Which is the best surgery for budd-chiari syndrome: Venous decompression or liver transplantation? a single-center experience with 50 patients

Abstract

The optimal treatment of Budd-Chiari syndrome (BCS) remains an open question. It is still a matter of controversial discussion whether venous decompression or liver transplantation is superior. To elucidate the role and prognosis of both surgical options in our own experience, a consecutive series of 50 patients treated between 1981 and 1993 was retrospectively analyzed. Twelve patients had different types of portosystemic shunts or local decompressive procedures, and transplantation was performed in 43 cases, including five with previous conventional surgery. The overall mortality of 18 of 50 was conventional surgery. The overall mortality of 18 of 50 was concentrated within the early postoperative period, with no patient lost after 1 year. In the venous decompression group, the success rate was only 29%, and treatment failure was closely related to the finding of cirrhosis or technical problems like vascular thrombosis. After transplantation, early complications were rejection, primary nonfunction, or graft necrosis, and contributed significantly to the risk of sepsis. Thirty of 43 liver recipients are currently alive, including four rescued after failed decompressive surgery, with 1- and 10-year survival of 69%, and excellent recurrence-free rehabilitation. These results clearly indicate that patient selection plays a dominant prognostic role in the treatment of BCS. Venous decompression and liver transplantation should both be integrated in a common therapeutic concept, and the individual decision for the preferred approach must be based on the leading clinical symptom: portal hypertension or liver failure, together with the assessment of reversibility of hepatic damage, and the potential of cure of the underlying disease.

Determinants of survival and the effect of portosystemic shunting in patients with Budd-Chiari syndrome

“…Other studies, mostly case series from surgical units, report on high survival rates after PSS with 5-year survival of 57% 11 to 94%. 9,10 However, most of these studies do not provide data on patient selection criteria, which play a major role in the long-term results of treatment, 21 nor do they take account of differences in time-point of shunting within the clinical course of patients.…”

“…Institutional experience and preferences as well as patient selection play a major role in the choice of treatment. 21 This creates a large degree of heterogeneity between study populations. Most studies on the effect of therapeutic interventions, in particular PSS, do not report selection criteria nor do they control for differences in baseline characteristics between patients who do or do not undergo PSS.…”

Timing of transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: An Italian hepatologist’s perspective

“…Other surgical techniques reported in that and other series had roughly unacceptable outcomes when reported [30,31,33] . We recently described a patient with IVC obstruction near the atrium and a previous severe complication of a trial of endovascular management, who had an excellent outcome after the replacement of the obstructed segment of the IVC with a caval homograft [35] .…”

“…In the same series, the mortality rates of patients with IVC involvement were very high after traditional surgery (mesoatrial shunts) and better results were reported using another technique (SSPCS + cavoatrial shunt) in 18 patients, all surviving after a follow-up of 5 to 25 years [32] . However, outcome after surgical shunt is variable and worse results were reported by others [30,31,33] . In most of the above series, patients with liver failure were not considered for surgery but for liver transplantation [31][32][33] .…”

“…LT is used as a rescue therapy, while surgical treatments are rarely contemplated [1][2][3][4] . Surgical shunts for BCS can be very successful, although they are associated with rapid decompensation and high in-hospital mortality (about 25%), primarily due to the patients' poor general condition [29][30][31][32] . Previously, surgery was considered the first choice.…”