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      About Digestion: 3.2 Impact Factor I 6.4 CiteScore I 0.914 Scimago Journal & Country Rank (SJR)

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      Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View

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          Abstract

          Background

          Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%.

          Methods

          Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH.

          Results

          The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise.

          Conclusion

          The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.

          Zusammenfassung

          Hintergrund

          Eine Blutung aus Ösophagusvarizen ist eine lebensbedrohliche Komplikation der chronischen portalen Hypertension. Sie tritt bei 15% der Patienten auf und führt in 20-35% der Fälle zum Tod.

          Methoden

          Basierend auf einer Literaturrecherche und der persönlichen Erfahrung in der Therapie der portalen Hypertension schlagen wir einen Therapiealgorithmus für die Sekundärprophylaxe der Varizenblutung vor.

          Ergebnisse

          Die Hauptursachen für eine portale Hypertension in den Industrienationen sind eine äthyltoxische/virale Leberzirrhose und eine extrahepatische Pfortaderthrombose, meist auf dem Boden einer hämatologischen oder gerinnungsphysiologischen Erkrankung. Die primäre Therapie ist hier konservativ; im Fall des Blutungsrezidivs muss eine definitive Therapie erfolgen. Bei zugrunde liegender Lebererkrankung besteht diese in der Lebertransplantation, während bei guter Leberreserve oder gesundem Parenchym eine portale Dekompression angezeigt ist. Der transjuguläre intrahepatische portosystemische Shunt wird weitverbreitet eingesetzt, allerdings ist die Evidenz für die chirurgisch angelegten Shunts bei kompensierter Leberfunktion vergleichbar bis besser. Die Art des chirurgischen Shunts sollte anhand der Offenheit des portalvenösen Systems und der chirurgischen Expertise gewählt werden.

          Schlussfolgerung

          Die Therapieentscheidung sollte in einem interdisziplinären Team aus Gastroenterologen, interventionellen Radiologen und Viszeralchirurgen getroffen werden und die residuelle Leberfunktion, eine anstehende Lebertransplantation und die Morphologie des portalvenösen Systems berücksichtigen.

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          Most cited references60

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          Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators.

          Several treatments have been proven to be effective for variceal bleeding in patients with cirrhosis. The aim of this multicenter, prospective, cohort study was to assess how these treatments are used in clinical practice and what are the posttherapeutic prognosis and prognostic indicators of upper digestive bleeding in patients with cirrhosis. A training set of 291 and a test set of 174 bleeding cirrhotic patients were included. Treatment was according to the preferences of each center and the follow-up period was 6 weeks. Predictive rules for 5-day failure (uncontrolled bleeding, rebleeding, or death) and 6-week mortality were developed by the logistic model in the training set and validated in the test set. Initial treatment controlled bleeding in 90% of patients, including vasoactive drugs in 27%, endoscopic therapy in 10%, combined (endoscopic and vasoactive) in 45%, balloon tamponade alone in 1%, and none in 17%. The 5-day failure rate was 13%, 6-week rebleeding was 17%, and mortality was 20%. Corresponding findings for variceal versus nonvariceal bleeding were 15% versus 7% (P =.034), 19% versus 10% (P =.019), and 20% versus 15% (P =.22). Active bleeding on endoscopy, hematocrit levels, aminotransferase levels, Child-Pugh class, and portal vein thrombosis were significant predictors of 5-day failure; alcohol-induced etiology, bilirubin, albumin, encephalopathy, and hepatocarcinoma were predictors of 6-week mortality. Prognostic reassessment including blood transfusions improved the predictive accuracy. All the developed prognostic models were superior to the Child-Pugh score. In conclusion, prognosis of digestive bleeding in cirrhosis has much improved over the past 2 decades. Initial treatment stops bleeding in 90% of patients. Accurate predictive rules are provided for early recognition of high-risk patients.
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            Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation.

            Splanchnic vein thrombosis is a significant source of complications in candidates for liver transplantation. The aims of this study were: (a) to determine the prevalence of and risk factors for splanchnic vein thrombosis in cirrhotic patients awaiting transplantation and (b) to assess the usefulness of anticoagulation. A total of 251 cirrhotic patients listed for transplantation were analysed. All underwent systematic screening for thrombosis with Doppler ultrasonography. During the second period of the study, all patients with thrombosis received anticoagulation up to transplantation while during the first period none had received anticoagulation. The incidence of splanchnic vein thrombosis at evaluation was 8.4%. Seventeen additional patients (7.4%) developed de novo thrombosis after evaluation. Independent risk factors for thrombosis were low platelet count (77.4 (36.3) v 111.6 (69.2) 10(9)/l; p = 0.001), a past history of variceal bleeding (47.4% v 29.1%; p = 0.003), and a prolonged interval from listing to transplantation (8.5 (6.8) v 4.8 (4.4) months; p = 0.002). The proportion of partial or complete recanalisation was significantly higher in those who received (8/19) than in those who did not receive (0/10, p = 0.002) anticoagulation. Survival was significantly lower in those who had complete portal vein thrombosis at the time of surgery (p = 0.04). These results support a systematic screening for splanchnic vein thrombosis in patients awaiting transplantation. They suggest that in these patients, anticoagulation is safe and has a significant impact on recanalisation as well as prevention of extension of thrombosis.
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              Etiology, management, and outcome of the Budd-Chiari syndrome.

              The Budd-Chiari syndrome (BCS) is hepatic venous outflow obstruction. What is known about the syndrome is based on small studies of prevalent cases. To characterize the causes and treatment of incident BCS. Consecutive case series of patients with incident BCS, enrolled from October 2003 to October 2005 and followed until May 2006. Academic and nonacademic hospitals in France, Spain, Italy, Great Britain, Germany, Belgium, the Netherlands, Portugal, and Switzerland. Persons older than 16 years with definite hepatic outflow obstruction diagnosed by imaging. Persons with hepatic outflow obstruction due to heart failure, sinusoidal obstruction syndrome, cancer, or liver transplantation were excluded. Signs and symptoms; laboratory and imaging findings; diagnosis; treatment; and overall, transplantation-free, and intervention-free survival. 163 incident cases of BCS were identified. Median follow-up was 17 months (range, 0.1 to 31 months). Most patients (84%) had at least 1 thrombotic risk factor, and many (46%) had more than 1; the most common was myeloproliferative disorders (49% of 103 tested patients). Patients were mainly treated with anticoagulation (140 patients [86%]), transjugular intrahepatic portosystemic shunting (56 patients [34%]), or liver transplantation (20 patients [12%]), and 80 patients (49%) were managed noninvasively. Only 3 patients underwent surgical shunting. The survival rate was 87% (95% CI, 82% to 93%) at 1 year and 82% (CI, 75% to 88%) at 2 years. Treatment was not standardized across all centers, and data on important clinical variables were missing for some patients. Most patients with BCS have at least 1 thrombotic risk factor, and many have more than 1; myeloproliferative disorders are most common. One- and 2-year survival rates are good with contemporary management, which includes noninvasive therapies (anticoagulation and diuretics) and invasive techniques. Transjugular intrahepatic portosystemic shunting seems to have replaced surgical shunting as the most common invasive therapeutic procedure. Fifth Framework Programme of the European Commission.
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                Author and article information

                Journal
                Viszeralmedizin
                Viszeralmedizin
                VIM
                Viszeralmedizin
                S. Karger Verlag für Medizin und Naturwissenschaften GmbH (Wilhelmstrasse 20A, P.O. Box · Postfach · Case postale, D–79095, Freiburg, Germany · Deutschland · Allemagne, Phone: +49 761 45 20 70, Fax: +49 761 4 52 07 14, information@karger.de )
                1662-6664
                1662-6672
                December 2014
                3 December 2014
                1 December 2015
                : 30
                : 6
                : 409-415
                Affiliations
                Department of Surgery, University of Bonn, Bonn, Germany
                Author notes
                *Dr. med. Tim R. Glowka, MD, Department of Surgery, University of Bonn Medical Center, Sigmund-Freud-Straße 25, 53105 Bonn, Germany, tim.glowka@ 123456ukb.uni-bonn.de
                Article
                vim-0030-0409
                10.1159/000369575
                4513833
                26288608
                b66b6e5e-1768-4791-9902-cab546ff076b
                Copyright © 2014 by S. Karger GmbH, Freiburg
                History
                Page count
                Figures: 1, Tables: 2, References: 58, Pages: 7
                Categories
                Review Article • Übersichtsarbeit

                portal hypertension,portal/mesenteric vein thrombosis,surgical portocaval shunt,cirrhosis,esophageal varices

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