Hemodynamically efficient portal decompression: the concept of competing spontaneous and surgical shunts

Abstract

Introduction: Temporary portocaval shunt (PCS) has a positive impact on short-term outcomes after liver transplantation (LT). An alternative to this proximal shunt is a distal passive decompression through mesenterico-saphenous shunt (MSS). The goal of this study was to compare the efficiency of spontaneous and surgical distal versus proximal shunts and discuss their respective place during the anhepatic phase in regard to the anatomy of preexisting spontaneous shunts. Method: Patients transplanted in a 2-year period who underwent portal decompression during the anhepatic phase were included. Intraoperative and in-hospital course were compared according to 2 types of surgical decompression techniques: PCS (n = 44) and MSS (n = 77). The impact of spontaneous shunt anatomy on the hemodynamic and metabolic efficiency of surgical shunts using portal pressure and capillary lactate measurements as well as on early graft function were evaluated. Results: MSS and PCS showed a comparable hemodynamic and metabolic efficiency with no significant difference in terms of portal pressure variations and gut lactate production. There was no significant difference in terms of reperfusion syndrome, transfusion rate, renal failure nor early allograft dysfunction (p = 0.956, 0.575, 0.239 and 0.976 respectively). In case of competing shunts (example: PCS and splenorenal shunt or MSS and left gastric shunt), there was a significantly higher rate of EAD (67% vs 13%; p = 0.002). Conclusion: Classical portacaval anastomosis and passive mesenterico-saphenous shunt offer similar hemodynamic and metabolic efficiency without impacting on the outcomes after liver transplantation. Their respective place should be discussed in regard to the anatomy of preexisting portosystemic shunts.