Which treatment to choose for portal biliopathy with extensive portal thrombosis?

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.