Vibert Eric, Azoulay Daniel, Aloia Thomas, Pascal Gérard, Veilhan Luc-Antoine, Adam René, Samuel Didier, Castaing Denis
Centre Hépato-Biliaire, Hôpital Paul Brousse (AP-HP), Université Paris Sud, Villejuif, France.
Ann Surg. 2007 Jul;246(1):97-104. doi: 10.1097/SLA.0b013e318070cada.
Chronic portal obstruction can lead to formation of portal cavernoma (PC). Half of all patients with PC will develop cholestasis, termed portal biliopathy, and some will progress to symptomatic biliary obstruction. Because of the high hemorrhage risk associated with biliary surgery in patients with PC, the optimal therapeutic strategy is controversial.
Retrospective review of a single hepatobiliary center experience, including 64 patients with PC identified 19 patients with concurrent symptomatic biliary obstruction. Ten patients underwent initial treatment with a retroperitoneal splenorenal anastomosis. For the remaining 9 patients, portal biliopathy was managed without portosystemic shunting (PSS). Outcomes, including symptom relief, the number of biliary interventions, and survivals, were studied in these 2 groups.
Within 3 months of PSS, 7 of 10 patients (70%) experienced a reduction in biliary obstructive symptoms. Five of these 10 patients subsequently underwent uncomplicated biliary bypass, and none has recurred with biliary symptoms or required biliary intervention with a mean follow-up of 8.2 years. For patients without PSS, repeated percutaneous and endobiliary procedures were required to relieve biliary symptoms. Four of the 9 patients with persistent PC required surgical intrahepatic biliary bypass, which was technically more challenging. With a mean follow-up of 8 years, 1 of these 9 patients died of severe cholangitis, 1 remained jaundiced, and 7 were asymptomatic.
This study, which represents the largest published experience with the surgical treatment of patients with symptomatic portal biliopathy, indicates that retroperitoneal splenorenal anastomosis improves outcomes and should be the initial treatment of choice.
慢性门静脉梗阻可导致门静脉海绵样变性（PC）的形成。所有PC患者中有一半会发生胆汁淤积，即门静脉性肝病，部分患者会进展为有症状的胆道梗阻。由于PC患者进行胆道手术时出血风险高，最佳治疗策略存在争议。
回顾性分析单个肝胆中心的经验，包括64例PC患者，其中19例同时存在有症状的胆道梗阻。10例患者首先接受了腹膜后脾肾吻合术治疗。其余9例患者未进行门体分流术（PSS）来处理门静脉性肝病。对这两组患者的治疗结果进行了研究，包括症状缓解情况、胆道干预次数和生存率。
在PSS术后3个月内，10例患者中有7例（70%）胆道梗阻症状减轻。这10例患者中有5例随后顺利接受了胆道搭桥手术，平均随访8.2年，均未出现胆道症状复发或需要进行胆道干预的情况。对于未进行PSS的患者，需要反复进行经皮和内镜下胆道操作来缓解胆道症状。9例持续性PC患者中有4例需要进行技术上更具挑战性的手术肝内胆道搭桥术。平均随访8年后，这9例患者中有1例死于严重胆管炎，1例仍有黄疸，7例无症状。
本研究是已发表的关于有症状门静脉性肝病患者外科治疗的最大规模经验，表明腹膜后脾肾吻合术可改善治疗结果，应作为首选的初始治疗方法。
