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Elkrief L, Denecheau-Girard C, Magaz M, Praktiknjo M, Colucci N, Ollivier-Hourmand I, Dumortier J, Simon Talero M, Tellez L, Artru F, Meszaros M, Verhelst X, Tabchouri N, Beires F, Andaluz I, Leo M, Diekhöner M, Dokmak S, Fundora Y, Vidal-Gonzalez J, Toso C, Plessier A, Carlos Garcia Pagan J, Rautou PE. Abdominal surgery in patients with chronic noncirrhotic extrahepatic portal vein obstruction: A multicenter retrospective study. Hepatology 2024:01515467-990000000-00867. [PMID: 38683626 DOI: 10.1097/hep.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/22/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND AIMS In patients with noncirrhotic chronic extrahepatic portal vein obstruction (EHPVO), data on the morbimortality of abdominal surgery are scarce. APPROACH AND RESULTS We retrospectively analyzed the charts of 76 patients (78 interventions) with EHPVO undergoing abdominal surgery within the Vascular Disease Interest Group network. Fourteen percent of the patients had ≥1 major bleeding (unrelated to portal hypertension) and 21% had ≥1 Dindo-Clavien grade ≥3 postoperative complications within 1 month after surgery. Fifteen percent had ≥1 portal hypertension-related complication within 3 months after surgery. Three patients died within 12 months after surgery. An unfavorable outcome (ie, ≥1 abovementioned complication or death) occurred in 37% of the patients and was associated with a history of ascites and with nonwall, noncholecystectomy surgical intervention: 17% of the patients with none of these features had an unfavorable outcome, versus 48% and 100% when one or both features were present, respectively. We then compared 63/76 patients with EHPVO with 126 matched (2:1) control patients without EHPVO but with similar surgical interventions. As compared with control patients, the incidence of major bleeding ( p <0.001) and portal hypertension-related complication ( p <0.001) was significantly higher in patients with EHPVO, but not that of grade ≥3 postoperative complications nor of death. The incidence of unfavorable postoperative outcomes was significantly higher in patients with EHPVO than in those without (33% vs. 18%, p =0.01). CONCLUSIONS Patients with EHPVO are at high risk of major perioperative or postoperative bleeding and postoperative complications, especially in those with ascites or undergoing surgery other than wall surgery or cholecystectomy.
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Affiliation(s)
- Laure Elkrief
- Faculté de médecine et service d'hépato-gastroentérologie, CHRU de Tours, ERN RARE-LIVER, France
- Inserm, Centre de recherche sur l'inflammation, UMR, Paris, France
| | | | - Marta Magaz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Departament de Medicina i Ciències de la Salut, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Universitat de Barcelona
| | | | - Nicola Colucci
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Jérôme Dumortier
- Service d'Hépatogastroentérologie, Hôpital Edouard Herriot, Lyon
| | - Macarena Simon Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Tellez
- Departamento de Gastroenterología y Hepatología Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Florent Artru
- Service d'hépato-gastroentérologie, CHUV, Lausanne, Switzerland
| | | | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Belgium
| | - Nicolas Tabchouri
- Service de chirurgie digestive et de transplantation hépatique, CHRU de Tours, France
| | - Francisca Beires
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Irene Andaluz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Departament de Medicina i Ciències de la Salut, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Universitat de Barcelona
| | - Massimo Leo
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Mara Diekhöner
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Safi Dokmak
- AP-HP, Service de chirurgie hépato-biliaire et pancréatique, Hôpital Beaujon, DMU DIGEST, Clichy, France
| | - Yliam Fundora
- Department of General & Digestive Surgery, Institut de Malalties Digestives I Metabòliques, Hospital Clínic, University of Barcelona, IDIBAPS, Spain
| | - Judit Vidal-Gonzalez
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Christian Toso
- Service de chirurgie viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Aurélie Plessier
- Inserm, Centre de recherche sur l'inflammation, UMR, Paris, France
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Juan Carlos Garcia Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Departament de Medicina i Ciències de la Salut, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Universitat de Barcelona
| | - Pierre-Emmanuel Rautou
- Inserm, Centre de recherche sur l'inflammation, UMR, Paris, France
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
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Goel P, Bhatnagar V, Chennur VS. Makeshift Shunts in Extrahepatic Portal Vein Obstruction in Pediatric Population. J Indian Assoc Pediatr Surg 2024; 29:152-158. [PMID: 38616824 PMCID: PMC11014182 DOI: 10.4103/jiaps.jiaps_21_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/23/2021] [Accepted: 10/25/2021] [Indexed: 04/16/2024] Open
Abstract
Background and Objectives More than 20% of patients with extrahepatic portal vein obstruction (EHPVO) may be deemed as nonshuntable due to lack of a suitable vein. The role of "makeshift shunts" or "lesser shunts" assumes importance in such cases. In this report, the authors have shared their experience with the makeshift shunts in the management of portal hypertension in children with emphasis upon anatomic considerations, resolution of symptoms, outcomes after surgery, and shunt patency. Materials and Methods During the period 1983-2018, 138 children with portal hypertension were managed under the care of a single surgeon (VB). Of them, 134 were EHPVO. Children with EHPVO were treated with splenectomy and proximal lienorenal shunt (n = 107), splenectomy and devascularization (n = 21), and makeshift shunts (n = 6). Makeshift shunts comprised (i) side-to-side right gastroepiploic vein (Rt-GEV) to left renal vein (LRV) shunt (n = 1), (ii) superior mesenteric vein (SMV) to inferior vena cava (IVC) shunt using a spiral saphenous venous graft (n = 1), (iii) side-to-side inferior mesenteric vein (IMV) to LRV shunt (n = 2), (iv) side-to-side IMV to IVC shunt (n = 1), (v) end-to-side IMV to IVC shunt (n = 1), and (vi) side-to-side IMV to LRV shunt (n = 1) in a case of crossed fused renal ectopia. Results Following the creation of portosystemic shunt, a decline in portal pressure was demonstrated in all six patients. There was resolution of symptoms including hematemesis, melena, and anorectal variceal bleed. None of the patients demonstrated the features of hepatic encephalopathy. The associated portal cavernoma cholangiopathy (n = 1) also resolved following Rt-GEV to LRV shunt. Shunt patency was documented for the entire duration of follow-up (1.5-4 years) in five of six patients; the sixth patient demonstrated shunt block at 6-month follow-up but without recurrence of symptoms. Conclusions Makeshift shunts offer a viable alternative to standard portosystemic shunting in pediatric patients with a nonshuntable vein. The selection of such shunts is, however, subject to surgeon's preferences and has to be individualized to local anatomy.
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Affiliation(s)
- Prabudh Goel
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Veereshwar Bhatnagar
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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Shalaby S, Miraglia R, Senzolo M. Transjugular Intrahepatic Portosystemic Shunt in Nonmalignant Noncirrhotic Portal Vein Thrombosis and Portosinusoidal Vascular Disorder. J Clin Med 2024; 13:1412. [PMID: 38592220 PMCID: PMC10931999 DOI: 10.3390/jcm13051412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) emerges as a key treatment for portal hypertension (PH) complications. While international guidelines provide clear indications for its use in cirrhosis, empirical knowledge is notably scarcer in non-cirrhotic PH, particularly in nonmalignant noncirrhotic portal vein thrombosis (NNPVT) and in patients with portosinusoidal vascular disorder (PSVD). Patients afflicted by these rare diseases exhibit distinct clinical profiles compared to their cirrhotic counterparts, often characterized by a younger age, predominantly preserved hepatic functionality even in cases of severe PH, and a higher propensity for extensive splanchnic thrombosis, which intricately complicates TIPS placement, posing unique challenges for its creation. The objective of this review is to synthesize existing literature on the effectiveness, safety, specific indications, and clinical outcomes of TIPS in adult patients with NNPVT or PSVD, focusing also on the technical challenges of TIPS insertion in the presence of portal cavernoma.
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Affiliation(s)
- Sarah Shalaby
- Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
| | - Roberto Miraglia
- Radiology Service, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), 90127 Palermo, Italy;
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
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Buyruk AM, Erdoğan Ç, Tekin F, Turan İ, Özütemiz Ö, Ersöz G. The use of fully covered self-expandable metal stents in the endoscopic treatment of portal cavernoma cholangiopathy. BMC Gastroenterol 2023; 23:414. [PMID: 38017393 PMCID: PMC10683077 DOI: 10.1186/s12876-023-03042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND AIMS There are different therapeutic approaches for biliary strictures and reducing portal hypertension in patients with symptomatic portal cavernoma cholangiopathy (PCC). Endoscopic treatment includes endoscopic biliary sphincterotomy (EST), dilation of stricture with a biliary balloon, placement of plastic stent(s) and stone extraction. Fully covered self-expandable metal stent (FCSEMS) is placed as a rescuer in case of haemobilia seen after EST, dilation of stricture and removal of plastic stent rather than the stricture treatment itself. In this retrospective observational study, we sought to assess the clinical outcomes of FCSEMS as the initial treatment for PCC-related biliary strictures. MATERIALS AND METHODS Twelve symptomatic patients with PCC both clinically and radiologically between July 2009 and February 2019 were examined. Magnetic resonance cholangiopancreatography (MRCP) and cholangiography were employed as the diagnostic imaging methods. Chandra-Sarin classification was used to distinguish between biliary abnormalities in terms of localization. Llop classification was used to group biliary abnormalities associated with PCC. Endoscopic partial sphincterotomy was performed in all the patients. If patients with dominant strictures 6-8-mm balloon dilation was first performed. This was followed by removal of the stones if exist. Finally, FCSEMS placed. The stents were removed 6-12 weeks later. RESULTS The mean age of the patients was 40.9 ± 10.3 years, and 91.6% of the patients were male. Majority of the patients (n = 9) were noncirrhotic. Endoscopic retrograde cholangiopancreatography (ERCP) findings showed that 11 of the 12 patients were Chandra Type I and one was Chandra Type IIIa. All the 12 patients were Llop Grade 3. All patients had biliary involvement in the form of strictures. Stent placement was successful in all patients. FCSEMSs were retained for a median period of 45 days (30-60). Seven (58.3%) patients developed acute cholecystitis. There was no occurrence of bleeding or other complications associated with FCSEMS replacement or removal. All patients were asymptomatic during median 3 years (1-10) follow up period. CONCLUSIONS FCSEMS placement is an effective method in biliary strictures in case of PCC. Acute cholecystitis is encountered frequently after FCSEMS, but majority of patients respond to the medical treatment. Patients should be followed in terms of the relapse of biliary strictures.
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Affiliation(s)
| | - Çağdaş Erdoğan
- Department of Gastroenterology, University of Health Sciences, Ankara Etlik City Hospital, Ankara, Turkey.
| | - Fatih Tekin
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - İlker Turan
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Ömer Özütemiz
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Galip Ersöz
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
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Martín-Llahí M, Albillos A, Bañares R, Berzigotti A, García-Criado MÁ, Genescà J, Hernández-Gea V, Llop-Herrera E, Masnou-Ridaura H, Mateo J, Navascués CA, Puente Á, Romero-Gutiérrez M, Simón-Talero M, Téllez L, Turon F, Villanueva C, Zarrabeitia R, García-Pagán JC. Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:538-580. [DOI: 10.1016/j.gastrohep.2017.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
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Abstract
The term portal cavernoma cholangiopathy refers to the biliary tract abnormalities that accompany extrahepatic portal vein obstruction (EHPVO) and subsequent cavernous transformation of the portal vein. EHPVO is a primary vascular disorder of the portal vein in children and adults manifested by longstanding thrombosis of the main portal vein. Nearly all patients with EHPVO have manifestations of portal cavernoma cholangiopathy, such as extrinsic indentation on the bile duct and mild bile duct narrowing, but the majority are asymptomatic. However, progressive portal cavernoma cholangiopathy may lead to severe complications, including secondary biliary cirrhosis. A spectrum of changes is seen radiologically in the setting of portal cavernoma cholangiopathy, including extrinsic indentation of the bile ducts, bile duct stricturing, bile duct wall thickening, angulation and displacement of the extrahepatic bile duct, cholelithiasis, choledocholithiasis, and hepatolithiasis. Radiologists must be aware of this disorder in order to provide appropriate imaging evaluation and interpretation, to facilitate appropriate treatment and to distinguish this entity from its potential radiologic mimics.
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Affiliation(s)
- Lauren N Moomjian
- Department of Radiology, Virginia Commonwealth University Medical Center, 1250 East Marshall Street, PO Box Number 980615, Richmond, VA, 23298, USA.
| | - Sarah G Winks
- Department of Radiology, Virginia Commonwealth University Medical Center, 1250 East Marshall Street, PO Box Number 980615, Richmond, VA, 23298, USA
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Khuroo MS, Rather AA, Khuroo NS, Khuroo MS. Portal biliopathy. World J Gastroenterol 2016; 22:7973-7982. [PMID: 27672292 PMCID: PMC5028811 DOI: 10.3748/wjg.v22.i35.7973] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/22/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Portal biliopathy refers to cholangiographic abnormalities which occur in patients with portal cavernoma. These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal and cholecystic veins. Bile duct ischemia may occur due prolonged venous pressure effect or result from insufficient blood supply. In addition, encasement of ducts may occur due fibrotic cavernoma. Majority of patients are asymptomatic. Portal biliopathy is a progressive disease and patients who have long standing disease and more severe bile duct abnormalities present with recurrent episodes of biliary pain, cholangitis and cholestasis. Serum chemistry, ultrasound with color Doppler imaging, magnetic resonance imaging with magnetic resonance cholangiopancreatography and magnetic resonance portovenography are modalities of choice for evaluation of portal biliopathy. Endoscopic retrograde cholangiography being an invasive procedure is indicated for endotherapy only. Management of portal biliopathy is done in a stepwise manner. First, endotherapy is done for dilation of biliary strictures, placement of biliary stents to facilitate drainage and removal of bile duct calculi. Next portal venous pressure is reduced by formation of surgical porto-systemic shunt or transjugular intrahepatic portosystemic shunt. This causes significant resolution of biliary changes. Patients who persist with biliary symptoms and bile duct changes may benefit from surgical biliary drainage procedures (hepaticojejunostomy or choledechoduodenostomy).
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Dell’Era A, Seijo S. Portal vein thrombosis in cirrhotic and non cirrhotic patients: from diagnosis to treatment. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1215907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Alessandra Dell’Era
- Dipartimento di Scienze Biomediche e Cliniche ‘L. Sacco’, Università degli Studi di Milano, UOC Gastroenterologia - ASST Fatebenefratelli Sacco - Ospedale ‘Luigi Sacco’ Polo Universitario, Milan, Italy
| | - Susana Seijo
- CTO, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Safety of supramesocolic surgery in patients with portal cavernoma without portal vein decompression. Large single centre experience. HPB (Oxford) 2016; 18:623-9. [PMID: 27346144 PMCID: PMC4925800 DOI: 10.1016/j.hpb.2016.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/15/2016] [Accepted: 05/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Supra-mesocolic surgery (SMS) is complicated in patients with portal vein cavernoma (PC) and portal decompression is recommended. The aim of this study was to report a large single centre of SMS in patients with PC without portal decompression. METHODS Between 2006 and 2013, all patients who met inclusion criteria were analyzed retrospectively. The primary endpoint was the feasibility rate, surgical and postoperative outcome. The secondary endpoints were the long-term outcome of patients who underwent biliary bypass for cholangitis. Risk factors for complications were studied. RESULTS Thirty patients underwent 51 procedures. Pancreatitis was the main etiology of PC (19/30) and biliary obstruction was mainly related to the underlying disease and not to portal cholangiopathy (12/14). All planned procedures were successfully completed. Fourteen patients underwent biliary bypass. Median blood loss (250 ml), transfusion (n = 7), mortality (n = 0), overall morbidity (n = 12) and the median hospital stay (10 days). Good long-term control of cholangitis was achieved in the 9 patients alive with available follow-up. Significant risk factors for complications were a previous abdominal wall scar, previous intra-abdominal surgical field and liver fibrosis. CONCLUSION SMS can be safely performed in patients with PC. In patients with risk factors for complications, portal decompression should be discussed.
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Llop E, Seijo S. [Treatment of non-cirrhotic, non-tumoural portal vein thrombosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 39:403-10. [PMID: 26547613 DOI: 10.1016/j.gastrohep.2015.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/25/2015] [Accepted: 09/04/2015] [Indexed: 12/20/2022]
Abstract
Thrombosis of the splenoportal axis not associated with liver cirrhosis or neoplasms is a rare disease whose prevalence ranges from 0.7 to 3.7 per 100,000 inhabitants. However, this entity is the second most common cause of portal hypertension. Prothrombotic factors are present as an underlying cause in up to 70% of patients and local factors in 10-50%. The coexistence of several etiological factors is frequent. Clinical presentation may be acute or chronic (portal cavernomatosis). The acute phase can present as abdominal pain, nausea, vomiting, fever, rectorrhagia, intestinal congestion, and ischemia. In this phase, early initiation of anticoagulation is essential to achieve portal vein recanalization and thus improve patient prognosis. In the chronic phase, symptoms are due to portal hypertension syndrome. In this phase, the aim of treatment is to treat or prevent the complications of portal hypertension. Anticoagulation is reserved to patients with a proven underlying thrombophilic factor.
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Affiliation(s)
- Elba Llop
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - Susana Seijo
- CTO, Department of Medicine, Icahn School of Medicine at Mount Sinai, Nueva York, Estados Unidos.
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Agrawal S, Dhiman RK. Hepatobiliary quiz-10 (2014). J Clin Exp Hepatol 2014; 4:184-7. [PMID: 25755558 PMCID: PMC4188822 DOI: 10.1016/j.jceh.2014.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence. Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver. J Clin Exp Hepatol 2014; 4:S2-S14. [PMID: 25755591 PMCID: PMC4274351 DOI: 10.1016/j.jceh.2014.02.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 02/02/2014] [Indexed: 12/12/2022] Open
Abstract
Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.
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Key Words
- CBD, common bile duct
- CHD, common hepatic duct
- CT, computed tomography
- EHPVO, extrahepatic portal venous obstruction
- ERC, endoscopic retrograde cholangiography
- EUS, endoscopic ultrasound
- GRADE, Grading of Recommendations, Assessment, Development and Evaluation
- INASL, Indian National Association for Study of the Liver
- MRC, magnetic resonance cholangiography
- MRI, magnetic resonance imaging
- NCPF, non-cirrhotic portal fibrosis
- PSS, portosystemic shunt
- PVT, portal vein thrombosis
- UDCA, ursodeoxycholic acid
- USG, ultrasound
- cholestasis
- extrahepatic portal venous obstruction
- gallbladder varices
- obstructive jaundice
- portal hypertensive biliopathy
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