title: Therapeutic strategies in symptomatic portal biliopathy.
abstract: 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.
authors.affiliation: Centre Hépato-Biliaire, Hôpital Paul Brousse (AP-HP), Université Paris Sud, Villejuif, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Vibert
authors.forename: Daniel
authors.initials: D
authors.lastname: Azoulay
authors.forename: Thomas
authors.initials: T
authors.lastname: Aloia
authors.forename: Gérard
authors.initials: G
authors.lastname: Pascal
authors.forename: Luc-Antoine
authors.initials: LA
authors.lastname: Veilhan
authors.forename: René
authors.initials: R
authors.lastname: Adam
authors.forename: Didier
authors.initials: D
authors.lastname: Samuel
authors.forename: Denis
authors.initials: D
authors.lastname: Castaing
mesh_terms: 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