Shunt For Portal Hypertension Research Articles

Transjugular intrahepatic portosystemic shunt in portal hypertension: How to go further while staying on track?

Transjugular intrahepatic portosystemic shunt in portal hypertension: How to go further while staying on track?

Laparoscopic splenectomy and proximal splenorenal shunt for portal hypertension due to portal vein thrombosis in a patient with protein S deficiency

Portal vein thrombosis (PVT) is a rare condition in the general population that develops serious complications if left untreated for long time. We present a case of a 29-year-old woman who developed PVT due to protein S deficiency versus neonatal funiculitis. Over time, the patient developed upper gastrointestinal bleeding due to esophageal varices and hypersplenism with splenic sequestration that caused minor bleeding episodes. Laparoscopic splenectomy and proximal splenorenal shunt with distal pancreatectomy due to aneurysmal dilatations of the splenic artery were successfully performed to avoid mayor progression of portal hypertension. Patient was discharged with indefinite anticoagulation and after surgery platelets raised 3 3 ectomy and proximal splenorenal shunt for portal hypertension due to portal vein ombosis is an adequate surgery procedure which should be applied in these medical cases.

Portosystemic shunt for portal hypertension after Kasai operation in patients with biliary atresia.

Many biliary atresia (BA) patients will eventually develop liver failure even after a successful Kasai portoenterostomy. A common complication of long-term BA survivors with their native liver is problematic portal hypertension. The aim of this study was to defend the view that portosystemic shunts can delay or negate the need for transplantation in these children. A retrospective single center review of the efficacy of portosystemic shunts in BA patients after a successful Kasai portoenterostomy was conducted. From 1991 to 2017, 11 patients received portosystemic shunts. Median age of Kasai operation was 48 (36-61) days. Shunts were performed at the median age of 6.2 (4.1-6.8) years. Three of these eleven patients required subsequent liver transplantation. OS at 5 and 10years were 90.9% and 81.8%, respectively. TFS at 5 and 10years were 90.9% and 72.7%, respectively. Long-term complications included mild encephalopathy in 2 patients, hypersplenism in 3, and cholestasis in 1. Portosystemic shunt for the treatment of portal hypertension in carefully selected BA patients is an effective option in delaying or negating the need for liver transplantation.

Hepatobiliary and pancreatic: Spontaneous splenorenal shunts in portal hypertension

Why do some patients with cirrhosis show spontaneous improvement in features of portal hypertension? The answer is the development of increasing numbers of collateral channels that decompress the portal system and lower portal pressures. Common sites for these collaterals include the gastric cardia, rectum, retroperitoneum and umbilicus. Less commonly, collaterals may involve the left renal vein and, if large, can function as significant portosystemic shunts. Two patients with spontaneous splenorenal shunts are illustrated below. The patient whose image is shown in Fig. 1 was a woman, aged 31 years, who was diagnosed with autoimmune hepatitis at the age of 4 years. She had been taking prednisolone, 5 mg per day, for at least 10 years. On examination, she had a large spleen. Blood tests revealed a low white cell count and platelet count, abnormal coagulation studies and a low plasma albumin (19 g/L). Upper gastrointestinal endoscopy was normal. An abdominal ultrasound study showed splenomegaly and numerous dilated vessels in the splenic hilum but no ascites. She had antegrade portal blood flow (velocity 2.3 cm/s) and a hepatic venous pressure gradient of 8 mmHg. Selective catheterization of the superior mesenteric artery showed the mesenteric vein, a small portal vein, back flow to the splenic vein (black arrow) and a large shunt between the splenic and left renal vein (red arrow). The patient illustrated in Fig. 2 was a male, aged 31, who had portal hypertension because of portal vein thrombosis associated with factor V Leiden mutation. Over a period of 5 years, esophageal varices were treated by endoscopic ligation on several occasions. Subsequently, however, varices appeared to regress spontaneously. Abdominal gray-scale and color-Doppler sonography showed a large splenorenal shunt and this was confirmed by magnetic resonance imaging (arrows). Spontaneous splenorenal shunts appear to be uncommon in adults but may be more common when portal hypertension occurs in children.

ENDO-GIA Staplers for Side-to-Side Anastomosis of Veins

To study the application of ENDO-GIA staplers for the side-to-side anastomosis of veins. An animal study was conducted. Five dogs received side-to-side anastomosis of allograft IVC by ENDO-GIA staplers (Group 1). In addition, five received the same operation with right renal vein reimplantation to allograft IVC (Group 2). Five dogs, receiving the same operation as in Group 1 using polypropylene sutures (control group, Group 3). An autopsy was performed if the dogs survived more than 8 weeks. The IVC anastomosis remained patent in four subjects (80%) for Group 1, in five subjects (100%) for Group 2 and in four subjects (80%) for Group 3. From the results of our experiment, ENDO-GIA staplers can be considered for use in the side-to-side anastomosis of large veins such as piggyback cavacaval side-to-side anastomosis in cadaveric orthotopic liver transplantation (OLT) or side-to-side splenorenal shunt in portal hypertension.

Clinical experience with silicone rubber grafts as shunts in portal hypertension.

We report the use of a woven silicone rubber graft as an alternative prosthesis for a shunt in 8 patients with portal hypertension. Four patients were operated on as emergencies and 4 electively. In 4 cases the graft was used as a standard mesocaval H graft, in 2 as a portocaval H graft and in 2 cases it was used to simplify the Warren selective distal splenorenal shunt. The material has properties which make it a superior graft to existing prostheses and autogenous vein. Our results confirm the experience of others, that the poor risk patients do badly whatever form of shunt is performed, and of those who survive, the total portal shunt carries the risk of postoperative encephalopathy.

Long term follow-up of interposition mesocaval shunting in portal hypertension.

The long term results of 28 interposition mesocaval shunts performed between 1971 and 1975 are analysed over a follow-up period of 5-9 years. There were 6 emergency operations and 22 elective operations, with an overall operative mortality of 14.3 per cent and a 5-year survival for the complete series of 31.5 per cent (class A patients 55.5 per cent, class B 33 per cent and class C 0 per cent). Shunt patency at 7 months was 95 per cent but by 5 years this had fallen to 53 per cent. Further variceal bleeding occurred in 6 patients (31.5 per cent) in 4 of whom shunt occlusion was confirmed.

Surgical technique for inferior mesenteric vein to renal vein shunt in portal hypertension

An important role still exists for the creation of surgical portasystemic shunts. Multiple techniques have been described. However, no particular one is satisfactory for all clinical situations. The objective of the present paper is to describe an alternative surgical technique for the creation of a decompressive portasystemic shunt. This technique consists of an end-to-side anastomosis between the inferior mesenteric vein and the left renal vein. In our experience, the inferior mesenteric vein to left renal vein anastomosis may be a useful portal decompressive shunt for patients with otherwise difficult peri-portal or peri-pancreatic anatomic exposures. This technique should be a useful tool in the armamentarium of surgeons dealing with patients who need portal decompressive surgical shunts.

Binding cells of 125I-iodoamphetamine in rat liver.

We recently reported that transrectal or intestinal portal scintigraphy with 123I-iodoamphetamine (IMP) could be a useful method for the non-invasive and quantitative evaluation of the portosystemic shunt in portal hypertension, but what cells in the liver trap IMP has not been clarified. This study was aimed at elucidating whether IMP was extracted by parenchymal cells, sinusoidal endothelial cells, Kupffer cells or fat storing cells. Each type of liver cell was isolated from rats and cultured. The cells were incubated with 125I-IMP and the radioactivity of the lysate was determined. Nonspecific binding was assessed in the presence of an excess of unlabeled IMP, and specific binding was determined by subtracting the nonspecific from total binding. Specific binding observed in parenchymal cells, endothelial cells and Kupffer cells was 70.2 +/- 0.4, 4.2 +/- 1.4 and 2.3 +/- 0.8 pmol/well, respectively, but no specific binding was observed in fat storing cells. The binding in parenchymal cells was much higher than that in endothelial cells or Kupffer cells (p < 0.005). In addition, the binding to parenchymal cells reached equilibrium within 20 min and was not saturable over the concentration range tested (0.5-10 microM). These findings indicate that IMP is mostly extracted by parenchymal cells in the liver.

Portosystemic shunting in portal hypertension: evaluation with portal scintigraphy with transrectally administered I-123 IMP.

Portosystemic shunting was evaluated with rectal administration of iodine-123 iodoamphetamine (IMP) in seven patients without liver disease and 53 patients with liver cirrhosis. IMP (2-3 mCi [74-111 MBq]) was administered to the rectum through a catheter. Images of the chest and abdomen were obtained for up to 60 minutes with a scintillation camera interfaced with a computer. In all patients, images of the liver and/or lungs were observed within 5-10 minutes and became clear with time. In patients without liver disease, only liver images could be obtained, whereas the lung was visualized with or without the liver in all patients with liver cirrhosis. The portosystemic shunt index was calculated by dividing counts of lungs by counts of liver and lung. These values were significantly higher in liver cirrhosis, especially in the decompensated stage. Transrectal portal scintigraphy with IMP appears to be a useful method for noninvasive and quantitative evaluation of portosystemic shunting in portal hypertension.

Portal pressure correlated to visceral circulation times.

Visceral angiography was performed in 7 patients with normal portal pressure and in 10 with portal hypertension. Circulation times, size of vessels and portal pressure were determined. At celiac angiography a direct correlation was found between time for maximum filling of portal vein and portal pressure, provided no vascular abnormalities existed. At superior mesenteric angiography such a correlation was not found; loss of flow by shunts in portal hypertension being one explanation. Portocaval shunts are common in the celiac system, but uncommon in the superior mesenteric system.

Nonsurgical production of intrahepatic portosystemic venous shunts in portal hypertension with the double lumen balloon catheter

A nonsurgical production of intrahepatic shungs between the left portal and left hepatic vein was evaluated in twelve dogs with acute portal hypertension. Dilatation of the intrahepatic tract was achieved by means of a double lumen balloon catheter introduced into the portal system with the transjugular approach. The shunts proved to be effective in immediate reduction of increased portal pressure and no significant complications were encountered.

Spontaneous portorenal shunting in portal hypertension assessed by a dye dilution technique.

Using a dye dilution technique, blood flow was measured in the right and left renal veins in 12 patients with portal hypertension. There was evidence of spontaneous shunts to the left renal vein in all cases and at least in 4 cases to the right one. Spontaneous portal systemic shunts other than via esophageal varices is probably much higher than hitherto known.

Venous shunts in portal hypertension.

THE USE of shunts between the portal venous system and the vena cava or its branches has become a well-established method of combating the complications of portal hypertension.1The impetus of a reasonable surgical treatment has resulted in an improved understanding of the modes of production of portal hypertension. The frequent disproportion between the level of the portal pressure in intrahepatic disease and the degree of hepatic damage has been studied by Kelty and others.2These workers find that the regeneration of liver cells which improves hepatocellular function adds to the interference with portal blood flow. In cases of extrahepatic portal obstruction, the causes are narrowing down to those of congenital nature and those resulting from inflammation and thrombosis of the portal vein with subsequent organization along various lines. This organization may take the form of a single, extremely thick-walled vessel with small lumen, met with in one

Venous Shunts in Portal Hypertension

Venous Shunts in Portal Hypertension