Download PDF
Zentralbl Chir 2005; 130(3): 238-245
DOI: 10.1055/s-2005-836545
Originalarbeiten und Übersichten

© Georg Thieme Verlag Stuttgart · New York

Chirurgische Therapie der portalen Hypertension

Surgical Treatment of Portal HypertensionM. Wolff1 , A. Hirner1
  • 1Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Rheinische Friedrich-Wilhelms-Universität, Bonn
Further Information

Publication History

Publication Date:
20 June 2005 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Wegen des hohen Rezidivblutungsrisikos sollten heute alle Patienten nach einer ersten Varizenblutung bei portaler Hypertension eine Rezidivblutungsprophylaxe erhalten. Bei Ösophagusvarizen steht die endoskopische Eradikation mit Gummibandligaturen im Vordergrund. Bei Versagen der endoskopischen Therapie sollten dekomprimierende Shuntverfahren erwogen werden. Bei Patienten mit guter Langzeitprognose (Child-Pugh A, extrahepatische Pfortaderhochdruckformen) kommen wegen der besseren Langzeitergebnisse chirurgische Shunts (portokaval oder splenorenal) infrage. Bei schlechterer Leberfunktion (Child-Pugh B/C) und bei Kandidaten für eine Lebertransplantation sollte dem intrahepatischen Stent-Shunt (TIPS) der Vorzug gegeben werden. Ähnlich wie bei anderen palliativen Verfahren mit dem Charakter der Sekundärprophylaxe muss sowohl beim TIPS als auch bei chirurgischen Shunts eine spezielle Expertise vorausgesetzt werden, um Letalität und Morbidität gering zu halten. Bei extrahepatischen Pfortaderthrombosen mit dem Problem der Varizenblutung lassen sich hervorragende Langzeitergebnisse durch Shuntanlagen erzielen. Devaskularisierungs-Eingriffe kommen bei Fehlen shuntfähiger Pfortaderzuflüsse („Panthrombose”) infrage und können meist milzerhaltend durchgeführt werden.

Abstract

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

Schlüsselwörter

portale Hypertension - Varizenblutung - Shuntchirurgie - Pfortaderthrombose - Hypersplenismus

Key words

portal hypertension - variceal bleeding - portosystemic shunt surgery - portal vein thrombosis - hypersplenism

Literatur

  • 1 Alagille D, Carlier J C, Chiva M, Ziade R, Ziade M, Moy F. Long term neuropsychological outcome in children undergoing portal-systemic shunts for portal vein obstruction without liver disease.  J Pediatr Gastroenterol Nutr. 1986;  5 861-866
    PubMedSearch in Google Scholar
  • 2 Banares R, Casado M, Rodriguez-Laiz J M, Camunez F, Matilla A, Echenagusia A, Simo G, Piqueras B, Clemente G, Cos E. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding.  Am J Gastroenterol. 1998;  93 75-79
    CrossrefPubMedSearch in Google Scholar
  • 3 Bismuth H, Franco D, Alagille D. Portal diversion for portal hypertension in children. The first ninety patients.  Ann Surg. 1980;  192 18-24
    PubMedSearch in Google Scholar
  • 4 Burroughs A K, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis.  Scand J Gastroenterol. 2002;  37 249-252
    CrossrefPubMedSearch in Google Scholar
  • 5 Chalasani N, Clarc W S, Martin L G, Kamean J, Khan M A, Patel N H, Boyer T D. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting.  Gastroenterol. 2000;  118 138-144
    CrossrefPubMedSearch in Google Scholar
  • 6 Collins C, Ong J, Rypins E B, Sarfeh I J. Partial portacaval shunt for variceal hemorrhage. Longitudinal analysis of effectiveness.  Arch Surg. 1998;  133 590-593
    PubMedSearch in Google Scholar
  • 7 Condat B, Pessione F, Denninger M H, Hillaire S, Valla D. Recent portal or mesenteric venous thrombosis: increased recognition and frequent recalization on anticoagulant therapy.  Hepatology. 2000;  32 466-470
    CrossrefPubMedSearch in Google Scholar
  • 8 Cooley D A. Side-to-side splenorenal anastomosis with splenic preservation for portal hypertension.  Surg Gynecol Obstet. 1963;  116 627-629
    PubMedSearch in Google Scholar
  • 9 D'Amico G, Magliaro L, Bosch J. Treatment of portal hypertension: a meta-analytic review.  Hepatology. 1995;  22 332-354
    CrossrefPubMedSearch in Google Scholar
  • 10 de Ville de Goyet J, Alberti D, Clapuyt P, Otte J B. Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension.  J Pediatr Surg. 1999;  33 597-601
    PubMedSearch in Google Scholar
  • 11 DeFranchis R. Portal Hypertension III. Proceedings of the third Baveno international consensus workshop. Blackwell Science, Oxford 2001
  • 12 Denninger M H, Chait Y, Casadevall N, Hillaire S, Guillin M C, Bezeaud A, Erlinger S, Briere J, Valla D. Cause of portal or hepatic venous thrombosis in adults: the role of multiple concurrent factors.  Hepatology. 2000;  31 587-591
    CrossrefPubMedSearch in Google Scholar
  • 13 El-Khishen M A, Henderson J M, Millikan W J, Kutner M H, Warren W D. Splenectomy is contraindicated for thrombocytopenia secondary to portal hypertension.  Surg Gynecol Obstet. 1995;  160 233-238
    PubMedSearch in Google Scholar
  • 14 Ezzat F A, Abu-Elmagd K M, Aly M A, Fathy O M, el-Ghawlby N A, el-Fiky A M, el-Barbary M H. Selective shunt versus nonshunt surgery for management of schistosomal and nonschistosomal variceal bleeders.  Ann Surg. 1990;  212 97-108
    PubMedSearch in Google Scholar
  • 15 Ganguly S, Sarin S K, Bhatia V. The prevalence and spectrum of colonic lesions in patients with cirrhotic and non-cirrhotic portal hypertension.  Hepatology. 1995;  21 1226-1231
    CrossrefPubMedSearch in Google Scholar
  • 16 Gauthier F, DeDreuzy O, Valayer J, Montupet P H. H-type shunt with autologous venous graft for treatment of portal hypertension in children.  J Pediatr Surg. 1989;  29 1041-1043
    PubMedSearch in Google Scholar
  • 17 Gawish Y, El-Hammadi H A, Kotb M, Awad A T, Anwar M. Devascularization procedure and DSRS: a controlled randomized trial on selected haemodynamic portal flow pattern in schistosomal portal hypertension with variceal bleeding.  Int Surg. 2000;  85 325-330
    PubMedSearch in Google Scholar
  • 18 Grace N D, Groszmann R, Garcia-Tsao G, Burroughs A K, Pagliaro L, Makuch R. Portal hypertension and variceal bleeding: a report of a single topic symposium.  Hepatology. 1996;  28 868-880
    PubMedSearch in Google Scholar
  • 19 Heider T R, Azeem S, Galanko J A, Behrns K E. The natural history of pancreatitis induced splenic vein thrombosis.  Ann Surg. 2004;  239 876-882
    CrossrefPubMedSearch in Google Scholar
  • 20 Helmy A, Abdelkader S I, Schwaitzberg S D. Laparoscopic esophagogastric devascularization in bleeding varices.  Surg Endosc. 2003;  17 1614-1619
    CrossrefPubMedSearch in Google Scholar
  • 21 Helton W S, Maves R, Wicks K, Johansen K. Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients.  Arch Surg. 2001;  136 17-20
    CrossrefPubMedSearch in Google Scholar
  • 22 Henderson J M, Nagle A, Curtas S, Geisinger M, Barnes D. Surgical shunts and TIPS for variceal decompression in the 1990s.  Surgery. 2000;  128 540-547
    CrossrefPubMedSearch in Google Scholar
  • 23 Henderson M B. Role of distal splenorenal shunt for long-term management of variceal bleeding.  World J Surg. 1994;  18 205-210
    CrossrefPubMedSearch in Google Scholar
  • 24 Hillebrand D J, Kojouri K, Cao S, Runyon B A, Ojogho O, Conception W. Small-diameter portacaval H-graft shunt: a paradigm shift back to surgical shunting in the management of variceal bleeding in patients with preserved liver function.  Liver Transpl. 2000;  6 459-465
    CrossrefPubMedSearch in Google Scholar
  • 25 Inokuchi K, Sugimachi K. The selective shunt for variceal bleeding: a personal perspective.  Am J Surg. 1990;  160 48-53
    PubMedSearch in Google Scholar
  • 26 Isaakson B, Jeppsson B, Bengtsson F, Hannesson P, Herlin P, Bengmark S. Mesocaval shunt or repeated sclerotherapy: effects on rebleeding and encephalopathy.  Surgery. 1995;  117 498-504
    PubMedSearch in Google Scholar
  • 27 Janssen H LA, Wijnhoud A, Haagsma E B, Uum S HM van, Nieuwkerk C MJ van, Adang R P, Chamuleau R AFM, Hattum J van, Vleggaar F P, Hansen B E, Rosendaal F R, Hoek B van. Extrahepatic portal vein thrombosis: aetiology and determinants of survival.  Gut. 2001;  49 720-724
    CrossrefPubMedSearch in Google Scholar
  • 28 Jenkins R L, Gedaly R, Pomposelli J J, Pomfret E A, Gordon F, Lewis W D. Distal splenorenal shunt. Role, indications, and utility in the era of liver transplantation.  Arch Surg. 1999;  134 416-420
    CrossrefPubMedSearch in Google Scholar
  • 29 Kamath P S, Wiesner R H, Malinchoc M, Kremers W, Therneau T M, Kosberg C L, D'Amico G, Dickson E R, Kim W R. A model to predict survival in patients with end-stage liver disease.  Hepatology. 2001;  33 464-470
    CrossrefPubMedSearch in Google Scholar
  • 30 Kato T, Romero R, Koutouby R, Mittal N K, Thompson J F, Schleien C L, Tsakis A G. Portosystemic shunting in children during the era of endoscopic therapy: improved postoperative growth parameters.  J Pediatr Gastroenterol Nutr. 2000;  30 419-425
    CrossrefPubMedSearch in Google Scholar
  • 31 Khaitiyar J S, Luthra S K, Prasad N, Ratnakar N, Daruwala D K. Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt - A comparative study.  Hepatogastroenterology. 2000;  47 492-497
    PubMedSearch in Google Scholar
  • 32 Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis.  Br J Surg. 1997;  84 129-132
    CrossrefPubMedSearch in Google Scholar
  • 33 Kreft B, Strunk H, Flacke S, Wolff M, Conrad R, Gieseke J, Pauleit D, Bachmann R, Hirner A, Schild H H. Detection of thrombosis in the portal venous system: comparison of contrast enhanced MR angiography with intraarterial digital subtraction angiography.  Radiology. 2000;  216 86-92
    PubMedSearch in Google Scholar
  • 34 Maksoud J G, Miles S. Distal splenorenal shunt in children.  Ann Surg. 1982;  195 401-405
    PubMedSearch in Google Scholar
  • 35 Merkel C, Bolognesi M, Bellon S, Sacerdoti D, Bianco S, Amodio P, Gatta A. Long-term follow-up study of adult patients with non-cirrhotic obstruction of the portal system: comparison with cirrhotic patients.  J Hepatol. 1992;  15 299-303
    CrossrefPubMedSearch in Google Scholar
  • 36 Mitra SK Rao K LN, Narasinham K L, Dilawari J B, Batra Y K, Chawla Y, Thapa B R, Nagi B, Walia B NS. Side-to-side lienorenal shunt without splenectomy in non-cirrhotic portal hypertension in children.  J Pediatr Surg. 1993;  28 398-401
    PubMedSearch in Google Scholar
  • 37 Mohapatra M K, Mohapatra A K, Acharya S K, Sahni P, Nundy S. Encephalopathy in patients with extrahepatic obstruction after lienorenal shunts.  Br J Surg. 1992;  79 1103-1105
    PubMedSearch in Google Scholar
  • 38 Orloff M J, Bell R H, Orloff M S, Hardison W GM, Greenburg A G. Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices.  Hepatology. 1994;  20 863-872
    PubMedSearch in Google Scholar
  • 39 Orloff M J, Orloff M S, Girard B, Orloff S L. Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt.  J Am Coll Surg. 2002;  194 717-730
    CrossrefPubMedSearch in Google Scholar
  • 40 Orloff M L, Orloff M S, Rambotti M, Girard B. Is portal-systemic shunt worthwhile in Child's class cirrhosis? Long-term results of emergency shunt in 94 patients with bleeding varices.  Ann Surg. 1992;  216 256-268
    PubMedSearch in Google Scholar
  • 41 Orozco H, Mercado M A. The evolution of portal hypertension surgery. Lessons from 1 000 operations and 50 years' experience.  Arch Surg. 2000;  135 1389-1393
    PubMedSearch in Google Scholar
  • 42 Pande G K, Reddy V M, Kar P, Sahni P, Berry M, Tandon B N, Nundy S. Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow-up.  Br Med J. 1987;  295 1115-1117
    PubMedSearch in Google Scholar
  • 43 Paquet K J, Lazar A, Koussouris P, Hotzel B, Gad H A, Kuhn R, Kalk J F. Mesocaval interposition shunt with small-diameter polytetrafluoroethylene grafts in sclerotherapy failure.  Br J Surg. 1995;  82 199-203
    PubMedSearch in Google Scholar
  • 44 Perello A, Garcia-Pagan J C, Gilabert R, Suarez Y, Moitinho E, Cervantes F, Reverter J C, Escorsell A, Bosch J, Rodes J. TIPS is a useful long-term derivative therapy for patients with Budd-Chiari syndrome uncontrolled by medical therapy.  Hepatology. 2002;  35 132-139
    CrossrefPubMedSearch in Google Scholar
  • 45 Prasad S A, Gupta S, Kohli V, Pande G K, Sahni P, Nundy S. Proximal splenorenal shunts for extrahepatic portal venous obstruction in children.  Ann Surg. 1994;  219 193-196
    PubMedSearch in Google Scholar
  • 46 Rahmani O, Wolpert L M, Drezner A D. Distal inferior mesenteric veins to renal vein shunt for treatment of bleeding anorectal varices: case report and review of literature.  J Vasc Surg. 2002;  36 1264-1266
    PubMedSearch in Google Scholar
  • 47 Rikkers L F, Jin G. Surgical management of acute variceal hemorrhage.  World J Surg. 1994;  18 193-199
    CrossrefPubMedSearch in Google Scholar
  • 48 Rikkers L F, Jin G, Langnas A N, Shaw B W. Shunt surgery in the era of liver transplantation.  Ann Surg. 1997;  226 51-57
    CrossrefPubMedSearch in Google Scholar
  • 49 Roesch J, Keller F S. Transjugular intrahepatic portosystemic shunt: present status, comparison with endoscopic therapy and shunt surgery, and future prospectives.  World J Surg. 2001;  25 337-346
    CrossrefPubMedSearch in Google Scholar
  • 50 Rosemurgy A S, Bloomston M, Zervos E E, Goode S E, Pencev D, Zweibel B R, Black T J. Transjugular intrahepatic portosystemic shunt versus H-graft portacaval shunt in the management of bleeding varices: A cost-benefit analysis.  Surgery. 1997;  122 794-800
    CrossrefPubMedSearch in Google Scholar
  • 51 Rosemurgy A S, Serafini F M, Zweibel B R, Black T J, Kudryk B T, Nord H J, Goode S E. Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomised prospective trial.  J Gastrointest Surg. 2000;  4 589-597
    CrossrefPubMedSearch in Google Scholar
  • 52 Rossle M, Olschewski M, Siegerstetter V, Berger E, Kurz K, Grandt D. The Budd-Chiari syndrome: outcome after treatment with the transjugular intrahepatic portosystemic shunt.  Surgery. 2004;  135 394-403
    CrossrefPubMedSearch in Google Scholar
  • 53 Sarfeh I J, Rypins E B. Partial versus total portacaval shunt in alcoholic cirrhosis: results of a prospective, randomized clinical trial.  Ann Surg. 1994;  219 353-361
    CrossrefPubMedSearch in Google Scholar
  • 54 Sarin S K, Agarwal S R. Extrahepatic portal vein obstruction.  Sem Liver Dis. 2002;  22 43-58
    Thieme ConnectPubMedSearch in Google Scholar
  • 55 Sarin S K, Bansal A, Sasan S, Nigam A. Portal vein obstruction in children leads to growth retardation.  Hepatology. 1992;  15 229-233
    CrossrefPubMedSearch in Google Scholar
  • 56 Sarin S K, Lahoti D, Saxena S P, Murthi N S, Makwane U K. Prevalence, classification and natural history of gastric varices: long-term follow-up study in 568 patients with portal hypertension.  Hepatology. 1992;  16 1343-1349
    CrossrefPubMedSearch in Google Scholar
  • 57 Selzner M, Tuttle-Newhall J E, Dahm F, Suhocki P, Clavien P A. Current indication of a modified Sugiura procedure in the management of varicealbleeding.  J Am Coll Surg. 2001;  193 166-167
    CrossrefPubMedSearch in Google Scholar
  • 58 Sharma B C, Singh R P, Chawla Y K, Narasimhan K L, Rao K L, Mitra S K. et al . Effect of shunt surgery on spleen size, portal pressure and oesophageal varices in patients with non-cirrhotic portal hypertension.  J Gastroenterol Hepatol. 1997;  12 582-584
    CrossrefPubMedSearch in Google Scholar
  • 59 Shiffman M L, Jeffers L, Hoofnagle J H, Tralka T S. The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications.  Hepatology. 1995;  22 1591-1596
    CrossrefPubMedSearch in Google Scholar
  • 60 Shiyansky J, Roberts E, Superina R A. Distal splenorenal shunts for the treatment of severe thrombocytopenia from portal hypertension in children.  J Gastrointest Surg. 1999;  3 659-663
    PubMedSearch in Google Scholar
  • 61 Slakey D P, Klein A S, Venbrux A C, Cameron J L. Budd-Chiari syndrome: current management options.  Ann Surg. 2001;  233 522-527
    CrossrefPubMedSearch in Google Scholar
  • 62 Soybel D I. TIPS versus surgical decompression of portal hypertension.  Gastroenterology. 1997;  112 1768-1770
    PubMedSearch in Google Scholar
  • 63 Tomokawa M, Hashizume M, Saku M, Tanoue K, Ohta M, Sugimachi K. Effectiveness of gastric devascularization and splenectomy for patients with gastric varices.  J Am Coll Surg. 2000;  191 498-503
    CrossrefPubMedSearch in Google Scholar
  • 64 Tuerler A, Wolff M, Dorlars D, Hirner A. Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate.  Gastrointest Endosc. 2001;  53 228-230
    CrossrefPubMedSearch in Google Scholar
  • 65 Valla D C, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management.  J Hepatol. 2000;  32 865-871
    CrossrefPubMedSearch in Google Scholar
  • 66 Warren W D, Henderson J M, Millikan W J, Galambos J T, Bryan F C. Management of variceal bleeding in patients with noncirrhotic portal vein thrombosis.  Ann Surg. 1988;  207 623-634
    PubMedSearch in Google Scholar
  • 67 Wolff M, Hirner A. Current state of portosystemic shunt surgery.  Langenbecks Arch Surg. 2003;  388 141-149
    CrossrefPubMedSearch in Google Scholar
  • 68 Wolff M, Kalff J C, Textor J, Hirner A. Portosystemische Shuntchirurgie und transjugulärer Stent (TIPS) in Deutschland.  Chirurg. 1999;  70 447-452
    CrossrefPubMedSearch in Google Scholar
  • 69 Wolff M, Hirner A. Portale Hypertension und Pfortaderthrombose. In: Hepp W, Kogel H (Hrsg). Gefäßchirurgie. Urban und Fischer, München, Jena 2001; 589-606
  • 70 Zacks S L, Sandler R S, Biddle A K, Mauro M A, Brown R S. Decision-analysis of transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt for portal hypertension.  Hepatology. 1999;  29 1399-1405
    CrossrefPubMedSearch in Google Scholar

PD Dr. M. Wolff

Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie · Rheinische Friedrich-Wilhelms-Universität Bonn

Sigmund-Freud-Str. 25

53105 Bonn

Phone: 02 28/2 87 59 16

Fax: 02 28/2 87 48 56

Email: martin.wolff@ukb.uni-bonn.de