Chirurgische Therapie der portalen Hypertension

 

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Zusammenfassung

Wegen des hohen Rezidivblutungsrisikos sollten heute alle Patienten nach einer ersten Varizenblutung bei portaler Hypertension eine Rezidivblutungsprophylaxe erhalten. Bei Ösophagusvarizen steht die endoskopische Eradikation mit Gummibandligaturen im Vordergrund. Bei Versagen der endoskopischen Therapie sollten dekomprimierende Shuntverfahren erwogen werden. Bei Patienten mit guter Langzeitprognose (Child-Pugh A, extrahepatische Pfortaderhochdruckformen) kommen wegen der besseren Langzeitergebnisse chirurgische Shunts (portokaval oder splenorenal) infrage. Bei schlechterer Leberfunktion (Child-Pugh B/C) und bei Kandidaten für eine Lebertransplantation sollte dem intrahepatischen Stent-Shunt (TIPS) der Vorzug gegeben werden. Ähnlich wie bei anderen palliativen Verfahren mit dem Charakter der Sekundärprophylaxe muss sowohl beim TIPS als auch bei chirurgischen Shunts eine spezielle Expertise vorausgesetzt werden, um Letalität und Morbidität gering zu halten. Bei extrahepatischen Pfortaderthrombosen mit dem Problem der Varizenblutung lassen sich hervorragende Langzeitergebnisse durch Shuntanlagen erzielen. Devaskularisierungs-Eingriffe kommen bei Fehlen shuntfähiger Pfortaderzuflüsse („Panthrombose”) infrage und können meist milzerhaltend durchgeführt werden.

Abstract

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

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PD Dr. M. Wolff

Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie · Rheinische Friedrich-Wilhelms-Universität Bonn

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Email: martin.wolff@ukb.uni-bonn.de