Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1995 May;221(5):459–468. doi: 10.1097/00000658-199505000-00003

Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation. Lessons and prospects.

R E Hermann 1, J M Henderson 1, D P Vogt 1, J T Mayes 1, M A Geisinger 1, C Agnor 1
PMCID: PMC1234618  PMID: 7748027

Abstract

OBJECTIVE: The 50-year experience with surgery for the treatment of portal hypertension and bleeding varices at the Cleveland Clinic is reviewed. SUMMARY BACKGROUND DATA: A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transesophageal ligation of varices or devascularization of the esophagus and stomach with splenectomy; portal-systemic (total) shunts; distal splenorenal (selective) shunts; endoscopic sclerotherapy; transjugular intrahepatic portal-systemic shunts; and liver transplantation. METHODS: Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994. RESULTS: Our use of these procedures has changed as experience and new techniques for managing portal hypertension have evolved. Most ligation--devascularization--splenectomy procedures were performed before 1980; they provide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is rebleeding. Total shunts were performed most frequently before 1980; with patient selection, operative mortality was reduced to 8%, control of bleeding was achieved in more than 90%, but the incidence of encephalopathy was high (30%). Selective shunts provide almost equal protection from rebleeding with less post-shunt encephalopathy. We currently use selective shunts for patients with good liver function. Liver transplantation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patients. CONCLUSIONS: The selection of patients for these procedures is the key to the successful management of portal hypertension.

Full text

PDF
459

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aron R., Zapolanski A., Cooperman A. M., Hermann R. E. Regional portal hypertension. Cleve Clin Q. 1979 Spring;46(1):1–5. doi: 10.3949/ccjm.46.1.1. [DOI] [PubMed] [Google Scholar]
  2. BRITTON R. C., CRILE G., Jr Late results of transesophageal suture of bleeding esophageal varices. Surg Gynecol Obstet. 1963 Jul;117:10–14. [PubMed] [Google Scholar]
  3. Blakemore A. H., Lord J. W. The Technic of Using Vitallium Tubes in Establishing Portacaval Shunts for Portal Hypertension. Ann Surg. 1945 Oct;122(4):476–489. doi: 10.1097/00000658-194510000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. CRILE G., Jr Transesophageal ligation of bleeding esophageal varices, a preliminary report of 7 cases. AMA Arch Surg. 1950 Oct;61(4):654–660. doi: 10.1001/archsurg.1950.01250020660005. [DOI] [PubMed] [Google Scholar]
  5. Conn H. O. Transjugular intrahepatic portal-systemic shunts: the state of the art. Hepatology. 1993 Jan;17(1):148–158. [PubMed] [Google Scholar]
  6. Cooperman A. M., Hermann R. E. Ligation procedures in the management of portal hypertension. Surgery. 1977 Apr;81(4):382–385. [PubMed] [Google Scholar]
  7. Helton W. S., Belshaw A., Althaus S., Park S., Coldwell D., Johansen K. Critical appraisal of the angiographic portacaval shunt (TIPS). Am J Surg. 1993 May;165(5):566–571. doi: 10.1016/s0002-9610(05)80436-2. [DOI] [PubMed] [Google Scholar]
  8. Henderson J. M., Gilmore G. T., Hooks M. A., Galloway J. R., Dodson T. F., Hood M. M., Kutner M. H., Boyer T. D. Selective shunt in the management of variceal bleeding in the era of liver transplantation. Ann Surg. 1992 Sep;216(3):248–255. doi: 10.1097/00000658-199209000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Henderson J. M. Variceal bleeding: which shunt? Gastroenterology. 1986 Oct;91(4):1021–1023. doi: 10.1016/0016-5085(86)90710-9. [DOI] [PubMed] [Google Scholar]
  10. Hermann R. E., Taylor P. C. The results of selection of patients for portal-systemic shunt. Surg Gynecol Obstet. 1971 Dec;133(6):1008–1012. [PubMed] [Google Scholar]
  11. Hermann R. E., Traul D. Experience with the Sengstaken-Blakemore tube for bleeding esophageal varices. Surg Gynecol Obstet. 1970 May;130(5):879–885. [PubMed] [Google Scholar]
  12. Idezuki Y., Kokudo N., Sanjo K., Bandai Y. Sugiura procedure for management of variceal bleeding in Japan. World J Surg. 1994 Mar-Apr;18(2):216–221. doi: 10.1007/BF00294404. [DOI] [PubMed] [Google Scholar]
  13. Iwatsuki S., Starzl T. E., Todo S., Gordon R. D., Tzakis A. G., Marsh J. W., Makowka L., Koneru B., Stieber A., Klintmalm G. Liver transplantation in the treatment of bleeding esophageal varices. Surgery. 1988 Oct;104(4):697–705. [PMC free article] [PubMed] [Google Scholar]
  14. Keagy B. A., Schwartz J. A., Johnson G., Jr Should ablative operations be used for bleeding esophageal varices? Ann Surg. 1986 May;203(5):463–469. doi: 10.1097/00000658-198605000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Orloff M. J., Orloff M. S., Rambotti M., Girard B. Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Long-term results of emergency shunt in 94 patients with bleeding varices. Ann Surg. 1992 Sep;216(3):256–268. doi: 10.1097/00000658-199209000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Orozco H., Mercado M. A., Takahashi T., Hernández-Ortiz J., Capellán J. F., Garcia-Tsao G. Elective treatment of bleeding varices with the Sugiura operation over 10 years. Am J Surg. 1992 Jun;163(6):585–589. doi: 10.1016/0002-9610(92)90562-6. [DOI] [PubMed] [Google Scholar]
  17. Rikkers L. F., Burnett D. A., Volentine G. D., Buchi K. N., Cormier R. A. Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding. Early results of a randomized trial. Ann Surg. 1987 Sep;206(3):261–271. doi: 10.1097/00000658-198709000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Rikkers L. F. Is the distal splenorenal shunt better? Hepatology. 1988 Nov-Dec;8(6):1705–1707. doi: 10.1002/hep.1840080638. [DOI] [PubMed] [Google Scholar]
  19. Ringe B., Lang H., Tusch G., Pichlmayr R. Role of liver transplantation in management of esophageal variceal hemorrhage. World J Surg. 1994 Mar-Apr;18(2):233–239. doi: 10.1007/BF00294407. [DOI] [PubMed] [Google Scholar]
  20. Rodríguez A. E., Hermann R. E., McCormack L. J. Portal-systemic shunts in the treatment of portal hypertension. Cleve Clin Q. 1965 Oct;32(4):181–189. doi: 10.3949/ccjm.32.4.181. [DOI] [PubMed] [Google Scholar]
  21. Sanyal A. J. TIPS: the new kid on the block. Hepatology. 1994 Oct;20(4 Pt 1):1092–1095. [PubMed] [Google Scholar]
  22. Starzl T. E., Demetris A. J., Van Thiel D. Liver transplantation (2). N Engl J Med. 1989 Oct 19;321(16):1092–1099. doi: 10.1056/NEJM198910193211606. [DOI] [PubMed] [Google Scholar]
  23. Taylor P. C., Hertzer N. R., Hermann R. E. Differential portal pressures in relation to prognosis and to survival of patients undergoing portacaval shunt. Cleve Clin Q. 1968 Oct;35(4):183–191. doi: 10.3949/ccjm.35.4.183. [DOI] [PubMed] [Google Scholar]
  24. Terblanche J., Northover J. M., Bornman P., Kahn D., Silber W., Barbezat G. O., Sellars S., Campbell J. A., Saunders S. J. A prospective controlled trial of sclerotherapy in the long term management of patients after esophageal variceal bleeding. Surg Gynecol Obstet. 1979 Mar;148(3):323–333. [PubMed] [Google Scholar]
  25. Vogt D. P., Santoscoy T., Cooperman A. M., Hermann R. E. Surgical management of portal hypertension and esophageal varices. 10 year experience. Am J Surg. 1983 Aug;146(2):274–279. doi: 10.1016/0002-9610(83)90390-2. [DOI] [PubMed] [Google Scholar]
  26. Voorhees A. B., Jr, Chaitman E., Schneider S., Nicholson J. F., Kornfeld S., Price J. B., Jr Portal-systemic encephalopathy in the noncirrhotic patient. Effect of portal-systemic shunting. Arch Surg. 1973 Nov;107(5):659–663. doi: 10.1001/archsurg.1973.01350230017005. [DOI] [PubMed] [Google Scholar]
  27. Warren W. D., Millikan W. J., Jr, Henderson J. M., Wright L., Kutner M., Smith R. B., 3rd, Fulenwider J. T., Salam A. A., Galambos J. T. Ten years portal hypertensive surgery at Emory. Results and new perspectives. Ann Surg. 1982 May;195(5):530–542. doi: 10.1097/00000658-198205000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Warren W. D., Millikan W. J., Jr, Smith R. B., 3rd, Rypins E. B., Henderson J. M., Salam A. A., Hersh T., Galambos J. T., Faraj B. A. Noncirrhotic portal vein thrombosis. Physiology before and after shunts. Ann Surg. 1980 Sep;192(3):341–349. doi: 10.1097/00000658-198009000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Westaby D., Macdougall B. R., Williams R. Improved survival following injection sclerotherapy for esophageal varices: final analysis of a controlled trial. Hepatology. 1985 Sep-Oct;5(5):827–830. doi: 10.1002/hep.1840050520. [DOI] [PubMed] [Google Scholar]
  30. Whipple A. O. The Problem of Portal Hypertension in Relation to the Hepatosplenopathies. Ann Surg. 1945 Oct;122(4):449–475. doi: 10.1097/00000658-194510000-00001. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES