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1 . 2022

Portosystemic shunting surgery in patients with extrahepatic vein obstruction and portal hypertension

Abstract

Aim – а retrospective analysis of the portocaval shunting surgery results in patients with extrahepatic portal vein obstruction and noncirrhotic portal hypertension.

Material and methods. The results of portosystemic shunting surgery were analyzed in 407 patients with extrahepatic portal vein obstruction and portal hypertension from 1975 to 2020. The median age was 26.5 years; 216 women and 191 men were included. Indications for surgery were recurrent gastroesophageal variceal bleeding or its high-risk endoscopic markers, along with the inapplicability of endoscopic treatment.

Results. Portosystemic shunting surgery in this category of patients presents a significant difficulty due to a small diameter of the portal system vessels to be anastomosed, as well as their postphlebitic changes (sclerosis and perceptible vessel wall thinning). The implementation of microsurgical technique elements and H-type shunt formation with an autovenous or synthetic graft allowed to increase the feasibility of portosystemic shunting from 10–15% to >50%. The most frequent and significant complications of the early postoperative period were gastroesophageal bleedings (most often associated with shunt patency violation) and chyloperitoneum caused by dilated lymphatic collectors transection and the use of coagulating devices to prevent lymphorrhea. Postoperative mortality was 1.50%. The best results were obtained from the “side-to-side” shunting with the main portal vessels. The feasibility was 17.0% for splenorenal shunts and 27.8% for mesocaval shunts (of the total number of shunts performed). The most frequent and quite effective was H-type mesocaval shunt, however stenosis and thrombosis of this shunt type occurred 4.76 times more often than after the “side-to-side” shunting. During the long-term follow-up, the main complication was gastroesophageal bleeding (8.60%) associated with shunt thrombosis (5.20%) or stenosis (3.40%). Shunt encephalopathy occurred in 1.60% of cases. Long-term mortality associated with complications of portal hypertension and surgical consequences was 3.40%.

Conclusion. Portosystemic bypass surgery is to be the operation of choice in patients with extrahepatic portal hypertension and the threat of variceal bleeding if any portal system vessel suitable for shunting is presented. The long-term follow-up results indicate a high efficiency of these surgery in the variceal hemorrhage prevention. In the majority of cases, portosystemic shunting in patients with extrahepatic portal hypertension allows to ensure their complete medical and social rehabilitation for a long time.

Keywords:mesocaval shunt; splenorenal shunt; portocaval shunting; portosystemic shunting; extrahepatic portal vein obstruction; extrahepatic portal hypertension; esophageal and gastric varices; variceal bleeding

Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
For citation: Lebezev V.M., Manukyan G.V., Fandeyev E.E., Kitsenko E.A., Musin R.A., Rizaeva S.A. Portosystemic shunting surgery in patients with extrahepatic vein obstruction and portal hypertension. Clinical and Experimental Surgery. Petrovsky Journal. 2022; 10 (1): 114–27. DOI: https://doi.org/10.33029/2308-1198-2022-10-1-114-127  (in Russian)

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CHIEF EDITOR
CHIEF EDITOR
Sergey L. Dzemeshkevich
MD, Professor (Moscow, Russia)
Вскрытие
Medicine today

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