Which Treatment to Choose for Portal Biliopathy with Extensive Portal Thrombosis?

Abstract

Background: Portal biliopathy refers to abnormalities of the biliary tract developing in relation to portal hypertension. Portosystemic splenorenal or mesenterico-caval shunting is a safe and effective method to relieve biliary obstruction in symptomatic patients but is unfeasible in cases of extensive thrombosis of the splenic and superior mesenteric veins. In such cases, a makeshift portosystemic shunt between a suitable portal varix and the caval system can be an interesting alternative. Methods: This study describes 3 patients admitted for symptomatic portal biliopathy caused by idiopathic portal cavernoma associated with extensive portal thrombosis. A makeshift portosystemic shunt was carried out after preoperative portal imaging had demonstrated the presence of a suitable splanchnic varix. Results: The makeshift portosystemic shunt was performed by direct anastomosis in 2 patients and by prosthetic interposition in 1 case. Shunting was between a splanchnic varix and the inferior vena cava in 2 cases and the left renal vein in 1 case. Postoperative morbidity was nil and follow-up ranging from 2 to 12 years showed good results with no recurrence of biliary obstruction. Conclusion: In patients presenting symptomatic portal biliopathy associated with extensive thrombosis of the portal system, a makeshift portosystemic shunt is preferable to repeated endoscopic procedures or intrahepatic biliodigestive bypass, provided that a suitable varix is available.

Clinical Usefulness of Endoscopic Palliation in Patients with Biliary Obstruction Caused by Hepatocellular Carcinoma

“…We found that the successful response to EBD in jaundiced patients with bile duct invasion of HCC depended upon relatively mild jaundice and preserved liver function and intact portal vein flow. These results can be supported by the findings that the damage to the liver reduces the elimination of bilirubin from the body [17] and portal biliopathy per se in relation to extensive thrombosis of the portal system induces deep chronic jaundice [18,19]. In addition, appropriate palliation by EBD increased the probability of receiving essential treatment for HCC and further resulted in favorable survival outcomes, regardless of pre-procedural bilirubin concentration.…”

Therapeutic approaches for portal biliopathy: A systematic review

“…In cases in which PB is due to biliary compression by PC, the detension of collateral vessels obtained with the reduction of portal pressure by PSS can resolve in the same time biliary obstruction[30]. The most common PSS performed are proximal spleno-renal shunt or mesocaval shunt, but other types of surgical shunts include meso-gonadal vein shunt, meso-renal shunt, right-porto ovarian shunt, shunt between a portal varix and cava[41,48-51]. …”

Portal biliopathy as a complication of extrahepatic portal hypertension: Etiology, presentation and management

“…In patients with symptomatic PB, other variant forms of PSS can be performed with good results. Particularly, shunts between a splanchnic varix and the inferior vena cava or the left renal vein have also been described [32]. In patients with no vein available for shunt, a splenectomy with devascularization may alter the natural history of PB, probably by decreasing overall portal flow, and can thus be considered as a therapeutic procedure [33].…”