PORTAL-VEIN THROMBOSIS IN THE ADULT - SURGICAL IMPLICATIONS IN AN ERAOF DYNAMIC IMAGING

Extrahepatic portal vein thrombosis (EHPVT) is the leading cause of va riceal hemorrhage in patients with healthy livers; however, in an era of dynamic imaging, the incidental discovery of EHPVT places a special burden on the surgeon to understand the surgical implications of the disease in this setting. During the period 1989 to 1995, 23 patients ( 12 males and 11 females) were found to have EHPVT. In 20 (87%), this w as an unexpected finding on ultrasound (11 of 23), abdominal CT scan ( 9 of 23), or both (9 of 23). In two patients, the diagnosis was suspec ted and confirmed with angiography, whereas in the other, the lesion w as discovered at surgery. Only seven (30%) had hemorrhage as a present ing complaint. More typically (61%), abdominal pain alone or pain with sepsis was the indication for evaluation. In 20 patients (87%), there was an identifiable etiology for the EHPVT. A total of 15 operations were performed on 12 patients (52%), in 7 (4, variceal hemorrhage, and 3, bowel ischemia) as a direct consequence of the EHPVT and in five, for conditions not directly related to the EHPVT. Three of the 23 pati ents (13%) died, two (17%) following surgery and one (9%) from advance d malignant disease. No patients with hemorrhage (seven), even those w ho required a shunt for decompression (three) or devascularization (on e), died. We found that the diagnosis of EHPVT is usually not related to variceal hemorrhage, but rather, abdominal symptoms that serve as a n indication for the imaging study. Three subsets of patients emerged: (1) those requiring no surgery (11 patients), (2) those requiring sur gery related to hemorrhage (4 patients), and (3) those requiring surge ry for conditions other than varices (8 patients). In any of these cir cumstances, mortality (13%) was related to the underlying disease proc ess rather than EHPVT. Given the earlier recognition of EHPVT, the nat ural history of the disease has been altered, with outcome reflecting the underlying disease rather than the sequelae of portal hypertension .