Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: surgical management

Abstract

Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.

Endoscopic Management of Portal Cavernoma Cholangiopathy: Practice, Principles and Strategy

“…[14][15][16][17] In many centers, endoscopic management has remained confined to establishing drainage of the obstructed biliary system before surgery, in the expectation that either the obstruction would resolve after a period of endoscopic drainage or that portosystemic shunt surgery (PSS), with or without second-stage biliary surgery, would provide definitive management. However, as the complexity of patients with symptomatic PCC was realized, with biliary strictures, calculi or both being present in the extrahepatic, intrahepatic or both locations, and as the difficulties and limitations of surgical management became clear, 11,[18][19][20] most workers accepted that the optimal management of symptomatic PCC required appropriate use of both endoscopic and surgical interventions. When surgery is unsuccessful, the only option available for patients is repeated stent exchanges for prolonged periods or lifelong.…”

“…Eleven series published between 1992 and 2011 9,10,12,13,[18][19][20][21][22][23] have reported a mean frequency of 26.3% (16-85%) for biliary calculi among a total of 331 patients, including 143 with symptomatic PCC. Prevalence of both, gallbladder (mean 13.6%, range 0-69%) as well as biliary ductal calculi (mean 17.8%, range 0-77%), is increased and prevalence is much higher in symptomatic PCC, being 60.8% overall in 143 symptomatic patients (35.1% for gallstones, 41.2% for choledocholithiasis).…”

“…Prevalence of both, gallbladder (mean 13.6%, range 0-69%) as well as biliary ductal calculi (mean 17.8%, range 0-77%), is increased and prevalence is much higher in symptomatic PCC, being 60.8% overall in 143 symptomatic patients (35.1% for gallstones, 41.2% for choledocholithiasis). 5,[9][10][11]18 While increased prevalence of gallstones in PCC remains inadequately explained, it appears that biliary stasis due to collateral compression or stricture formation results in the high prevalence of biliary calculi and that formation of these calculi may precipitate biliary obstruction and trigger symptoms in patients with PCC. 9,10 MANAGEMENT Endoscopic clearance of CBD calculi in patients with PCC was first reported by Bhatia and Sarin in 1995.…”

Surgical Management of Portal Cavernoma Cholangiopathy

“…Although the majority of these patients will benefit from portal decompression alone and not require biliary drainage there is a subset (30-50%) who do not improve and require a biliary drainage procedure such as a Rouxen-Y hepaticojejunostomy. 7,9,10 Direct biliary drainage has also been attempted but such procedures are often associated with torrential bleeding from the collaterals around the bile duct. It was then proposed that biliary drainage should be done at a later stage after the portal decompression as the pressure in the collaterals around the bile duct is reduced making the procedure less hazardous.…”

“…However there is a small group (28-50%) of patients in whom PCC is not relieved after a shunt procedure and these will need drainage to reverse their biliary obstruction either via a stent or a surgical drainage procedure like a hepaticojejunostomy. [7][8][9][10][11] These patients present late in life and have usually had repeated episodes of cholangitis and stent exchanges. 2-4% of patients in whom the biliary obstruction has been present for a long time may go on to develop secondary biliary cirrhosis.…”