Invited critique

Abstract

Background: The distal splenorenal shunt (DSRS) is designed to maintain hepatopetal portal vein flow while decompressing gastroesophageal varices. However, over time, as the underlying liver disease progresses, the DSRS loses its selectivity. The most common method of addressing this issue during orthotopic liver transplantation is shunt ligation with or without splenectomy. Dismantling the shunt increases the complexity of the transplantation, and splenectomy may increase the risk of infection. Hypothesis: Anastomosis of the donor portal vein to the left renal vein without dismantling the shunt is an effective method of portal vein reconstruction for patients with a patent DSRS. Design: Retrospective analysis. Setting: University-based teaching hospital, Miami, Fla. Patients: Five liver transplant recipients with patent DSRS who received an orthotopic liver transplant between September 1996 and August 1999. Interventions: The donor portal vein was anastomosed end-to-end to the left renal vein during liver transplantation. Main Outcome Measures: Perioperatve morbidity, portal vein flow by Doppler study, patient survival, and graft survival. Results: In all patients, the graft liver reperfused promptly via flow through the left renal vein with adequate decompression of the bowel. Normal portal venous flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. At the mean follow-up of 16 months, 4 patients were alive with well-functioning grafts. Conclusions: This novel technique has the advantage of decreasing the complexity of the procedure, without requiring splenectomy, while securing adequate portal perfusion. Additionally, it can be applied without modifications in patients with portal vein thrombosis.