1. Portal hypertension and its complications
The cathedra of the faculty and hospital surgery of the treatment faculty of the Tashkent medical academy

2. Anatomy of the portal vein’s system

3. Syndrome of the portal hypertension
Constant increasing of the pressure in the portal vein over 12 mm.h.p
1. Increasing of the resistance to the portal blood flow (at the level of liver, upper and lower)
2. Increasing of the volume of portal blood

4. Распределение циррозов печени по этиологии
By the data of opening - from 1 to 11%
Death from 14 to 47 to 100 ths.

5. Pathogenesis of the portal hypertension at the cirrhosis of the liver
а) mechanical (not regressive) factor: development of the fibrous tissue and realignment of the blood flow in the liver
б) dynamical factor: regressive of the perysinusoid myofibroblastes and smooth muscular cells of the portocollateral vessels

6. Pathogenesis of the portal hypertension at the cirrhosis of the liver
Compensative stage
Portal pressure mm.hy.p.
Portal pressure mm.hy.p.
Reduced portal blood flow
Formation of the portosystem shunts
Sub compensated stage
Portal pressure mm.hy.p.
Sharp reducing of the portal blood flow
Large portosystem shunting
Splanchneous and system vasodilatation
Ascitis
Decompensated stage

7. Reasons of the extrahepatical portal hypertension
1. Primary extrahepatical portal hypertension
- Anomalies of the development of the portal and lienalis veins
2. Secondary extrahepatical hypertension
- Omphalitis, phlebitis of the umbilical veins, sepsis
- Inflammatory diseases of the organs of the abdominal cavity (pancreatitis, appendicitis and others)
-traumas, including operative
А. Total EPH
Б. Segmental IPH

8. Reasons of the suprahepatical portal hypertension
1.Oblitering endophlebitis of the hepatic veins
2. Segmental occlusion of the lower cava vein (in the area of entering of the hepatic veins) with the defeat of the hepatic veins.
3. Segmental occlusion of the lower cava vein upper than the mouth of the hepatic veins and without their significant defeat
а. Membranous closing of the lower cava vein
б. Scar narrowing of the lower cava vein
4. Total thrombosis of the lower cava vein with the following block of the hepatic veins

9. Natural portocaval shunts
КЖВ
ЛЖВ ВВ
НБВ
ВБВ

10. Classification of the portal hypertension (M.D.Paciora)
By the level of the block of the portal blood circulation
1.suprahepatical block of the portal blood circulation
2. intrahepatical block of the portal blood circulation.
3. extrahepatical block of the portal blood circulation.
4. combined block of the portal blood circulation.
by the clinic currency and state of the porto-hepatical blood circulation:
А. Compensated stage
Б. subcompensated stage
В. decompensated stage

11. Clinic picture Palmar erytema Medusa’s head Gynecomastia
Vascular stars

12. Laboratory methods of diagnostic
Anemia
hypersplenism
Reducing of the number of the leucocytes, erythrocytes, trombocytes
Signs of the cytolytic process and hepatical insufficiency:
Increasing bilerubin, AST, ALT
Reduced albumin, protrombin, cholesterin, fibrinogen
Dysproteinemia

13. International classification by Child-Pugh
SIGN
Balls 1 2 3
Ascitis
Absence
Transitory
Constant
Encephalopathy
Significant
Bilerubin
To 30 mcmol\l
30-50 mcmol/l
Over 50 mcmol\l
Albumin
Over 35 g\l
35-28 g\l
Less than 28 g\l
Protrombine index
65-100%
65-55%
Less than 55%
class А – 5-6 balls, class В – 7-9 balls, class С – 10 and more

14. X-ray methods Extended unpaired vein Right side hydrotorax
Varicous extended veins of stomach and esophagus

15. Ultra sonic research spleenomegaly Extended portal vein
USR. Reduced liver

16. Color dopplerography Thrombosis of the portal vein Spleenorenal shunts
Extended umbilical vein
ОК=ЛСК ППС
Portocaval shunts

17. Degree of the extension of the esophageal varicous veins by Shercinger A.K.
To 3 mm
VEV of esophagus and stomach II
3-5 mm
III
Over 5 mm

19. Pik’s cirrhosis.increased liver. Extended ICV.
Computer tomography
Pik’s cirrhosis.increased liver. Extended ICV.
Spiral hepatical artery
Decompensated stege
Spleenorenal shunts

20. Redionuclear methods of research
Sccyntigraphy with Tekhneciy 99 at the cirrhosis of the liver

21. MRT
thrombosis of the trunk of the portal vein with developed collaterals
Arteriovenous fistulaфистула

22. Scheme of the angiographic research

23. Angiographic methods of the research. Caeliacography.
Caeliacography at the CL at the decompensated stage

24. Angiographic researches Not direct portography
Spleenoportographhy

25. Angiographic research. Transcutaneus transhepatical portography
Thrombosis of the portal vein
Extended portorenal shunts
Extended gastroesophageal shunts

26. Angiographic researches Inferior cavagraphy and hepatoveingraphy
Stenosis of the inferior cava vein
Occlusion of the inferior cava vein
Stenosis of the renal vein
Occlusion of the hepatic vein

27. Instrumental methods of diagnostic. Biopsy.

28. methods of treatment of the portal hypertension. Classification.
Conservative
Combined
Surgical
Endovascular
Endoscopic

29. Tasks of the surgical treatment of the portal hypertension:
1. Decompression of the portal system
2. Separation of the portal system from the most weak “bleeding” places of the gestroesophageal veins at the different levels.
3. Fight against ascitis

30. Surgical methods of treatment
Operation of A.S.Talma
Omentonephropexy
1. Reducing of the blood flow to the portal system
2. improvement of the blood circulation of the liver
3. Correction of the hypersleenism
Spleenectomy

31. Surgical methods of treatment .
Operations of the direct portocaval shunting

32. Surgical methods of treatment Operations of the portocaval shunting

33. Selective portosystem shunting
Distal spleenorenal anastomosis
Partial spleenorenal anastomosis

34. Selection of the patients and results of the portosystem shunting
Life saving at the patients elder than 40 years is lower in 2 times
Age – not elder than 50 years
Class А by the classification of Child-Pugh
Postoperative death
Class A about 10%
Class С over 50%
Normal factors of the constructive function of myocard
Encephalopathy – 5-23%
Life saving 2 years –75%, 3 years – 60%, 5 years – 50%
Portal blood flow over 500 ml\min

35. Separating operations
operation of Sugiura
Common postoperative death 15-28%, at the patients with the PH - 5,5%.

36. Transplantation of the liver

37. X-ray endovascular surgery of the portal hypertension

38. Chronic embolization of the lienalis artery
Reducing of the portal pressure on mm.hyd.p.(in a middle 56,44,3 mm.hyd.p.)

39. Liquidation of the hyperspleenism
Change of the angioarchitechtonic of the hepatolienalis zone and clinic efficiency of the ELA
Liquidation of the hyperspleenism
Hepetoarterialising effect
Improvement of the functional factors of the liver
ЛЖА СА
ЖСА

40. Caeliacography after ELA
Chronic embolization
Reembolization

41. Method of transcutaneus transhepaticak embolization of the VEV of the esophagus

42. Transjugular system shunting

43. Transjugular transhepatical portosystem shunting

44. Transhepatical portosystem shunting
US research
Angiography after shunting
Self-extending stent

45. Complications of the portal hypertension
1. gastro-esophageal bleedings
2. ascitis
3. Acute hepatical insufficiency

46. Pathogenesis of bleedings from the GIP

47. Conservative haemostatic therapy
Modern methods of treatment of bleeding from the VEV of esophagus and stomach at the portal hypertension
Conservative haemostatic therapy
Tamponade with the Blackmore’s probe
Endoscopic treatment
Endovascular treatmaent
Urgent surgical intervantions

48. Methods of the conservative therapy of bleedings from the VEV of the esophagus and syomach
- anti-shock acctions
- vasoconctrictors
- haemostatics
- haemo- and plasmotransfusions
- desintixicative therapy
-hepatoprotectors
The bleeding is stoppable in 70-95%

49. Probe of Sengstaken-Blakemore
Complications : obstruction of the pharynx, aspiration pneumonia, breakups and ulcers of the esophagus

50. Blackmore’s probe. Scheme.

51. Endoscopic methods of treatment лечения
Sclerosing
Liging

52. Operations at the bleeding from the VEVE Sewing of the bleeding veins
Sewing apparates

53. Transhepatical shunting

54. Surgical treatment of ascitis at the portal hypertension
Types of ascitis at the PH:
а. Transitory ascitis – under the action of therapy the state of the patient improves and ascitis reduces
б. Resistance ascitis – the therapy is not effective or gives temporary effect
в.dystrophic ascitis – terminal stage of the disease
Spontaneous ascitis-peritonitis – 8%. Death – 50%
Pathogenesis

55. Surgical treatment of the ascitis at the portal hypertension
Peritoneovenous shunting by Le Veen
Lymphovenous anastomosis by Koch and Schreiber
Embolization of the lienalis artery
Transjugular portosystem shunting

56. Conclusion
1. Portal hypertension – spreaded disease, in the most cases inducted with cirrhosis of the liver.
2 treatment and prevention of bleedings from the VEV of the esophagus and stomach are the base of the indications to the surgical treatment at the portal hypertension
3.Surgical treatment is limited with the compensated stages of the portal hypertension
4.mini-invasive interventions include all the categories of the forms and stages of the portal hypertension and are able to effective
-correct defeated portohepatical haemodynamic
Prevent and treat bleedings from the VEV of the esophagus and stomach
Act to to functional state of the liver