Overhaus Marcus, Garcia Park Lydia, Fimmers Rolf, Glowka Tim R, van Beekum Cornelius, Manekeller Steffen, Kalff Jörg C, Schaefer Nico, Vilz Tim
Klinik für Allgemein- und Viszeralchirurgie, Malteser Krankenhaus Sankt Hildegardis, Köln, Deutschland.
Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Deutschland.
Zentralbl Chir. 2018 Oct;143(5):480-487. doi: 10.1055/a-0710-5095. Epub 2018 Oct 24.
The most dangerous complication of portal hypertension is the formation of oesophageal varices, as the risk of bleeding is up to 80%. In order to reduce pressure reduction in the portosystemic circulation and as secondary prophylaxis, the TIPSS procedure has proven successful. In patients with portal vein thrombosis, portosystemic shunt surgery is possible to reduce the risk of variceal bleeding. However, if thrombosis of the mesentericoportal axis or hepatic encephalopathy is imminent, interventional or surgical creation of a portosystemic shunt is contraindicated. As a last resort to avoid recurrent bleeding or in case of inexorable bleeding, a devascularisation procedure may be indicated. The aim of this study was to investigate perioperative complications, morbidity and mortality, the incidence of postoperative recurrent bleeding, and patient survival after devascularisation surgery.
We retrospectively analysed 55 patients with a history of variceal haemorrhage or acute bleeding without the possibility of an invasive or operative portosystemic shunt for complication rate, recurrent variceal recurrence, rebleeding and survival.
While complications for elective surgery were 61%, they increased significantly in emergency surgeries (75%, p = 0.002), especially for severe complications (Dindo/Clavien grade III - V° [14 vs. 58%, p = 0.002]). Devascularisation significantly reduced varicosis occurrence. Furthermore, only 16% of patients suffered recurrent bleeding in a follow-up period of up to 24 years. Median survival (MS) after devascularisation surgery was 169 ± 23 months. After elective surgery, MS was 194 ± 25 months, but after emergency surgery only 49 ± 16 months. No patient showed any hepatic encephalopathy during their hospital stay.
Devascularisation surgery is well suited for secondary prophylaxis in patients with fundic and oesophageal varices and portal hypertension with no possibility of portosystemic shunt or with impending hepatic encephalopathy. However, if the operation is performed in an emergency situation, significantly more major complications occur and the outcome is significantly worse. Therefore, especially in the absence of an opportunity of lowering pressure in the portal venous system and with progressive varices, elective devascularisation should be considered at an early stage.
门静脉高压最危险的并发症是食管静脉曲张的形成，因为出血风险高达80%。为了降低门体循环的压力并作为二级预防措施，经颈静脉肝内门体分流术（TIPSS）已被证明是成功的。对于门静脉血栓形成的患者，可行门体分流手术以降低静脉曲张出血的风险。然而，如果肠系膜门静脉轴血栓形成或肝性脑病即将发生，则禁忌进行介入或手术创建门体分流。作为避免复发出血的最后手段或在出血无法控制的情况下，可能需要进行去血管化手术。本研究的目的是调查去血管化手术后的围手术期并发症、发病率和死亡率、术后复发出血的发生率以及患者生存率。
我们回顾性分析了55例有静脉曲张出血史或急性出血且无法进行侵入性或手术门体分流的患者的并发症发生率、静脉曲张复发、再出血和生存率。
择期手术的并发症发生率为61%，而急诊手术的并发症发生率显著增加（75%，p = 0.002），尤其是严重并发症（Dindo/Clavien III - V级[14%对58%，p = 0.002]）。去血管化显著降低了静脉曲张的发生率。此外，在长达24年的随访期内，只有16%的患者出现复发出血。去血管化手术后的中位生存期（MS）为169±23个月。择期手术后，MS为194±25个月，但急诊手术后仅为49±16个月。住院期间没有患者出现任何肝性脑病。
去血管化手术非常适合于患有胃底和食管静脉曲张以及门静脉高压且无法进行门体分流或即将发生肝性脑病的患者的二级预防。然而，如果在紧急情况下进行手术，会出现明显更多的严重并发症，且预后明显更差。因此，特别是在没有机会降低门静脉系统压力且静脉曲张进展的情况下，应尽早考虑择期去血管化手术。
