Therapeutic strategies in symptomatic portal biliopathy.
BACKGROUND
Chronic portal obstruction can lead to formation of portal cavernoma (PC). Half of all patients with PC will develop cholestasis, termed portal biliopathy, and some will progress to symptomatic biliary obstruction. Because of the high hemorrhage risk associated with biliary surgery in patients with PC, the optimal therapeutic strategy is controversial.


METHODS
Retrospective review of a single hepatobiliary center experience, including 64 patients with PC identified 19 patients with concurrent symptomatic biliary obstruction. Ten patients underwent initial treatment with a retroperitoneal splenorenal anastomosis. For the remaining 9 patients, portal biliopathy was managed without portosystemic shunting (PSS). Outcomes, including symptom relief, the number of biliary interventions, and survivals, were studied in these 2 groups.


RESULTS
Within 3 months of PSS, 7 of 10 patients (70%) experienced a reduction in biliary obstructive symptoms. Five of these 10 patients subsequently underwent uncomplicated biliary bypass, and none has recurred with biliary symptoms or required biliary intervention with a mean follow-up of 8.2 years. For patients without PSS, repeated percutaneous and endobiliary procedures were required to relieve biliary symptoms. Four of the 9 patients with persistent PC required surgical intrahepatic biliary bypass, which was technically more challenging. With a mean follow-up of 8 years, 1 of these 9 patients died of severe cholangitis, 1 remained jaundiced, and 7 were asymptomatic.


CONCLUSIONS
This study, which represents the largest published experience with the surgical treatment of patients with symptomatic portal biliopathy, indicates that retroperitoneal splenorenal anastomosis improves outcomes and should be the initial treatment of choice.
Vibert
Eric
E
Centre Hépato-Biliaire, Hôpital Paul Brousse (AP-HP), Université Paris Sud, Villejuif, France.
Azoulay
Daniel
D
Aloia
Thomas
T
Pascal
Gérard
G
Veilhan
Luc-Antoine
LA
Adam
René
R
Samuel
Didier
D
Castaing
Denis
D
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D002648:Child; D002758:Cholangiography; D002779:Cholestasis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D003251:Constriction, Pathologic; D004322:Drainage / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011169:Portal Vein; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D014652:Vascular Diseases / Q000150:complications* / Q000175:diagnosis