P3.50: Portal hypertensive surgery for management of diffuse portomesenteric venous thrombosis - Surgical technique and long-term outcome

Abstract

Introduction: Patients with diffuse portomesenteric venous thrombosis (PMVT) are often referred to the abdominal organ transplant centers particularly those with experience in gut transplantation. Despite the proven therapeutic efficacy of multivisceral transplantation (MVTx) for these complex patients, the forgotten different modalities of portal hypertensive surgery could be a better alternative particularly for those with compensated liver disease and gut varices in the milieu of a thrombophilic state. Methods: Between Aug2012 and Jan2019, a total of 28 patients referred to our center with diffuse PMVT underwent surgical intervention. Indication was history of variceal bleeding and occult varices in the setting of thrombophilia. All except 1 were adults with a mean age of 42±15 yrs. Precipitating causes of PMVT were thrombophilia (78%) and pancreatitis (18%). All patients had clinical, endoscopic and radiologic evidence of PMVT with stigmata of extra-hepatic portal hypertension. Variceal bleeding was reported in 36% patients. Type of shunt was determined intra-operative suitable visceral vascular anatomy and transplantation dictated by co-existence of advanced liver disease. Results: Portal hypertensive surgery was performed in 27 patients (96%) while MVTx was performed in one. The surgical modality was atypical non-selective portosystemic shunt in 14 patients (52%) and gastro-esophageal devascularization in the remaining 13 (48%). Partial gastric devascularization was commonly performed in patients with atypical shunt that may not completely decompress the left portal hypertensive compartment. Splenectomy was unavoidable in 4 patients. The utilization of autologous and synthetic vascular grafts are shown in Table 1. With a mean follow up of 40±26 months, overall shunt patency was radiologically documented in 78% patients. Recurrence of bleed occurred in only 1 patient (7%) despite shunt patency. Throughout the follow up period, surgical complications were minor (grade I & II) in 64% patients and major (grade III & IV) in 21% [Clavien grade]. With one mortality due to acute leukemia, all patients are currently alive with an overall survival rate of 96%. Conclusion: Portal hypertensive surgery is a viable alternative to MVTx for the management of diffuse PMVT and preserved hepatic function. Portal decompressive surgery should always be considered for thrombophilic patients with silent gut varices who are in need of life-long anticoagulation therapy.