Hemodynamic Changes with Cirrhosis of the Liver

Johnson, George; Dart, Charles H.; Peters, Richard M.; Macfie, Jefferys A.

doi:10.1097/00000658-196605000-00006

Cited by 58 publications

(3 citation statements)

References 17 publications

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“…Presinuosoidal intrahepatic arteriovenous fistulas were also described by Popper and associates in 1952 [20]. Womack and his colleagues have in recent years emphasized the role of arteriovenous shunting in cases of portal hypertension [23,24]. Womack's studies led him to conclude that there was an extensive network of arteriovenous fistulas within the wall of the stomach.…”

Section: Pathophysiologymentioning

confidence: 87%

“…In a communication in 1966, he and his associates described a procedure to include a transthoracic approach, splenectomy, and resection of the greater curvature of the stomach with ligation of arterial branches to the cardia. Varices, if present, were oversewn [24,118]. This operation combined division of venous collaterals, reduction in arterial flow to the stomach, and direct ligation of the varices.…”

Section: Direct Variceal Controlmentioning

confidence: 99%

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Surgical treatment of portal hypertension: A historical perspective

Donovan

1984

World j. surg.

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Portal hypertension has been treated surgically by diversion of blood from the portal system, by interruption of the flow of blood to esophageal varices, or by direct obliteration of the varices. At the beginning of the twentieth century, portal diversion was achieved by omentopexy and, in a few patients, by the creation of a portacaval shunt. The latter operation was abandoned because of high mortality and morbidity rates, including shunt encephalopathy. In the 1940's, interest was renewed in the portacaval shunt. Improved understanding of hepatic physiology and the establishment of precise criteria for selection of cases for surgery resulted in a low operative mortality rate. The operation was highly successful in the control of hemorrhage from esophageal varices but was associated with an undesirable incidence of impairment of hepatic function. Currently, selective decompression of varices by the distal splenorenal shunt is under evaluation as a method of preventing variceal hemorrhage, while preserving hepatic function. Elimination of the threat of hemorrhage from varices by arterial ligation, sclerotherapy, or direct suture has been practiced for almost a century. The result remains one of temporary control with recurrent hemorrhage in the majority of cases.Ascites was formerly considered the dominant manifestation of portal hypertension. Currently, it is usually well controlled by diuretics. Surgery is reserved for the rare case of intractable ascites, often with hepatorenal syndrome. In such cases, a shunt is established between the peritoneal cavity and the systemic venous system, a procedure first performed early in this century.

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Section: Pathophysiologymentioning

confidence: 87%

Section: Direct Variceal Controlmentioning

confidence: 99%

Surgical treatment of portal hypertension: A historical perspective

Donovan

1984

World j. surg.

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“…The 3 main historical factors leading to the introduction of selective shunting were: (a) the demonstration that portacaval shunts controlled bleeding, but the resultant loss of portal venous perfusion led to high morbidity and mortality rates [2][3][4]; (b) devascularization procedures did not satisfactorily control bleeding, but had a low incidence of liver failure and encephalopathy [5,6]; and (c) maintenance of portal venous perfusion was defined as the critical variable in preserving liver function [7,8]. The rationale thus emerged that the ideal surgical approach to long-term management of the patient with variceal bleeding should be based on the following 3 physiological goals: selective decompression of gastroesophageal varices, maintenance of mesenteric and portal perfusion of the liver, and maintenance of high intestinal venous pressure.…”

mentioning

confidence: 99%

The distal splenorenal shunt: An update

Henderson

Millikan

1984

World j. surg.

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The distal splenorenal shunt (DSRS), as the prototype for selective variceal decompression, has evolved over the 17 years since its introduction. Attention to detail in the preoperative assessment and perioperative management will minimize morbidity. Reported experience from over 25 centers has shown an average overall operative mortality rate of 9%, shunt patency and bleeding control rates in excess of 90%, encephalopathy in from 0 to 18% of cases, and a 5‐year survival rate between 50 and 60%. Non‐alcoholic cirrhotics (70–80%) have a significantly (p< 0.05) greater 5‐year survival rate than do alcoholic cirrhotics (45%). The 6 prospective randomized trials comparing DSRS to total portal systemic shunts have been conducted primarily in alcoholic cirrhotics; they show no significant difference in survival. Current experience in schistosomiasis and portal vein thrombosis shows selective variceal decompression to be superior to total shunt. Quantitative data prior to and 1 year after DSRS show a fall in liver volume, stabilization of hepatocyte function, and variable change in hemodynamics: alcoholic cirrhotics have a 70% chance of losing portal venous flow, while nonalcoholics maintain portal perfusion. Loss of portal venous flow is associated with a systemic hyperdynamic response in those with poorer hepatocyte function. Splenopancreatic disconnection is currently being studied in an attempt to maintain portal perfusion better and preserve liver volume. We conclude that the DSRS has achieved its pathophysiological goals of preventing recurrent variceal bleeding, while maintaining hepatocyte function. Modifications in management and the operative procedure are evolving from increased understanding of the pathology of the underlying causes of the portal hypertension leading to variceal bleeding.

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Hemodynamic Observations Following Arterialization of the Portal Vein

Tutassaura¹

1972

Arch Surg

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Hemodynamic Changes with Cirrhosis of the Liver

Cited by 58 publications

References 17 publications

Surgical treatment of portal hypertension: A historical perspective

Surgical treatment of portal hypertension: A historical perspective

The distal splenorenal shunt: An update

Hemodynamic Observations Following Arterialization of the Portal Vein

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