Mesocaval Shunt Research Articles

Hemodynamics and Hepatic Energy Metabolism in Canine Model of Acute Hepatic Venous Occlusion with Mesocaval Shunt

The relationship between portal hemodynamics and the energy metabolism of the liver with acute hepatic venous occlusion (HVO) was investigated by assessing the changes in the hepatic blood flow, arterial blood ketone body ratio (AKBR) and adenylate energy charge potential (ECP) of the liver tissue in canine model. Acute HVO was induced by the ligation of both the supra- and infrahepatic inferior vena cava (IVC) over the protruding ends of a heparin-coated polyethylene cannula inserted into the IVC. All dogs with only HVO (n = 5) died within 30 min. HVO dogs with additional mesocaval (MC) shunt (n = 10) survived longer than 7 days, during which time their AKBR were maintained in the normal range (over 1.0). ECP was also maintained above the normal level (over 0.850) during the 28-day period. Along with increasing portal pressure caused by the narrowing of the shunt anastomosis, the hepatic blood flow decrease gradually, resulting in a sudden decrease in AKBR and ECP when the portal pressure increased over 11 mm Hg. It is suggested that the normalization of portal pressure is one of the most important factors for maintaining the hepatic energy metabolism and that MC shunt is an effective therapy for maintaining the function of the liver with HVO, as long as portal pressure can be kept within normal range.

Pregnancy in Liver Cirrhosis

Eleven patients with liver cirrhosis who had a pregnancy between 1974 and 1992 are reported. Prior to pregnancy 2 patients were splenectomized, 1 of them also had an unsuccessful mesocaval shunt and therefore underwent sclerotherapy. Furthermore, 3 patients were managed by injection sclerotherapy, 6 patients had episodes of hepatocellular failure and 5 had signs of hypersplenism. Gastrointestinal hemorrhage associated with pregnancy was noted in 6 patients. Jaundice was encountered in 2 patients, a raised bilirubin level in 3, ascites in 3, impairment of the synthetic liver function in 5, thrombocytopenia in 8, hemorrhagic diathesis in 5, and infectious puerperal complication in 5 patients. Esophageal sclerotherapy was used in 5 and transfusion in 6 patients. Of 12 births, 6 newborns were small-for-date and 1 of them died. Three neonates were preterm. Fetal wastage did not occur. The present data suggest that gastrointestinal hemorrhage in liver cirrhosis contributes to developing fetal growth retardation; cirrhotic patients can be prepared for pregnancy and the hematemesis during pregnancy can successfully be managed by esophageal sclerotherapy.

Chylous Ascites: A Rare Complication of Liver Cirrhosis

Chylous Ascites: A Rare Complication of Liver Cirrhosis

Surgical intervention in children with portal hypertension

Over a 5-year period 252 children with bleeding oesophageal varices secondary to portal hypertension were treated by endoscopic injection scletherapy. Surgical treatment was restricted to patients with bleeding complications following sclerotherapy and the occasional problem of symptomatic splenomegaly (2 children). Sclerotherapy failure was due to the development of varices not accessible to sclerotherapy (gastric fundus 7, duodenum 1, jejunum 1, unidentified site in small bowel 1) and to continued bleeding from oesophageal ulcers in 2 children. There were 5 children with Child's grade A cirrhosis. Fifteen children (4.4 % of the total; median age 8.7 years, range 1.5 – 18 years) underwent 16 operations during this period, which included 13 porto-systemic shunts (8 lieno-renal and 5 meso-caval) and 3 oesophageal transections/devascularisations. Sclerotherapy was not attempted in 1 of the 2 children treated for continued bleeding from oesophageal varices. Two lieno-renal shunts thrombosed and 1 of these patients underwent a meso-caval shunt. There were no deaths in this group of patients during a median follow-up of 40 months. One child with biliary atresia has developed a mild intermittent encephalopathy. The use of injection sclerotherapy for bleeding oesophageal varices with surgical intervention limited to patients failing treatment resulted in low morbidity and no mortality in a large group of children with portal hypertension.

Complications and limitations of injection sclerotherapy in portal hypertension.

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.

Surgical Measures for Active Variceal Bleeding

Surgical options for acute variceal bleeding should be considered when injection sclerotherapy fails on two occasions. Which surgical approach is used depends on local expertise, compliance of the patient, Child’s grade, and the availability of liver transplantation. In the acutely bleeding situation the choice probably lies between the esophageal transection and devascularization procedure and a mesocaval shunt. The Sugiura procedure has little merit outside Japan, and an emergency portacaval shunt should be avoided in patients who are possible liver transplant recipients.

Occlusion of Liver Veins (Budd-Chiari Syndrome) in Childhood: A Case Report

The Budd-Chiari syndrome is a rare cause of portal hypertension during childhood. We report on a 2-year-old boy suffering from liver congestion and ascites. No cause for the occlusion of the liver veins was found. There was an almost complete occlusion of the subdiaphragmatic vena cava due to compression by a hypertrophic lobus caudatus. Normal venous pressure could be demonstrated below this subtotal occlusion while numerous venous collaterals into the areas of the venae azygos and hemiazygos were encountered. A mesocaval shunt operation, therefore, seemed to be appropriate. There was, however, no decrease in production of ascites postoperatively. Repeat cavography now showed an elevation of venous pressure caused by the additional inflow of portal blood which could not, as expected, be compensated by caval collaterals. Therefore, a mesoatrial shunt was performed eight days after the first operation. However, even this additional shunt did not decrease the enormous production of ascites, and the child finally died. Hemodynamic and lymphodynamic pathways of the Budd-Chiari syndrome are discussed. Possibly a mesoatrial shunt in the first place, followed by a mesocaval shunt, would have been the better operative strategy.

Investigation of the portal perfusion index after low diameter mesocaval interposition and distal splenorenal shunt — a prospective study

In 50 consecutive patients portal blood flow was determined using computed liver perfusion scintigraphy preoperatively and at 6, 12, 24, 36, 48, 60, 72, and 84 months postoperatively between 1 January 1983 and 1 January 1990. All 25 subjects had undergone placement of a distal splenorenal shunt (DSRS) and 25, insertion of low-diameter PTFE mesocaval interposition shunt (LDMIS) between 15 January 1983 and 1 January 1988. Indications for shunt operation included recurrent variceal hemorrhage in spite of long-term endoscopic sclerotherapy, a Child-Pugh classification of A or B, a sonographically determined liver volume of between 1000 and 2500 ml, exclusion of the activity and progression of liver disease by biopsy and stenosis of the hepatic artery or coeliac trunk. DSRS was performed when the portal perfusion index (PPI) was greater than 30% (normal values 56 +/- 5%) and LDMIS was carried out when the PPI was 10% to 30%. In all cases the underlying disease was liver cirrhosis of alcoholic (n = 34, 68%) or hepatic (n = 12, 24%) etiology. Five patients who underwent LDMIS had originally scheduled for DSRS at a PPI of greater than 30%; because the DSRS would have been technically difficult due to severe chronic pancreatitis, a LDMIS was performed. One in-hospital death due to liver failure had occurred in each group by 1 January 1990. One patient in the DSRS group and two in the LDMIS group died later, and in each group one patient was lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Dilatation of the inferior vena cava using an expandable metal stent in Budd-Chiari syndrome

Caval compression secondary to hypertrophy of the caudate lobe is a well known complication of Budd-Chiari syndrome. This paper describes the use of an expandable metal stent to overcome external caval compression. Meso-caval shunting was subsequently performed with a good end result.

Hepatic encephalopathy induced by small bowel obstruction in a noncirrhotic child with portal vein thrombosis

A case of hepatic encephalopathy in a noncirrhotic child, who has undergone a previous mesocaval shunt for extrahepatic portal vein thrombosis, is presented. Hepatic encephalopathy developed 5 years after the operation and is believed to have been precipitated by the presence of small bowel obstruction. Exploratory laparotomy and lysis of an adhesion relieved the obstruction and led to the resolution of the encephalopathy.

Evaluation of temporary portal vein arterialization: the minimum arterialized blood flow for maintaining liver viability

The effect of temporary portal vein arterialization (PVA) on hepatic energy metabolism was investigated by changes in the arterial blood ketone body ratio (KBR) and hepatic energy charge (EC) level in 17 dogs. The KBR decreased markedly after clamping the hepatic hilar vessels combining mesocaval shunt and remained at a low level throughout hepatic ischemia. After PVA, the KBR was rapidly restored and maintained at sufficient levels. EC at 60 min after arterialization also recovered to the preclamping level. By reducing the arterial shunt flow, the critical point of arterialized blood flow for maintaining the KBR at high levels was assessed to be about 10% of the total hepatic blood flow (THBF). These findings demonstrate that temporary PVA is an effective method for maintaining the functional capacity of the liver, and that the minimum arterialized blood flow needed to preserve liver viability is only about 10% of the total hepatic blood flow.

Current Management of the Budd-Chiari Syndrome

Twenty-six patients with the Budd-Chiari syndrome were treated surgically at the Johns Hopkins Hospital. Twenty-one of the patients were female and five were male, with a median age at diagnosis of 37 years. Nine patients had polycythemia vera, 6 were receiving estrogen therapy, 5 had a previous hepatitis A or B infection, and 4 had cirrhosis. There was one case each of hepatic malignancy, paroxysmal nocturnal hemoglobinuria, and idiopathic thrombocytopenic purpura. In five cases no etiologic factors or associated disorders were identified. Ascites was the most common presenting feature in this group of patients. Hepatic function at the time of diagnosis, as measured by standard serum chemistries, was only minimally abnormal. The diagnosis of the Budd-Chiari syndrome was confirmed in all 26 patients by hepatic vein catheterization. Inferior vena cavography was also performed and revealed caval occlusion in 4 patients, significant caval obstruction in 13 patients, and a normal vena cava in 9 patients. Interpretation of the vena cavogram was helpful in selecting the appropriate surgical procedure for each patient. Twenty-three of the twenty-six patients underwent percutaneous liver biopsy before operation, with no morbidity or mortality. Four patients had well-established cirrhosis noted on biopsy. Thirty mesenteric-systemic venous shunts were performed on the 26 patients. In 11 patients a mesocaval shunt was performed and in one instance conversion to a mesoatrial shunt was required as a second procedure. In 15 patients a mesoatrial shunt was performed as the initial procedure. Graft thrombosis occurring in 2 of these 15 patients prompted one revision in 1 patient and 2 revisions in the second patient. After mesenteric-systemic venous shunt, eight of the patients (31%) died before discharge from the hospital. The remaining 18 patients in this series were discharged from the hospital alive and well with patent shunts. Patients were followed for a median of 43 months (range, 9 months to 13 years). Five late deaths occurred between 5 and 84 months after the operation. Three- and five-year actuarial survival rates were 65% and 59%, respectively.

Liver transplantation in patients with previous portasystemic shunt

Over a 9-year period, 58 patients who had previous portasystemic shunt procedures underwent orthotopic liver transplantation (OLTx) under a cyclosporine-steroid immunosuppressive regimen. The types of shunt used were distal splenorenal (18 patients), mesocaval (17 patients), end-to-side portacaval (11 patients), side-to-side portacaval (5 patients) and proximal splenorenal (7 patients). The mean interval between shunt and transplantation was 6 years. There was no statistical difference in survival between patients with previous shunts and the entire population of patients with primary liver transplantation performed during the same period of time. Age, sex, shunt patency, status of portal vein, and use of vein or artery graft did not affect survival. Child's classification had a significant influence on graft survival, even though no difference was subsequently observed in patient survival. A progressively improved intraoperative strategy and the use of veno-venous bypass and University of Wisconsin preservation solution had a significant impact on blood loss, length of operation, length of stay in intensive care unit, and ultimately, on survival. Distal splenorenal and mesocaval shunts with no or minimal hilum dissection are safer shunts if subsequent transplantation is planned; in fact, their 9-year survival was 87%, whereas all other shunts were associated with a survival no better than 52% (p less than 0.006).

Surgical procedures for bleeding esophagogastric varices when sclerotherapy fails: A prospective study

In a 7-year period, 692 patients were admitted to the Heinz-Kalk Hospital with bleeding esophageal varices. All patients were first treated with endoscopic sclerotherapy (ES). Fourteen patients exsanguinated during the first 2 hours of admission or refused treatment. Long-term injection sclerotherapy was performed in 311 Child-Pugh C patients. Among the remaining 367 patients, 182 were in class A and 185, class B. In 194 patients, ES was successful. In 173 patients with at least two rebleeding episodes despite long-term sclerotherapy, specific selection criteria were used to assess suitability for a shunt. Eighty-eight patients received a shunt: 54, a narrow-lumen mesocaval (NLMS) shunt; 32, a distal splenorenal shunt; 1, a portacaval shunt; and 1, a proximal splenorenal Linton shunt. There was no significant difference in mortality at 30 days; however, late mortality in the ES group was 36% and in the shunt group, 17%. This difference was statistically significant in favor of the shunt operation (p less than 0.01). Thus, using specific selection criteria, shunt procedures performed in Child-Pugh class A and B patients are the best form of treatment for bleeding esophagogastric varices resistant to long-term ES. Furthermore, the narrow-lumen mesocaval shunt is a good alternative to the distal splenorenal shunt if the latter is technically impossible to perform or hemodynamically not advisable.

Diagnosis and management of the Budd-Chiari syndrome

Occlusion or obstruction of hepatic venous outflow results in the Budd-Chiari syndrome. The disorder should be suspected in any patient who suddenly develops massive ascites, and the diagnosis can be confirmed quickly and accurately by hepatic venography. In the absence of surgical intervention, survival is rare. Inferior venacavography and percutaneous liver biopsy can be performed safely in these patients, and both procedures provide useful information for the selection of appropriate surgical therapy. Most cases of the Budd-Chiari syndrome are amenable to mesocaval or mesoatrial shunting. Those patients with documented cirrhosis or fulminant hepatic failure are best managed by orthotopic liver transplantation.

Ultrasonography and doppler duplex compared with angiography in follow-up of mesocaval shunt patency

Ultrasonography and doppler duplex compared with angiography in follow-up of mesocaval shunt patency

Ultrasonography and Doppler Duplex Compared with Angiography in Follow-up of Mesocaval Shunt Patency

Thirty-four patients with portal hypertension of various etiologies were operated upon with an interposition mesocaval Goretex graft. During a period of 6 years 84 angiographic and ultrasonographic (US) examinations (53 B-mode, and 31 Doppler Duplex) were performed, with few exceptions within 3 days. Angiography served as the ‘gold standard’. Shunt patency was correctly interpreted as normal in B-mode US in 38 examinations. Shunt occlusion, definite or probable, was seen in 12 B-mode examinations, where angiography demonstrated occlusion in 6 and patency in the remaining 6 shunts. Shunt occlusion was not observed sonographically in one examination. US was technically inadequate on two occasions. Doppler Duplex showed shunt patency in all 31 examinations, which was correct according to angiography. Both B-mode US, in 6 out of 6 examinations, and Doppler Duplex, in 7 out of 9 examinations failed to reveal shunt stenosis. Five patients with abundant venous collaterals (in one case with aberrant vascular anatomy) were not possible to evaluate even after the introduction of Doppler Duplex, which otherwise facilitated the evaluation. We suggest that US including Doppler should be the primary modality for follow-up in patients with interposition mesocaval Goretex grafts.

Portal Vein Thrombosis of the Adolescent: Indications for Autologous Internal Jugular Vein Interposition Meso-Caval Shunt

Endoscopic sclerotherapy is now the treatment of first choice for oesophageal varices. However, in spite of its efficiency and safety, recurrent bleeding remains possible and oesophageal sclerosis does not cure other potentially incapacitating symptoms related to portal hypertension. This report describes four adolescents with prehepatic hypertension for whom sclerotherapy was inadequate. They were treated successfully by an autologous internal jugular vein interposition mesocaval shunt. This operation is safe, decompresses the whole splanchnic territory and obviates the need for long term endoscopic surveillance.

Liver Transplantation for Variceal Hemorrhage

At the present time, liver transplantation must be considered among the treatment options for patients with variceal hemorrhage. For a significant percentage of variceal bleeders throughout the world, however, transplantation is not a viable option either because the patient is not an appropriate transplant candidate or because of the etiology of the patient's portal hypertension. Sclerotherapy and portosystemic shunts remain the mainstay of therapy for these patients. The survival rates with liver transplantation are superior to those reported for other therapies for variceal hemorrhage in patients who have moderate or severe liver disease in addition to variceal hemorrhage. Child's C patients whose variceal hemorrhage is controlled medically should be evaluated for transplantation and receive chronic sclerotherapy while they wait on the transplant list. If the variceal hemorrhage cannot be controlled medically in a transplant candidate, then the patient should undergo an emergency shunt procedure. The shunt of choice is a large-bore H-graft mesocaval or mesorenal shunt. This shunt effectively controls the acute hemorrhage, is relatively simple to perform, does not adversely impact on the subsequent liver transplant, and can simply be ligated after the transplant is completed. Patients who experience variceal hemorrhage as the only manifestation of their liver disease should be treated initially with endoscopic sclerotherapy. For that small group of patients who are either not candidates for sclerotherapy or who rebleed despite sclerotherapy, the choice of shunt or transplantation is presently a difficult one, because both therapies provide excellent results in this group of patients. The choice of therapy should be made on an individual basis and only after consultation with both transplant and shunt surgeons. If a shunt is chosen, we prefer the DSRS because it maintains hepatic portal perfusion in many patients and does not require dissection of the porta hepatis. The management of patients with a prior portosystemic shunt at the time of transplantation depends on the type of shunt and the duration of time between the shunt and the transplant. Shunts not involving the hepatic hilum have little adverse impact on the performance of the transplant. There are insufficient data to assess accurately the effect of a prior portacaval shunt on the transplant. However, our clinical experience and that of other transplant groups indicate that the transplantation of these patients is technically more difficult than that of patients with shunts not involving the hilum. With the availability of other shunting procedures that do not involve extensive dissection of the hepatic hilum, there is little role for either end-to-side or side-to-side portacaval shunts in patients who are potential liver transplant candidates.(ABSTRACT TRUNCATED AT 400 WORDS)

The Interposition Mesocaval Shunt

The interposition mesocaval C-shunt is an excellent alternative for the management of bleeding esophageal varices. The comparable operative mortality, long-term survival, and minimal operative time and blood loss make it the emergency shunt of choice. The C-shunt modification has improved long-term patency and ease of operation. The interposition mesocaval shunt also is increasing in importance as the best portosystemic shunt in those patients who may eventually require liver transplantation.