Coronary renal shunt via splenic vein for portal hypertension after splenectomy

Abstract

Objective To investigate the clinical efficacy of coronary renal shunt via splenic vein for portal hypertension (PHT) after splenectomy. Methods The retrospective descriptive study was adopted. The clinical data of 5 patients with PHT who were admitted to the People's Hospital of Ningxia Autonomous Region from August 2012 to April 2015 were collected. Operative procedures: two procedures of coronary renal shunt via splenic vein (SV) were carried out after primary splenectomy. Procedure 1: the SV was freed from the residual end to the right for 5-6 cm in length and end-to-side spleno-renal shunt was carried out. The anterior wall of superior mesenteric vein (SMV) was exposed beneath the pancreatic neck and dissected behind the neck upward until the upper edge of the SV and its confluence with the left gastric vein (LGV) were exposed. The SV was ligated with clip between portal vein (PV) and LGV to let blood flow from LGV drain through the whole course of SV to left renal vein (LRV). Procedure 2: the peritoneum at the inferior border of the pancreas was incised, and the junctions of the SV and SMV and junctions of the SV and LGV were exposed. The inferior mesenteric vein (IMV) was divided between ligations. Dissection of the SV was carried out to the left for 3-4 cm in length and was divided. Its distal end was tied and proximal stump anastomosed to LRV by the end-to-side anastomosis. The SV was ligated with clip between PV and LGV. The right gastric and gastroepiploic vessels were ligated at the junction of the antrum and the body, and from this point, the hepatogastric ligment and the omentum were divided upward and downward respectively to completely separate the venous flow between the hepatointestinal area and the stomach in the two procedures. Patients took oral enteric-coated aspirin and warfarin after operation. (1) Intraoperative observation indicators included surgical procedures, operation time, volume of blood loos and free portal pressure (FPP). (2)Postoperative observation indicators included recovery of patients, time to anal exsufflation, time for diet intake, time of abdominal drainage, duration of hospital stay and occurrence of complications. (3)The follow-up using telephone interview and outpatient examination was performed to detect the changes of platelet (PLT), portal vein thrombosis (PVT), patency of spleno-renal vein anastomosis, oral anticoagulants and gastroesophageal varices up to October 2015. Measurement data with skewed distribution were analyzed by M (range). Results (1)Intraoperative observation indicators: 5 patients underwent successful coronary renal shunt via splenic vein. Two patients received procedure 1 and 3 patients received procedure 2. Operation time and volume of blood loss were 226 minutes (range, 195-298 minutes) and 425ml (range, 235-820 mL). FPP was 3.46 kPa (range, 2.69-4.61 kPa) before spleen resection, 2.69 kPa (range, 2.11-3.07 kPa) after spleen resection, 2.98 kPa (range, 2.30-3.36 kPa) after spleno-renal anastomosis, respectively. (2)Postoperative observation indicators: 5 patients had good recovery, and time to anal exsufflation, time for fluid diet intake, time of abdominal drainage removal and duration of hospital stay were respectively 3 days (range, 2-4 days), 3 days (range, 2-4 days), 5 days (range, 4-9 days) and 14 days (range, 10-17 days). Of 5 patients, 1 was complicated with pleural effusion and atelectasis and 1 with serum tumescence of incision. (3) Follow-up situations: 5 patients were followed up for a median time of 18 months (range, 6-36 months). The level of postoperative PLT was continuously growing, and the dose of oral warfarin was increased according to the level of growing PLT. The follow-up results of procedure 1 in 2 patients: 1 patient was followed up for 36 months and complicated with splenic vein thrombosis at postoperative month 6, and underwent transcatheter hepatic arterial chemoembolization (TACE) due to primary liver cancer at postoperative month 12, and then no special treatment was conducted due to splenic vein occlusion and sever esophageal varices without red-color sign or bleeding at postoperative month 36. The other patient was followed up for 24 months, and didn't undergo special treatment due to mild hepatic encephalopathy with a level of blood ammonia of 76 μmol/L at postoperative month 3, and then was found to have mild esophageal varices at postoperative month 18 by computed tomography (CT) and gastroscopy. Three patients using procedure 2 were followed up at month 6, 12, 18, with increased body mass index (BMI) and without occurrence of peritoneal effusion and hepatic encephalopathy, and they were complicated with mild gastroesophageal varices by reexamination of CT angiography and gastroscopy at postoperative month 6. Conclusion Coronary renal shunt via splenic vein for PHT after splenectomy could relieve hypersplenism and reduce selectively vein decompression of gastroesophageal varices. Key words: Portal hypertension; Coronary renal shunt; Trans-splenic vein; Splenectomy; Selective shunt