Revisiting the Role of Surgery in Non-cirrhotic Portal Hypertension: An Ambispective Observational Study in a Tertiary Care Centre.

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) and non-cirrhotic portal fibrosis (NCPF) come under the broad category of non-cirrhotic portal hypertension (NCPH). Current management of this condition primarily focuses on controlling and preventing variceal bleeding through endoscopic and medical therapy, with surgery typically reserved for cases where endotherapy fails. However, the role of surgical interventions, either shunt surgery or splenectomy with esophagogastric devascularization, warrants re-evaluation due to their possible efficacy in controlling variceal bleeding. In addition, surgery addresses other complications associated with NCPH, including symptomatic splenomegaly, hypersplenism, and portal biliopathy.

METHODS

In this ambispective single-centre study, patients with NCPH who underwent either proximal splenorenal shunt (PSRS) or splenectomy with esophagogastric devascularization were included. Preoperative data were extracted from electronic medical records, while postoperative follow-up focused on assessing rebleeding episodes, esophagogastroduodenoscopy findings, hematological parameters, and the requirement for additional endoscopic interventions. Optimal outcome was defined as the absence of rebleeding/new-onset bleeding, resolution of varices to grade 0-I, and no postoperative requirement for endoscopic therapy.

RESULTS

Rebleeding or new-onset bleeding occurred postoperatively in only one patient (2.5%) from the entire study population. Overall, optimal outcomes were achieved in 43 patients (74.1%). On subgroup analysis, 21 patients (84%) of the PSRS group and 22 patients (66.6%) who underwent splenectomy with devascularization achieved optimal outcomes. Surgical intervention was associated with significant improvement in hemoglobin, total leukocyte count, and platelet count, along with a marked reduction in variceal grade on follow-up endoscopy.

CONCLUSION

Surgical management in NCPH is highly effective in preventing rebleeding from esophagogastric varices and yields favorable outcomes in terms of variceal resolution and reduced postoperative need for endoscopic interventions. These findings support the consideration of surgery as a primary management option in selected patients with NCPH and not just in those who have failed medical and endoscopic options.