Lienorenal Shunt Research Articles

Makeshift Shunts in Extrahepatic Portal Vein Obstruction in Pediatric Population.

More than 20% of patients with extrahepatic portal vein obstruction (EHPVO) may be deemed as nonshuntable due to lack of a suitable vein. The role of "makeshift shunts" or "lesser shunts" assumes importance in such cases. In this report, the authors have shared their experience with the makeshift shunts in the management of portal hypertension in children with emphasis upon anatomic considerations, resolution of symptoms, outcomes after surgery, and shunt patency. During the period 1983-2018, 138 children with portal hypertension were managed under the care of a single surgeon (VB). Of them, 134 were EHPVO. Children with EHPVO were treated with splenectomy and proximal lienorenal shunt (n = 107), splenectomy and devascularization (n = 21), and makeshift shunts (n = 6). Makeshift shunts comprised (i) side-to-side right gastroepiploic vein (Rt-GEV) to left renal vein (LRV) shunt (n = 1), (ii) superior mesenteric vein (SMV) to inferior vena cava (IVC) shunt using a spiral saphenous venous graft (n = 1), (iii) side-to-side inferior mesenteric vein (IMV) to LRV shunt (n = 2), (iv) side-to-side IMV to IVC shunt (n = 1), (v) end-to-side IMV to IVC shunt (n = 1), and (vi) side-to-side IMV to LRV shunt (n = 1) in a case of crossed fused renal ectopia. Following the creation of portosystemic shunt, a decline in portal pressure was demonstrated in all six patients. There was resolution of symptoms including hematemesis, melena, and anorectal variceal bleed. None of the patients demonstrated the features of hepatic encephalopathy. The associated portal cavernoma cholangiopathy (n = 1) also resolved following Rt-GEV to LRV shunt. Shunt patency was documented for the entire duration of follow-up (1.5-4 years) in five of six patients; the sixth patient demonstrated shunt block at 6-month follow-up but without recurrence of symptoms. Makeshift shunts offer a viable alternative to standard portosystemic shunting in pediatric patients with a nonshuntable vein. The selection of such shunts is, however, subject to surgeon's preferences and has to be individualized to local anatomy.

Clinical outcomes related to portal pressures before and after embolization of large portosystemic shunts in cirrhosis

Objectives: Embolization of large portosystemic shunts effectively controls gastric variceal bleeding and prevents hepatic encephalopathy. The significance of dynamic changes in hepatic venous pressure gradient before and after embolization on clinical events and patient outcomes remains unknown. Methods: In this retrospective single-center series, 46 patients with gastric variceal bleeding, hepatic encephalopathy, or both undergoing embolization (January 2018 to October 2020) were included, and dynamic changes in portal pressures were analyzed against patient outcomes. Results: Males predominated. The most common portosystemic shunt syndrome was the lienorenal shunt. In all, 34 patients underwent embolization for hepatic encephalopathy and 11 for gastric variceal bleeding. The proportion of patients surviving at the end of 12 and 32 months was 86.96 and 54.35%, respectively. The hepatic venous pressure gradient before shunt embolization was 13.4 ± 3.2 and 16.9 ± 3.7 mm Hg after occlusion ( p < 0.001). Bleeding from varices on overall follow-up was notable in five patients (10.9%), and overt hepatic encephalopathy in four ( N = 42, 9.5%) patients at 6–12 months. The development of infections within 100 days and beyond the first year was associated with the risk of dying at the end of 12 and 32 months, respectively. Elevation of hepatic venous pressure gradient by >4 mm Hg from baseline and an absolute increase to >16 mm Hg immediately post-procedure significantly predicted the development of early- and late-onset ascites, respectively. Conclusion: Close monitoring for the development of infections and optimization of beta-blockers and diuretics after shunt embolization may improve clinical outcomes and help identify patients who will benefit from liver transplantation pending prospective validation.

Portal cavernoma cholangiopathy: Update and recommendations on diagnosis and management.

Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.

Renal Implications of Left Renal Vein Ligation for Portal Flow Augmentation in Liver Transplantation.

Spontaneous lienorenal shunts (SLS) siphon blood away from the portal circulation and may compromise portal inflow in liver transplantation (LT). Performing a left renal vein ligation (LRVL) is a relatively easy and efficacious method of overcoming this portal 'steal'. However, given the delicate state of renal function in these patients, its short and long term effects remain undefined. The aim of this study was to evaluate the efficacy of LRVL in augmenting portal flow and safety with regards to renal function. A prospectively collected database of 1638 consecutive LT recipients between January 2010 and August 2020 was reviewed. Twenty-eight patients who underwent LRVL were identified. There were six paediatric recipients, who were analysed separately. Data with regards to imaging, renal function, intraoperative portal hemodynamics, and renal morbidity were analysed. Of the 22 adults, 21 underwent live donor LT. 22.5% had a pre-transplant history of acute kidney injury (AKI). Pre-operative CT demonstrated portal vein thrombosis and SLS in 63.6% and 92.9% of patients respectively. LRVL resulted in a significant augmentation of portal hemodynamics in both the adult and paediatric recipients. Postoperatively, 14.3% and 35.7% of patients developed chylous drain output and AKI respectively. Of 13 patients who underwent CT at various timeframes, 5 patients had a partial re-canalisation of LRV at 6months. From renal and portal standpoints, LRVL is a safe and effective technique of augmenting portal inflow. Further large-scale multicentre studies and consensus will help define an objective algorithmic approach to LT recipients with SLS.

Splenectomy with proximal spleno-left portal shunt for extrahepatic portal vein obstruction in children

PurposeTo report our initial experience with splenectomy and proximal spleno-left portal shunt as an alternative to the standard Rex shunt, when not applicable, in children with Extrahepatic Portal Vein Obstruction (EHPVO). MethodsPatients from March 2015 till September 2018, with EHPVO not suitable for Rex shunt or whose caregivers refused to consent for Internal Jugular Vein (IJV) dissection were assessed and prepared for splenectomy with proximal spleno-left portal shunt. The operative technique includes splenectomy, freeing of the splenic vein from the pancreatic bed till its junction with the inferior mesenteric vein, and then anastomosis with the intrahepatic left portal vein at the Rex recess. A distal lieno-renal shunt was performed in one patient and was excluded from the study. ResultsA total of 14 patients (mean age: 4.6 years) underwent splenectomy with proximal spleno-left portal shunt during the study period. The mean operative time was 246 min, while the mean postoperative hospital stay was 4.1 days. The patients' follow up period ranged from 6 to 42 months (median: 19.6 months). Only two patients had a single attack of variceal bleeding, 2 and 2.5 months postoperative respectively, and required endoscopic management with no further bleeding episodes. While the rest of patients showed an improvement of their variceal grades after the surgery. ConclusionSplenectomy with proximal spleno-left portal shunt seems to be a valuable alternative to the standard Rex shunt in treatment of children with EHPVO unsuitable for or following unsuccessful Rex shunt. Level of evidenceIV

Correlation of Hepatic Artery Resistive Index with Portal Pressure and Serum Nitric Oxide Levels in Patients with Extrahepatic Portal Vein Obstruction.

Aim:The aim was to study the correlation of hepatic artery resistive index (HARI) with the portal pressure (PP) and its surrogate marker serum nitric oxide (NO) levels and to determine the validity of HARI as noninvasive indirect marker of PP in extrahepatic portal venous obstruction (EHPVO) pre- and postoperatively.Methods:A prospective study was conducted on 19 patients with EHPVO undergoing proximal lienorenal (LR) shunt or devascularization from February 2016 to January 2018. HARI, calculated from Doppler sonography, and NO were measured preoperatively and 14, 30 and 90 days postoperatively. Intraoperatively, PP was measured before splenectomy, and both PP and NO were measured postshunt.Results:Mean age was 10.58 ± 2.85 years, and male:female ratio was 15:4. LR shunt was done in 16 while three patients required devascularization. There was a significant fall in the HARI (0.06 ± 0.02, P = 0.02), NO (14.31 ± 2.66 μmol/l, P < 0.001), and PP (11.81 ± 1.03 mmHg, P < 0.001) following shunt surgery. However, fall in HARI did not correlate with fall in PP. Preoperative HARI also did not correlate with preshunt/devascularization PP nor with preoperative NO. Postoperatively, HARI did not correlate with NO at 14-, 30-, and 90-day follow-up.Conclusion:HARI bears no correlation with PP or NO. Hence, it cannot be used as an indirect marker of PP.

Emergency proximal lienorenal shunt(LRS) for variceal bleeding in patients with extrahepatic portal venous obstruction(EHPVO)

Emergency proximal lienorenal shunt(LRS) for variceal bleeding in patients with extrahepatic portal venous obstruction(EHPVO)

Diagnostic non-invasive model of large risky esophageal varices in cirrhotic hepatitis C virus patients.

To build a diagnostic non-invasive model for screening of large varices in cirrhotic hepatitis C virus (HCV) patients. This study was conducted on 124 post-HCV cirrhotic patients presenting to the clinics of the Endemic Medicine Department at Mansoura University Hospital for evaluation before HCV antiviral therapy: 78 were Child A and 46 were Child B (score ≤ 8). Inclusion criteria for patients enrolled in this study was presence of cirrhotic HCV (diagnosed by either biopsy or fulfillment of clinical basis). Exclusion criteria consisted of patients with other etiologies of liver cirrhosis, e.g., hepatitis B virus and patients with high MELD score on transplant list. All patients were subjected to full medical record, full basic investigations, endoscopy, and computed tomography (CT), and then divided into groups with no varices, small varices, or large risky varices. In addition, values of Fibrosis-4 score (FIB-4), aminotransferase-to-platelet ratio index (APRI), and platelet count/splenic diameter ratio (PC/SD) were also calculated. Detection of large varies is a multi-factorial process, affected by many variables. Choosing binary logistic regression, dependent factors were either large or small varices while independent factors included CT variables such coronary vein diameter, portal vein (PV) diameter, lieno-renal shunt and other laboratory non-invasive variables namely FIB-4, APRI, and platelet count/splenic diameter. Receiver operating characteristic (ROC) curve was plotted to determine the accuracy of non-invasive parameters for predicting the presence of large esophageal varices and the area under the ROC curve for each one of these parameters was obtained. A model was established and the best model for prediction of large risky esophageal varices used both PC/SD and PV diameter (75% accuracy), while the logistic model equation was shown to be (PV diameter × -0.256) plus (PC/SD × -0.006) plus (8.155). Values nearing 2 or more denote large varices. This model equation has 86.9% sensitivity and 57.1% specificity, and would be of clinical applicability with 75% accuracy.

Noncirrhotic portal hypertension: Medical and endoscopic management.

Noncirrhotic portal hypertension: Medical and endoscopic management.

Portal hypertension: A critical appraisal of shunt procedures with emphasis on distal splenorenal shunt in children.

Background:Extrahepatic portal venous obstruction (EHPVO) is the most common cause of pediatric portal hypertension. We analyzed the investigative protocol and results of portosystemic shunts in this group of patients.Materials and Methods:A total of 40 consecutive children aged below 12 years operated with a diagnosis of extra-hepatic portal hypertension formed the study group. Historical data and clinical data were collected. All patients underwent upper gastrointestinal endoscopy, ultrasound Doppler and computed tomographic portogram pre-operatively and post-operatively. Results with respect to shunt patency, hypersplenism and efficacy of different radiological investigations were collected.Results:A total of 40 patients, 28 boys and 12 girls constituted the study group. Lienorenal shunt (LRS) was performed in 14 patients; distal splenorenal shunt in 21 patients and side-to-side lienorenal shunt in 4 patients, inferior mesenteric renal shunt was performed in 1 patient. Follow-up ranged from 36 to 70 months. At a minimum follow-up of 3 years, 32 (80%) patients were found to have patent shunts. Patent shunts could be visualized in 30/32 patients with computer tomographic portogram (CTP) and 28/32 with ultrasound. Varices regressed completely in 26/32 patients and in the rest incomplete regression was seen. Spleen completely regressed in 19/25 patients. Hypersplenism resolved in all patients with patent shunts.Conclusions:Portosystemic shunting in children with EHPVO is a viable option. While long-term cure rates are comparable with sclerotherapy, repeated hospital visits are reduced with one time surgery. Pre-operative and post-operative assessment can be performed with complimentary use of ultrasound, CTP and endoscopy.

Early Experiences with Management of Extra Hepatic Portal Vein Obstruction

Introduction: Extrahepatic portal vein obstruction (EHPVO), a rare condition, is increasingly being diagnosed due to easier availability of proper diagnostic tools and early referrals. Here we report our series of 16 cases of EHPVO who were treated at our hospital. The aim of this paper is to share our early experiences of managing this rare and difficult condition. Methods: A retrospective analysis of patients’ records admitted with the diagnosis of EHPVO for a period of 18 months from Jan 2008 to June 2010 was performed. Patients were followed up for at least 9 months, their demographic data and outcome of surgery was analysed. Results: Of the 10 cases fulfilling the inclusion criteria, 9 underwent surgical therapy. Distal lienorenal shunt was performed in 4 patients, proximal lienorenal shunt in 2 patients and devascularisation procedure in 3 patients. Rebleeding was seen in 2 patients. The prognosis of EHPVO was good in patients without a severe underlying disease at a median follow up of 9 months. Conclusion: Conventional surgical therapies have a good outcome in management of EHPVO in our context. Medical Journal of Shree Birendra Hospital; July-December 2012/vol.11/Issue2/4-6 DOI: http://dx.doi.org/10.3126/mjsbh.v11i2.7898

Management of Bleeding in Extrahepatic Portal Venous Obstruction

Extrahepatic portal venous obstruction, although rare in the western world, is a common cause of major and life threatening upper gastrointestinal bleeding among the poor in developing countries. Patients have large spleens and stunted growth. The diagnosis is easily confirmed by Doppler ultrasonography. Endoscopy sclerotherapy is the best option for the control of acute variceal bleeding. For secondary prophylaxis of bleeding, the choice lies between repeated sclerotherapy and a portosystemic shunt. We believe that due consideration should be given to performing a splenectomy and a lienorenal shunt. Performed by experienced surgeons, it carries a low operative mortality of 1%, a rebleeding rate of about 10%, removes the large spleen, reverses hypersplenism, and is not followed by portosystemic encephalopathy. Most importantly, it is a onetime procedure particularly suited to those who have little access to blood transfusion and sophisticated medical facilities.

Efficacy of Balloon-occluded Retrograde Transvenous Obliteration of Large Spontaneous Lienorenal Shunt in Patients with Severe Recurrent Hepatic Encephalopathy with Foam Sclerotherapy: Initial Experience

PurposeBalloon-occluded retrograde transvenous obliteration (BRTO) is a widely accepted treatment for gastric varices, but data are limited in regard to its role in the management of hepatic encephalopathy (HE). This study evaluated the efficacy of BRTO with foam sclerotherapy in the management of HE arising as a result of spontaneous large portosystemic shunts. Materials and MethodsEight sessions of BRTO with sodium tetradecyl sulfate foam were performed in seven patients with cirrhosis complicated by HE. All patients had portosystemic communication (ie, gastro-/lienorenal shunt) on preprocedure computed tomography. Clinical and laboratory parameters including arterial ammonia level were evaluated in all patients before and after the procedure. ResultsTechnical success rates were 86% (six of seven) for the first BRTO session and 100% (one of one) for the second. Follow-up imaging revealed complete obliteration of the varices in five of seven patients (71%) and partial obliteration in the remaining two. Immediate clinical improvement of HE was observed in six of seven patients (86%), with postprocedural decrease in arterial ammonia levels; one patient showed delayed improvement. Procedure-related complications (eg, abnormal liver function test results, acute kidney injury with leukocytosis) were encountered in two patients. All patients showed clinical and symptomatic improvement at the time of discharge and during a follow-up of 4 months (with visits at 1 mo and 3 mo later). ConclusionsInitial experience suggests that BRTO is an effective procedure in the management of HE arising as a result of large portosystemic shunts.

Multidetector CT venography and contrast-enhanced MR venography of the inferior mesenteric vein in paediatric extrahepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) is a common cause of paediatric portal hypertension and the only permanent treatment is shunt surgery. The inferior mesenteric vein (IMV) is a portal venous channel that can be used for the shunt when the splenic vein/superior mesenteric vein is thrombosed or when a lienorenal shunt is not possible. To compare MDCT venography (MDCTV) and contrast-enhanced MR venography (CEMRV) for visualisation of the IMV in children with EHPVO. This was a prospective study of 26 children (4-12 years, median 10 years) who underwent MDCTV and CEMRV. The IMV visualisation was graded using 4- and 2-point scales and the difference in visualisation was assessed by calculating the exact significance probability (P). The IMV was visualised in all children on MDCTV and 25/26 children on CEMRV (96%). The images were diagnostic in 23/26 children (88%) on MDCTV and in 18/26 (69%) children on CEMRV (P=0.063). MDCTV and CEMRV are comparable for IMV visualisation with a tendency toward MDCTV being superior.

Extrahepatic portal venous obstruction: Is the knife irrelevant?

A study on long term outcomes following variceal eradication in patients with extrahepatic portal venous obstruction (EHPVO) was clearly needed. In this issue of the Journal, Thomas et al. present the results of long-term follow up of a cohort of patients treated with endoscopic variceal sclerotherapy (EST). Of the 223 patients treated between 1985 and 1994, they had follow up data available for 198 patients. On a retrospective analysis of these data, 34 (17.2%) patients had rebleeding after initial variceal eradication, 39 (19.7%) had reappearance of esophageal varices and 19 (9.5%) had de novo appearance of fundal varices. The mean duration from the time of eradication of varices to rebleeding was 5.4 (range 1 to 16) years. Based on these results, the authors suggest that endoscopic variceal eradication is an effective treatment modality for bleeding esophageal varices in patients with EHPVO. This study, though retrospective, is quite thorough. 1 It clarifies several questions, while throwing up some new ones. First, the authors base their premise on a cohort of patients in whom they had achieved successful initial hemostasis and long term variceal eradication. A large majority (87%) of their patients presented with active variceal bleeding. However, we remain unsure of the outcome in patients in whom initial EST failed to achieve hemostasis. In 10%–15% of patients, endoscopic treatment may not achieve initial control of bleeding. 2,3 This subset of patients is important since their exclusion may mislead us into believing that EST is successful in all patients with variceal bleeding due to EHPVO. Secondly, 12 patients were lost to follow up from the initial cohort of 223 patients; did these patients die or undergo some other form of treatment elsewhere? No doubt the long term results are important, but without these initial data, establishing the overall efficacy of EST in this group of patients would be incomplete. In the broader clinical perspective, the treatment options available for patients with EHPVO must include surgery. Evidence in the Western literature indicates that if shunt surgery has a role in treatment of portal hypertension, it is in patients with non-cirrhotic portal hypertension, and especially those with EHPVO. 4,5 From India too, excellent long term results of proximal lieno-renal shunt (PLRS) have been reported in such patients. Of 160 children who underwent PLRS with splenectomy at our institution, the overall mortality was 1.9% (elective: 1/140 [0.7%]; emergency 2/20 [10%]), rebleeding rate was 11% and actuarial survival at 15 years by life-table analysis was 95%. 6,7 None of these patients developed encephalopathy. The procedure cured hypersplenism in all the patients who had this. Only one patient developed meningococcal meningitis, which recovered following treatment. Similarly, a study from Chandigarh that included 104 patients with non-cirrhotic portal hypertension who had undergone side-to-side lieno-renal shunt showed a shunt patency rate of 87%, a rebleeding rate of 10%, and no occurrence of encephalopathy after a mean follow up of 54 months. 8 Thus, surgery is a one-time treatment procedure with durable, long term efficacy in preventing variceal rebleeding. Long term studies (15–40 years) from the West have repeatedly shown that shunt surgery with or without splenectomy (proximal lieno-renal, side-to-side splenorenal, distal splenorenal or mesocaval) for EHPVO in children and adults, is associated with shunt patency rates between 90% and 95%, rebleeding rates of 5%–10%, no encephalopathy and 15-year actual survival rates of 95%. 5,9–11 These studies have found portosystemic shunts to be consistently effective for bleeding esophagogastric varices due to EHPVO.

Management of massive haemobilia in an Indian hospital

Massive haemobilia carries a mortality of 25% in most reports. Although previously it was mainly due to road accidents or homicidal attempts it is now more often due to iatrogenic trauma like percutaneous liver biopsy and biliary drainage. However the management protocol is not established and there have been few reports of this serious condition from India. To review the causes of massive haemobilia and outline its management in an Indian hospital. We retrospectively analysed the records of 20 consecutive patients with massive haemobilia (blood requirement more than 1400 ml/day) admitted to our department over six years from a prospectively maintained database. There were 10 males and 10 females who had a mean age of 43 (range 15-65) years. Haemobilia accounted for 9 percent of patients admitted with upper gastrointestinal bleeding who were seen over this period. The commonest cause was iatrogenic (11) including laparoscopic cholecystectomy (6), Whipple's operation, endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), hepatic stone extraction and removal of biliary stent (1 each). The others had accidental trauma (4), visceral aneurysms (2), biliary stones (2) and chronic pancreatitis (1). The commonest clinical presentation was massive gastrointestinal bleeding. The dual phase computed tomography (CT) scan correctly identified the site of bleeding and other associated conditions in all the 11 patients in whom it was done. Conventional angiography was done in 8 patients with transarterial embolisation (TAE) being attempted in 6 and successful in 2 patients. Operations were performed in 18 patients for the following indications - failure of angiographic embolisation (6), failure of endoscopic sclerotherapy (EST) (1), duodenal erosion (2), portal biliopathy (1), haemoperitoneum (1), bile leak (1), pseudocyst (1), liver necrosis (1) and other hepatobiliary conditions (4). The surgical procedures to control bleeding were ligation of aneurysms (8), repair of the hepatic artery (4), right hepatectomy (3), lienorenal shunt, cholecystectomy and under-running of the duodenal papilla (1 each). The overall mortality was 4 patients (20 percent). There was no mortality in patients with bleeding aneurysms; the mortality being significantly higher in patients with non-aneurysmal bleeding (p=0.0049: Fishers' exact test). In our experience haemobilia was usually due to an iatrogenic cause with a pseudoaneurysm following a diagnostic or therapeutic intervention(most often laparoscopic cholecystectomy) being the commonest aetiology. A dual phase CT scan accurately identified the site of bleeding. Angiographic embolisation often failed to stop bleeding and mortality was significantly higher in patients with non-aneurysmal bleeding. We should perhaps consider early surgery for haemobilia once the bleeding site has been localised by CT scan.

A ten year prospective experience with semi-elective shunt in selected patients for bleeding oesophageal varices.

In a prospective study from 1972 to 1982, 38 patients with bleeding oesophageal varices and relatively good liver function were treated by semi-elective or emergent shunt 2-4 weeks after admission. There were no deaths within 3 months of surgery. This constituted 30% of the total 125 patients admitted with bleeding varices during that period. No referred case for treatment of portal hypertension was included in this study. The procedures performed were end-to-side portacaval shunt in 30 cases, lieno renal shunt in seven cases and interposition mesenterico-caval shunt in one case. All patients were admitted to a special unit with a two stage policy of management. Immediate endoscopic diagnosis and balloon tamponade in those with continued bleeding was followed by shunt in selected cases. Follow-up of the 38 patients showed a cumulative survival at 1 year of 89%, at 3 years of 75% and 5 years of 65%. In four cases (13%) a clinical diagnosis of portal systemic encephalopathy was made, all were controlled by medical management. In four of ten follow-up deaths, liver failure was the cause, in none of these cases was encephalopathy a problem. It is concluded that with a policy of early diagnosis and control of haemorrhage, 30% of a typical series of prospectively studied patients admitted with bleeding varices can be treated without mortality by definitive surgery. There was low incidence of encephalopathy and no cases of incapacitating mental confusion. Centralization of treatment and prospective study is essential for the implementation of such a policy of management.

Long term follow-up of patients following successful selective and non-selective portasystemic shunt surgery.

The long term morbidity and mortality of two consecutive groups of patients undergoing successful shunt surgery for bleeding oesophageal varices has been studied. Twenty-seven patients with a non-selective shunt in the form of a mesocaval Dacron 'H' graft and 21 patients with selective variceal decompression via a distal lienorenal shunt, all of whom had a patent shunt on discharge from hospital, were included in the study. Shunt associated encephalopathy was documented in 77% of the patients following mesocaval shunts and only 19% of patients following distal lienorenal surgery. Other postoperative morbidity was largely related to problems with the synthetic Dacron graft. Late shunt blockage, often resulting in recurrent variceal bleeding, was documented in 25% of these patients and shunt infection was responsible for complicating fatal disseminated sepsis in 18.5%. Long term survival, as assessed by life table analysis, following distal lienorenal shunt surgery was consistently better than that following mesocaval shunts. This was largely due to specific problems which could be directly related to the synthetic nature of the Dacron graft. It is concluded that the mesocaval Dacron interposition graft carries the potentially lethal long term complications of shunt blockage and infection rendering it unsuitable as a portasystemic shunt. Provided that successful surgery can be performed the distal lienorenal shunt may be a more appropriate alternative due to its reduced shunt related morbidity and, possibly, mortality.

Splenectomy and proximal lieno-renal shunt in a factor five deficient patient with extra-hepatic portal vein obstruction

BackgroundThe clinico-surgical implication and successful management of a rare case of factor five (V) deficiency with portal hypertension and hypersplenism due to idiopathic extra-hepatic portal venous obstruction is presented.Case presentationA 16-year old boy had gastro-esophageal variceal bleeding, splenomegaly and hypersplenism. During preoperative workup prolonged prothrombin time and activated partial thromboplastin time were detected, which on further evaluation turned out to be due to factor V deficiency. Proximal lieno-renal shunt and splenectomy were successfully performed with transfusion of fresh frozen plasma during and after the surgical procedure. At surgery there was no excessive bleeding. The perioperative course was uneventful and the patient is doing well on follow up.ConclusionSurgical portal decompressive procedures can be safely undertaken in clotting factor deficient patients with portal hypertension if meticulous surgical hemostasis is achieved at operation and the deficient factor is adequately replaced in the perioperative period.

Hepatic myelopathy: A rare complication following extrahepatic portal vein occlusion and lienorenal shunt

A 19-year-old gentleman presented with slowly progressive spastic paraparesis, 2 years after the therapeutic lienorenal shunt for portal hypertension secondary to cirrhosis and portal vein occlusion. After 2 years of initial evaluation, the motor functions had not worsened further. He did not have any obvious clinical or EEG features of hepatic encephalopathy. Other causes for myelopathy were ruled out. Contribution of portal vein occlusion to portosystemic shunting has not been reported previously in patients with 'hepatic myelopathy.' This uncommon complication needs to be considered in patients with shunt surgery for relieving portal hypertension.