Effects of hepatotrophic factors on the liver after portacaval shunt in rats with portal hypertension

Background Portacaval shunt （PCS） prevent hepatotrophic factors from flowing into the liver, but they enter directly the systemic circulation and worsen liver injury. This study was designed to investigate the effects of hepatotrophic factors through the portal vein on the liver in rats with portal hypertension after portacaval shunt. Methods Intrahepatic portal hypertension （IHPH） was induced by intragastric administration of carbon tetrachloride, and end-to-side PCS was performed. Eight normal rats served as controls, and eight rats with IHPH served as IHPH model （IHPH group）. Another 32 rats with IHPH-PCS were randomly subdivided into 4 groups： normal saline （NS） given to 8 rats, hepatocyte growth factor （HGF） 8, insulin （INS） 8, hepatocyte growth factor and insulin （HGF＋INS） 8. Hepatotrophic factors were infused into the portal vein through an intravenous catheter. Portal venous pressure （PVP） was measured. The levels of serum alanine aminotransferase （ALT） and aspartate aminotransferase （AST） were tested biochemically and those of hyaluronic acid （HA） and laminin （LN） were measured by radioimmunoassay. Hepatic fibrosis was assessed histologically and the expression of collagens type I and In were detected immunohistochemically. Ultrastructural change of hepatocytes and the number of mitochondria were observed under an electron microscope. The data were compared between groups and subgroups by Student-Newman-Keuls procedure with SPSS 10.0.Results PVP was significantly higher in the IHPH rats than in the control rats （P〈0.05）. The levels of serum ALT, AST, HA, and LN, hepatic fibrosis score, the amount of collagen deposition, collagens type I and III increased more significantly in the IHPH group than in the control rats （P〈0.05）. The number of mitochondria decreased more significantly in the IHPH rats than in the control rats （P〈0.05）. The levels of serum ALT, AST, HA and LN as well as hepatic fibrosis score, the amount of collagen deposition, and the amount of collagens type I and M in the HGF and HGF＋INS rats were significantly lower than those in the NS rats （P〈0.05）. The damage to hepatocyte ultrastructure was markedly alleviated and the number of mitochondria was increased more significantly in the HGF and HGF＋INS rats than in the NS rats under an electron microscope.Conclusions Perfusion of exogenous hepatotrophic factors through the portal vein can alleviate liver injury, minimize the damage to the ultrastructure of hepatocyte, protect liver function, and lessen hepatic fibrosis in rats with portal hypertension after PCS.

Small-diameter prosthetic H-graft portacaval shunts in the treatment of portal hypertension

Background Portasystemic shunts, especially total shunts, are effective tools for reducing portal pressure and controlling variceal bleeding but lead to high risk of encephalopathy and accelerating liver failure. The purpose of this study is to evaluate the clinical effects of small-diameter expanded polytetrafluoroethylene (ePTFE ) H-graft portacaval shunts in the treatment of portal hypertension.Methods Thirty-one patients with portal hypertension were treated with ePTFE small-diameter H-graft portacaval shunts from December 1995 to April 2002. Twenty-one had externally ringed grafts and 10 had non-ringed grafts; 20 had 10 mm diameter grafts and 11 had 8 mm grafts. The left gastric artery and coronary vein were ligated in 22 patients. Additionally, 6 patients underwent pericardial devascularization, and splenectomies were performed on 30 patients.Results An average decrease of free portal pressure (FPP) from (32. 13 ±4. 86) cmH2O before shunting to (12. 55 ±5. 57) cmH2O after shunting was observed. Portal blood flow was reduced by 1/3 compared with the levels measured before shunting. Twenty-eight patients survived after the operation, and no upper gastrointestinal rebleeding occurred in the follow-up period (40. 2 months on average). We lost contact with one patient. Color Doppler ultrasonography and/or portography revealed the shunts to be patent in 28 cases and occluded in 2 (6. 4%) cases. Encephalopathy developed in 4 patients (12. 9%).Conclusion Small-diameter ePTFE H-graft portacaval shunts can effectively reduce portal pressure. Moreover, the majority of the hepatopetal flow from the portal vein can be adequately maintained. The reinforced shunts may achieve a higher rate of patency. Morbidity from encephalopathy was less frequent than in pateints receiving total shunts. Small-diameter H-graft portacaval shunts are also effective in preventing recurrent variceal bleeding.

Partial portacaval shunt with H-grafts to treat portal hypertension

Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity(especially encephalopathy,liver failure and occlusion).The results of partial portacaval shunts[small-diameter expanded polytetrafluoroethylene(ePTFE)H-graft portacaval shunt]were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension.Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006.Thirty-three had externally ringed grafts and ten had non-ringed ones.Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm.The left gastric artery and coronary vein were ligated in all the cases.Six had pericardial devascularization and splenectomy was performed in 42.An average decrease of free portal pressure(FPP)from(33.24 P4.78)cmH2O before shunting and(13.65P5.65)cmH2O after shunting was observed.The portal blood flow was reduced by one-third of that before shunt.Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period(50.5 months in average).Two were out of contact.Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases(3/41,7.3%).Encephalopathy developed in five cases(5/41,12.2%).Partial(small-diameter ePTFE H-graft)portacaval shunting can reduce the portal pressure effectively.Majority of the hepatic flow from the portal vein can be maintained adequately.The shunts with reinforced grafts can keep a higher rate of patency.The morbidity of encephalopathy was lower than those with total shunt.The partial portacaval shunt is effective in preventing recurrent variceal bleeding.

Long-term results of small-diameter proximal splenorenal venous shunt:A retrospective study

AIM:To investigate recurrent variceal hemorrhage and long-term survival rates of patients treated with partial proximal splenorenal venous shunt.METHODS:Patients with variceal hemorrhage who were treated with small-diameter proximal splenorenal venous shunt in Ruijin Hospital between 1996 and 2009 were included in this study.Shunt diameter was determined before operation using Duplex Doppler ultrasonography.Peri-operative and long-term results in term of rehemorrhage,encephalopathy and mortality were followed up.RESULTS:Ninety-eight patients with Child A and B variceal hemorrhage received small-diameter proximal splenorenal venous shunt with a diameter of 7-10 mm.After operation,the patients’mean free portal pressure (P<0.01)and the flow rate of main portal vein(P< 0.01)decreased significantly compared with that before operation.The rates of rebleeding and mortality were 6.12%(6 cases)and 2.04%(2 cases),respectively.Ninety-one patients were followed up for 7 mo-14 years (median,48.57 mo).Long-term rates of rehemorrhage and encephalopathy were 4.40%(4 cases)and 3.30% (3 cases),respectively.Thirteen patients(14.29%)died mainly due to progressive hepatic dysfunction.Fiveand ten-year survival rates were 82.12%and 71.24%,respectively.CONCLUSION:Small-diameter proximal splenorenal venous shunt affords protection against variceal rehemorrhage with a low occurrence of encephalopathy in patients with normal liver function.

Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.

Surgical treatment of portal hypertension

Portal hypertension is a common disease with high mortality and serious influence on the life quality of patients. At present, shunt and disconnection are commonly used for the treatment of portal hyperten- sion. In recent years, combined procedures of shunt and disconnection have evoked the potential interest of surgeons. Initial experimental studies and clinical observations showed that the combined procedures are ideal for treating portal hypertension. Transju- gular intrahepatic portacaval shunt (TIPS) is a new minimally invasive technique in treating portal hy- pertension. Some surgeons have tried to perform dis- connection under laparoscopy with success. Liver transplantation will be the focus of portal hyperten- sion surgery in the future.