoogle Scholar
  27. 27.
    Palani CK, et al. Endoscopic sclerotherapy in acute variceal hemorrhage. Am J Surg. 1981;141(1):164–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Hui Ng NB, et al. Endoscopic evaluation in children with end-stage liver disease associated portal hypertension awaiting liver transplant. J Pediatr Gastroenterol Nutr. 2016;63(3):365–9.CrossRefGoogle Scholar
  29. 29.
    Luigiano C, et al. Role of endoscopy in management of gastrointestinal complications of portal hypertension. World J Gastrointest Endosc. 2015;7(1):1–12.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Steevens C, et al. Massive duodenal variceal bleed; complication of extra hepatic portal hypertension: endoscopic management and literature review. World J Gastrointest Pharmacol Ther. 2015;6(4):248–52.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    de Paulo GA, et al. Treatment of esophageal varices: a randomized controlled trial comparing endoscopic sclerotherapy and EUS-guided sclerotherapy of esophageal collateral veins. Gastrointest Endosc. 2006;63(3):396–402. quiz 463CrossRefPubMedGoogle Scholar
  32. 32.
    Ring EJ, et al. Using transjugular intrahepatic portosystemic shunts to control variceal bleeding before liver transplantation. Ann Intern Med. 1992;116(4):304–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Petersen B. Intravascular ultrasound-guided direct intrahepatic portacaval shunt: description of technique and technical refinements. J Vasc Interv Radiol. 2003;14(1):21–32.PubMedGoogle Scholar
  34. 34.
    Tripathi D, et al. Ten years’ follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre. Eur J Gastroenterol Hepatol. 2004;16(1):9–18.CrossRefPubMedGoogle Scholar
  35. 35.
    Riggio O, et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol. 2008;103(11):2738–46.CrossRefPubMedGoogle Scholar
  36. 36.
    Boyer TD, Haskal ZJ. American Association for the Study of Liver Diseases Practice Guidelines: the role of transjugular intrahepatic portosystemic shunt creation in the management of portal hypertension. J Vasc Interv Radiol. 2005;16(5):615–29.CrossRefPubMedGoogle Scholar
  37. 37.
    Middleton WD, Teefey SA, Darcy MD. Doppler evaluation of transjugular intrahepatic portosystemic shunts. Ultrasound Q. 2003;19(2):56–70. quiz 108 – 10CrossRefPubMedGoogle Scholar
  38. 38.
    Cho SK, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007;189(6):W365–72.CrossRefPubMedGoogle Scholar
  39. 39.
    Patel A, Fischman AM, Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices. AJR Am J Roentgenol. 2012;199(4):721–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Wang YB, et al. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: a meta-analysis. J Gastroenterol Hepatol. 2016;31(4):727–33.CrossRefPubMedGoogle Scholar
  41. 41.
    Smith-Laing G, et al. Role of percutaneous transhepatic obliteration of varices in the management of hemorrhage from gastroesophageal varices. Gastroenterology. 1981;80(5 pt 1):1031–6.PubMedGoogle Scholar
  42. 42.
    Zhu K, et al. Partial splenic embolization for hypersplenism in cirrhosis: a long-term outcome in 62 patients. Dig Liver Dis. 2009;41(6):411–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Marsh JW, et al. Liver transplantation today. Postgrad Med. 1987;81(5):13. -6, 19, 22-3CrossRefPubMedGoogle Scholar
  44. 44.
    Adler M, et al. Prognosis of hepatic transplantation as a function of biological, immunological and functional preoperative findings. Acta Gastroenterol Belg. 1987;50(3):365–8.PubMedGoogle Scholar
  45. 45.
    Huang L, et al. Transjugular intrahepatic portosystemic shunt versus surgical shunting in the management of portal hypertension. Chin Med J (Engl). 2015;128(6):826–34.CrossRefGoogle Scholar
  46. 46.
    Orloff MJ. Fifty-three years’ experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in Cirrhosis: 1958-2011. JAMA Surg. 2014;149(2):155–69.CrossRefPubMedGoogle Scholar
  47. 47.
    Rocko JM, Swan KG. The Eck-Pavlov connection. Am Surg. 1985;51(11):641–4.PubMedGoogle Scholar
  48. 48.
    Stipa S, Balducci G, Ziparo V, Stipa F, Lucandri G. Total shunting and elective management of variceal bleeding. World J Surg. 1994;18:200–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Sarfeh IJ, Rypins EB, Mason GR. A systematic appraisal of portacaval H-graft diameters. Clinical and hemodynamic persepectives. Ann Surg. 1986;204:356–63.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Costa G, Cruz Jr RJ, Abu-Elmagd KM. Surgical shunt versus TIPS for treatment of variceal hemorrhage in the current era of liver and multivisceral transplantation. Surg Clin North Am. 2010;90(4):891–905.CrossRefPubMedGoogle Scholar
  51. 51.
    Henderson JM, Warren WD. Selective variceal decompression: current status and recent advances. Adv Surg. 1984;18:81–115.PubMedGoogle Scholar
  52. 52.
    Henderson JM, Millikan WJ, Warren WD. The distal splenorenal shunt: an update. World J Surg. 1984;8(5):722–32.CrossRefPubMedGoogle Scholar
  53. 53.
    Henderson JM, et al. Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial. Gastroenterology. 2006;130(6):1643–51.CrossRefPubMedGoogle Scholar
  54. 54.
    Inokuchi K, et al. New selective decompression of esophageal varices. By a left gastric venous-caval shunt. Arch Surg. 1970;100(2):157–62.CrossRefPubMedGoogle Scholar
  55. 55.
    Inokuchi K, Sugimachi K. The selective shunt for variceal bleeding: a personal perspective. Am J Surg. 1990;160(1):48–53.CrossRefPubMedGoogle Scholar
  56. 56.
    Harmantas A, et al. Selective vs total portosystemic shunts in the treatment of variceal hemorrhage in cirrhotic patients:: is there any advantage? Hepatol Res. 1999;14(2):144–53.CrossRefGoogle Scholar
  57. 57.
    Shaked A, Busuttil RW. Liver transplantation in patients with portal vein thrombosis and central portacaval shunts. Ann Surg. 1991;214(6):696.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Abouljoud MS, et al. A comparison of treatment with transjugular intrahepatic portosystemic shunt or distal splenorenal shunt in the management of variceal bleeding prior to liver transplantation. Transplantation. 1995;59(2):226–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Hassab M. Gastroesophageal decongestion and splenectomy in the treatment of esophageal varices in bilharzial cirrhosis: further studies with a report on 355 operations. Surgery. 1967;61(2):169–76.PubMedGoogle Scholar
  60. 60.
    Hassab M. Nonshunt operations in portal hypertension without cirrhosis. Surg Gynecol Obstet. 1970;131(4):648.PubMedGoogle Scholar
  61. 61.
    Sugiura M, Futagawa S. Esophageal transection with paraesophagogastric devascularizations (the Sugiura procedure) in the treatment of esophageal varices. World J Surg. 1984;8(5):673–9.CrossRefPubMedGoogle Scholar
  62. 62.
    Zong GQ, Fei Y, Liu RM. Comparison of effects of devascularization versus shunt on patients with portal hypertension: a meta-analysis. Chirurgia (Bucur). 2015;110(1):15–25.Google Scholar
  63. 63.
    Harrington PB, et al. Outcomes of patients who undergo cardiac surgical procedures after liver transplantation. Ann Thorac Surg. 2017;103(2):541–545.Google Scholar
  64. 64.
    Ceulemans LJ, et al. Combined liver-thoracic transplantation: single-center experience with introduction of the ‘Liver-first’ principle. Transpl Int. 2016;29(6):715–26.CrossRefPubMedGoogle Scholar
  65. 65.
    Abu-Elmagd KM, et al. Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg. 2009;250(4):567–81.PubMedGoogle Scholar
  66. 66.
    Abu-Elmagd K. The concept of gut rehabilitation and the future of visceral transplantation. Nat Rev Gastroenterol Hepatol. 2015;12(2):108–20.CrossRefPubMedGoogle Scholar
  67. 67.
    Henderson JM. Surgical therapies for management. Portal Hypertens. 2005:235–45.Google Scholar
  68. 68.
    Warren WD, Millikan WJ, Henderson JM, et al. Splenopancreatic disconnection: improved selectivity of distal splenorenal shunt. Ann Surg. 1986;204(4):347.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Kareem Abu-Elmagd
    • 1
  • Basem Soliman
    • 2
  • Ajai Khanna
    • 2
  • Masato Fujiki
    • 2
  • Bijan Eghtesad
    • 2
  • Guilherme Costa
    • 2
  1. 1.Transplant CenterCleveland ClinicClevelandUSA
  2. 2.Transplant Center, Department of General SurgeryCleveland ClinicClevelandUSA

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