The Devascularisation Procedure for the Treatment of Fundic and Oesophageal Varices in Portal Hypertension - a Retrospective Analysis of 55 Cases

Background 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. Patients and Methods 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. Results 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 degrees [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. Discussion 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.