Splenorenal Shunt Research Articles

Physiological reno-portal bypass in liver transplantation with non-tumorous portal vein thrombosis.

Reno-portal anastomosis (RPA) in presence of spleno-renal shunts (SRS) is a physiological option to restore blood flow in liver transplantation with portal vein thrombosis (PVT). Diffuse splanchnic venous system thrombosis (complex PVT) is its main indication but RPA proved to be useful in selected cases of less extensive thrombosis (non-complex PVT). Up until now only two monocentric and one multicentric case series has been published on this topic in addition to few anecdotal reports. After 2014, we introduced RPA in our institution to manage some cases of complex PVT in presence of SRS. Here, we present the evolution of indication to RPA. From 2014 to 2020, we performed ten RPA: nine patients presented non-complex and one complex PVT. Overall early and late complication rates were 66.6% and 50%, respectively. Two patients developed RPA stenosis, treated by interventional radiology. Self-resolving acute kidney injury (AKI) was observed in three cases. No re-transplantation was necessary. RPA was patent in all patients, with a mean follow-up of 41.9months. The overall patient survival was 70% at 1year and 60% at 3 and 5years. Four patients died at 1, 2, 3 and 20months from LT. Causes of deaths were, respectively, stroke, cerebral infection, sepsis (MOF) and sudden variceal bleeding in sinusoidal obstruction syndrome. The relative simplicity and effectiveness of RPA in presence of SRS allowed us to rely more and more often on this technique in liver transplantation with challenging non-complex PVT.

Application of proximal splenic vein embolization to interrupt complicated large splenorenal shunts in adult living donor liver transplantation

Application of proximal splenic vein embolization to interrupt complicated large splenorenal shunts in adult living donor liver transplantation

A Case of Acquired Hepato-Cerebral Degeneration after Splenorenal Shunt from Ethiopia

Acquired hepato-cerebral degeneration (AHD) is a neurologic syndrome caused by liver dysfunction and long-standing portosystemic shunting. There is scarce and conflicting information regarding the clinical course of AHD. We report the case of a 25-year-old male who underwent splenectomy and splenorenal shunt for recurrent UGIB 20 to Esophageal varices 20 to Non-Cirrhotic portal hypertension 20 to Non-Cirrhotic portal fibrosis and hypersplenism, in Mumbai, India. He presented with slow movement, hypophonia, gait instability, and rigidity of the lower extremities. In this paper, we discuss the patient’s case with literature review.

OUTCOMES OF PROXIMAL SPLENORENAL SHUNT SURGERY IN EXTRA HEPATIC PORTAL VEIN OBSTRUCTION (EHPVO) – EXPERIENCE FROM A TERTIARY CENTER IN GUJARAT, INDIA.

Background – Extra hepatic portal vein obstruction commonly presents with variceal bleeding and splenomegaly. Management with endoscopic means provide temporary palliation. A proximal splenorenal shunt is a denitive procedure with good results. Our aim was to evaluate the outcomes of splenectomy with proximal splenorenal shunt in patients with extrahepatic portal venous obstruction. Methods – The records of all patients with diagnosis of EHPVO who were operated for splenectomy with proximal splenorenal shunt during the period from January 2014 to august 2018 were analysed. Total of 34 patients with EHPVO were operated for splenectomy with proximal splenorenal shunt over the study period. Outcomes were evaluated in term of rebleeding, variceal regression shunt thrombosis and post shunt encephalopathy. Results – All the patients were below 30 years age. Shunt surgery lead to reversal of various degree of cytopenias and hypersplenism. Variceal regression was seen from large size (grade III and IV) to small size (grade II) in 74% of patients. We had low incidence of shunt block (5.88%), variceal rebleeding (2.94%) and no mortality. None of the patients developed encephalopathy during follow-up. Conclusion- Splenectomy with proximal splenorenal shunt is a single time safe procedure, with low morbidity and mortality; having low rates of variceal rebleeding and encephalopathy; with low cost in teaching hospital, thus can be considered as the main treatment approach in patients with EHPVO.

Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study.

Backgrounds/AimsProximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis.MethodsThis was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ2 test.ResultsEighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group.ConclusionsCP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

Introduction and objectivesSpontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT). PatientsWe identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected. ResultsAt presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12). ConclusionsSPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.

Functional side-to-side splenorenal shunts to treat extrahepatic portal vein thrombosis in children

BackgroundSurgical shunts are commonly used to manage complications resulting from extrahepatic portal vein thrombosis (EHPVT) in children. We describe a single-center experience utilizing a functional Side-to-Side Splenorenal Shunt (fSRS), created using either an enlarged inferior mesenteric vein (IMV) or left adrenal vein (LAV). MethodsPediatric patients with isolated EHPVT who were poor candidates for a Rex shunt and who underwent a fSRS procedure at our institution between 2003 and 2020 were reviewed. The pre/post shunt portosystemic gradient change, rates of early and late complications, postoperative shunt patency, and mortality were evaluated. ResultsTwelve EHPVT patients (mean age of 6.1 years) underwent a fSRS procedure. The mean portosystemic gradient change for the cohort was −11.7 mmHg (±4.9). There were no cases of recurrent variceal bleeding or episodes of shunt thrombosis reported after fSRS procedures. ConclusionsSurgical shunts continue to be an important adjunct in the treatment of complications related to EHPVT. The functional Side-to-Side Splenorenal Shunt is a safe alternative that is easy to perform, involves minimal dissection and requires only a single anastomosis.

Application of Proximal Splenic Vein Embolization to Interrupt Complicated Large Splenorenal Shunts in Adult Living Donor Liver Transplantation

Introduction: In adult living donor liver transplantation (ALDLT) for a patient who has large splenorenal shunts (SRS), their interruption is utmost important to maintain adequate portal flow by avoidance of portal steal through the preexisting SRS. We effectively managed most of the recipients with surgical ligation and/or additional radiologic embolization using by intraoperative cine-portogram (IOP). However, when complete interruption is not achieved in a few recipients having complicated large SRS, it may leave a chance of lethal portal flow steal afterwards. The aim of study is to evaluate efficacy and safety of proximal splenic vein embolization (PSVE) for recipients having complicated large SRS. Method: PSVE was performed in 13 patients between April 2014 and November 2017. We performed a retrospective analysis of preoperative images, postoperative graft and recipient outcomes, and presence of isolated portal hypertension. Results: Ten patients underwent PSVE as an additional secondary method because of for portal steal syndrome through the remaining SRS after surgical interruption and/or embolization, and 3 patients underwent PSVE only as a primary method of SRS interruption. In all 13 patients, portal steal on the final IOP completely disappeared after PSVE. All patients recovered with satisfactory regeneration of the partial liver graft without the reappearance of portosystemic collaterals, and there were no procedure-related complications. Conclusion: PSVE is an effective and safe procedure to secure adequate portal flow without portal steal for patients with complicated large SRS arising from multiple sites of the splenic vein or escaping to multiple terminal ends.

Extrahepatic Portal Vein Thrombosis in Childhood: Risk Factors, Clinical Manifestations, and Management

Objective: Extrahepatic portal vein thrombosis (EHPVT) is a common cause of portal hypertension in children. The aim of the present study was to identify the clinical manifestations and the risk factors for development of EHPVT in pediatric patients. Subjects and Methods: This was a single-center retrospective cohort study. A total of 12 children (6 boys and 6 girls) took part in the study. We noted the clinical presentations and the predisposing risk factors for development of EHPVT in all patients. In addition, as all of them had undergone an esophagogastroduodenoscopy for detection and grading of esophageal varices as part of the treatment algorithm, we analyzed the endoscopic findings and the therapeutic approach. Results: The median age of subjects at diagnosis was 3.5 years (range: 1–17 years). The most frequent initial clinical manifestation was upper gastrointestinal bleeding (6 cases, 50.0%) followed by splenomegaly (3 cases, 25.0%). The most frequent systemic risk factor for EHPVT was presence of inherited prothrombotic disorder (10 cases, 83.3%), and the most common local risk factor for EHPVT was umbilical vein catheterization (5 cases, 41.7%). Esophageal varices were revealed in all the study participants, and in the most cases, they were grade ≥2. Propranolol was used as primary or secondary prophylaxis in 7 children (58.3%), and in 5 children (41.7%), a shunt was performed (Meso-Rex bypass in 3 children and splenorenal shunt in 2 children). Conclusion: Patients with known systemic or local risk factors for EHPVT are indicated for proactive ultrasound screening for early diagnosis and timely management.

Microbiota transplants from feces or gut content attenuated portal hypertension and portosystemic collaterals in cirrhotic rats.

Liver cirrhosis and portal hypertension is the end of chronic liver injury with hepatic, splanchnic and portosystemic collateral systems dysregulation. Liver injury is accompanied by gut dysbiosis whereas dysbiosis induces liver fibrosis, splanchnic angiogenesis and dysregulated vascular tones vice versa, making portal hypertension aggravated. It has been proved that intestinal microbiota transplantation alleviates dysbiosis. Nevertheless, the influences of microbiota transplantation on cirrhosis-related portal hypertension are not so clear. Liver cirrhosis with portal hypertension was induced by bile duct ligation (BDL) in rats. Sham rats were surgical controls. Rats randomly received vehicle, fecal or gut (terminal ileum) material transplantation. The results showed that microbiota transplantation from feces or gut material significantly reduced portal pressure in cirrhotic rats (P=0.010, 0.044). Hepatic resistance, vascular contractility, fibrosis and relevant protein expressions were not significantly different among cirrhotic rats. However, microbiota transplantation ameliorated splanchnic hyperdynamic flow and vasodilatation. Mesenteric angiogenesis, defined by whole mesenteric window vascular density, decreased in both transplantation groups and phosphorylated endothelial nitric-oxide synthase (eNOS) was down-regulated. Portosystemic shunts determined by splenorenal shunt (SRS) flow decreased in both transplantation groups (P=0.037, 0.032). Shunting severity assessed by microsphere distribution method showed consistent results. Compared with sham rats, cirrhotic rats lacked Lachnospiraceae. Both microbiota transplants increased Bifidobacterium. In conclusion, microbiota transplantation in cirrhotic rats reduced portal pressure, alleviated splanchnic hyperdynamic circulation and portosystemic shunts. The main beneficial effects may be focused on portosystemic collaterals-related events, such as hepatic encephalopathy and gastroesophageal variceal hemorrhage. Further clinical investigations are mandatory.

First Clinical Experience of Venous Reconstruction With Autologous Vascular Prosthesis From the Sickle Ligament of the Liver With Partial Portosystemic Bypass Surgery

Aim of study. Presentation of our own first clinical experience of venous reconstruction in portosystemic bypass surgery with the use of autologous vascular prostheses of the falciform ligament of the liver in the splenorenal position in a patient with portal hypertension syndrome in the outcome of liver cirrhosis of viral etiology.Material and methods. Clinical observation of a patient born in 1978 with a diagnosis of cirrhosis of the liver of viral etiology (HCV) Child-Pugh A (6). MELD 10 points. Inactive phase. Intrahepatic portal hypertension syndrome. Esophageal varices grade III according to A. G. Scherzinger, gastric varices type I (GOV1) according to Sarin. Condition after repeated recurrent esophageal-gastric bleeding. Due to the high risk of another bleeding, as a secondary prevention of esophageal-gastric bleeding, partial splenorenal anastomosis of “H” - type was performed with the use of an autologous vascular prosthesis of the falciform ligament of the liver in the splenorenal position.Results. A flap measuring 60.0x20.0 mm was cut from the falciform ligament of the patient’s liver. From the latter, after adjusting the size of the graft to the individual needs of the patient, an autologous conduit was formed. It was used as an insert in the formation of an “H” - type splenorenal anastomosis with the imposition of two end-to-side anastomoses between the splenic vein and one end of the conduit and between the left renal vein and the other end of the conduit. The patency of the anastomosis was checked using intraoperative sonography. In a satisfactory condition, the patient was discharged for outpatient follow-up treatment at the place of residence. At the moment of writing the article, the follow-up period was 8 months. The bleeding did not recur. No varicose veins were found in the esophagus and stomach during control endoscopic examinations. The patency of the splenorenal shunt was confirmed by ultrasound dopplerography.Conclusion. The first clinical experience of venous reconstruction with portosystemic bypass surgery using as a possible replacement of autologous vascular prostheses of the falciform ligament of the liver in the splenorenal position in a patient with portal hypertension syndrome in the outcome of cirrhosis of the liver of viral etiology gives hope for the possibility of further successful testing of this method of splenorenal bypass surgery to reduce the risk of bleeding from varicose veins.

Clip-Assisted Endoscopic Cyanoacrylate Injection: A Novel Technique for Acute Gastroesophageal Variceal Bleeding.

Background and Aim: Endoscopic injection sclerotherapy is effective for the treatment of gastric variceal bleeding, but may cause fatal ectopic embolism. Spontaneous portosystemic shunts are one of the risk factors for ectopic embolism. This present study aims to evaluate the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection for the treatment of acute gastroesophageal variceal bleeding. Methods: The medical records of patients with gastroesophageal varices (GOVs) who underwent clip-assisted cyanoacrylate injection at the Ningbo First Hospital from March 2017 to August 2020 were reviewed. The outcomes were immediate hemostasis rate, early rebleeding rate, late rebleeding rate, and procedure-related complications. The gastrorenal and splenorenal shunts were evaluated by the computed tomography angiography. Results: A total of 9 patients with GOVs (GOV1 and GOV2) were analyzed, and 4 of the patients had spontaneous portosystemic shunts. The average number of clips used in each patient was 2.11 ± 1.96, and an average of 5.11 ± 1.76 mL of cyanoacrylate was injected into each patient. All patients completed immediate hemostasis. Two patients experienced rebleeding, including 1 case of early rebleeding and 1 case of late rebleeding (both due to cyanoacrylate extrusion) during a median follow-up of 367 days (interquartile range 270-855 days). Five patients underwent follow-up endoscopy; eradicated gastric varices (GVs) were revealed in 1 patient, and shrunken GVs were found in 4 patients. No serious complications, including ectopic embolism, were observed. Conclusion: The present study showed the efficacy and safety of clip-assisted endoscopic cyanoacrylate injection in acute GOV bleeding, but these results require verification by randomized controlled studies with larger sample numbers.

ЭФФЕКТИВНОСТЬ СПЛЕНОРЕНАЛЬНОГО ШУНТИРОВАНИЯ В ЛЕЧЕНИИ ДОПЕЧЕНОЧНОЙ ФОРМЫ ПОРТАЛЬНОЙ ГИПЕРТЕНЗИИ У ДЕТЕЙ

Objective. To evaluate the results of treatment of prehepatic portal hypertension (PPH) in children by method of side-to-side splenorenal bypass. Methods. A retrospective, monocentric analysis of 114 patients with prehepatic portal hypertension was carried out in the period from 2000 to 2018. The age of the patients was from 6 months up to 18 years, the average age 10,1±3,8 years (M±σ). All patients underwent side-to-side splenorenal shunt. In the postoperative period, on the 7<sup>th</sup> day, ultrasound examination of the abdominal organs with Doppler sonography (US) was performed to assess the volume of the spleen, the rate of portohepatic perfusion, the rate of blood flow along the side-to-side splenorenal shunt, as well as to assess its diameter. Control US was performed after the 1<sup>st</sup>, 3<sup>rd</sup>, 6<sup>th</sup>, 12<sup>th</sup> months; to assess the regression of esophageal and gastric varicose veins, the control esophagogastroduodenoscopy (EYD) was performed after 3<sup>rd</sup> , 6<sup>th</sup>, 12<sup>th</sup> months and then once a year. Subsequently, the control examination of the patients was carried out once a year. The follow-up was 2-18 years. Results. Out of 114 patients who underwent side - to - side splenorenal shunt, 5 (4,4%) patients had recurrent bleeding from the esophageal variceal vein at the follow-up period (2-18 years). One patient had intra-abdominal arrosive bleeding from side-to-side splenorenal shunt provoked by severe postoperative pancreatitis. The average diameter of the shunt was 12±1.9 mm. The spleen volume decreased by 39.7±10.3%. Portohepatic perfusion reduced by 39% in comparison with the indicators before surgery. The blood flow rate along the side -to-side splenorenal shunt was 2403±557.3 ml/min. in 95,4% of patients the regression of variceal vein was noted. Hypersplenism syndrome was arrested in 73.6% of children. Conclusion. Side -to- side splenorenal shunt is considered to be an effective method of portal decompression with the effectiveness inpreventingboth esophageal and gastricvariceal veins bleeding in 95,4% of patients. What this paper adds The results of treatment of the prehepatic portal hypertension by method of side-to-side splenorenal shunt have been firstly analyzed, and the effect of this variant of portosystemic shunt on portohepatic perfusion has been assessed. It has been established that this option of shunt is effective for the portal system decompression and occupies an intermediate position between selective and total variant of portosystemic shunt.

Splenorenal shunt for reconstruction of the gastric and splenic venous drainage during pancreatoduodenectomy with resection of the portal venous confluence

BackgroundResection of the portal venous confluence is frequently necessary for radical resection during pancreatoduodenectomy for cancer. However, ligation of the splenic vein can cause serious postoperative complications such as gastric/splenic venous congestion and left-sided portal hypertension. A splenorenal shunt (SRS) can maintain gastric and splenic venous drainage and mitigate these complications.PurposeThis study describes the surgical technique, postoperative course, and surgical outcomes of SRS after pancreatoduodenectomy.MethodsTen patients who underwent pancreatoduodenectomy and SRS between September 2017 and April 2019 were evaluated. After resection an end-to-side anastomosis between the splenic vein and the left renal vein was performed. Postoperative shunt patency, splenic volume, and any SRS-related complications were recorded.ResultsThe rates of short- and long-term shunt patency were 100% and 60%, respectively. No procedure-associated complications were observed. No signs of left-sided portal hypertension, such as gastrointestinal bleeding or splenomegaly, and no gastric/splenic ischemia were observed in patients after SRS.ConclusionSRS is a safe and effective measure to mitigate gastric congestion and left-sided portal hypertension after pancreatoduodenectomy with compromised gastric venous drainage after resection of the portal venous confluence.

P-125 REX SHUNT IN A DEVELOPING COUNTRY – IS IT POSSIBLE?

Extrahepatic portal vein obstruction (EHPVO) is a frequent cause of noncirrhotic portal hypertension in children. Describe the experience in the surgical treatment of EHPVO in children, in a developing country. Retrospective case series study, with medical records review of patients with EHPVO, who underwent surgical treatment, by an experienced surgeon, between July 2016 and May 2019. Patient profile, laboratory test, images, liver histology, surgery performed, postoperative complications and shunt patency were analysed. 12 patients, median age of 4 years, umbilical catheterization was present in 8 patients (66,6%). Ten patients performed portography, and 60% had type A by Baveno VI criteria. Despite normal liver tests, liver biopsy revealed ductular proliferation in 83,3% of patients and mild portal fibrosis in 66,7%. Splenomegaly was present in 91,7% and thrombocytopenia in 83,3%. All patients had oesophageal varices and gastrointestinal bleeding occurred in 83,3%. Among the coagulation tests, the deficiency of C and S proteins is noteworthy in most patients, with 72,3% and 63,6% respectively. It was possible to perform meso-Rex bypass in 10 patients (83,3%); in the other 2 distal splenorenal shunt was performed. Early post-operative complications occurred in 58,3% of patients, the most common was ascites in 4 (33,3%), which resolved in less than 1 month. One patient developed shunt thrombosis in the first 7 days after surgery, not resolved with thrombectomy. In outpatient follow-up one patient developed thrombosis in the Rex shunt and another 4 had stenosis. All of them underwent to interventional radiology. Currently 8 of 10 meso-Rex patients (80%) have patent shunt. Rex shunt is possible in developing countries with an experienced surgeon and multidisciplinary team.

ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ РЕБЕНКА С ОВАРИКОВАРИКОЦЕЛЕ НА ФОНЕ СИНДРОМА ПОРТАЛЬНОЙ ГИПЕРТЕНЗИИ

A complex case report of the diagnosis and surgical correction of ovaricovaricocele (OVC) in a girl with portal hypertension syndrome is presented. The disease manifested itself with symptoms atypical for portal hypertension – dysmenorrhagia and persistent recurrent pelvic pain. The cause of OVC was thrombosis of the left renal vein after splenorenal shunt. Venous hypertension of the left kidney persisted even after creating a mesenteric-caval anastomosis and improving portal hemodynamics. Left-sided ovarian-caval shunt was made with a good clinical effect, which was confirmed by angiography.

Wandering splenomegaly reduction after splenopexy.

Introduction and importanceA wandering spleen is characterized by excessive splenic mobility due to the laxity of its ligaments, which leads to spleen migration and its long mobile vascular pedicle is liable to torsion. The purpose of this paper was to present a wandering splenomegaly reduction after splenic detorsion and splenopexy.Case presentationA 14-year-old boy presented a symptomatic visible pelvic wandering splenomegaly with torsion of the splenic pedicle. He was submitted to laparotomy, detorsion of the spleen, and splenopexy to the left diaphragm and surrounded peritoneum. The patient had an uneventful follow-up and was discharged from the hospital on the second postoperative day. All laboratory exams went to normal. The size of the spleen reduced from the 22 × 16 × 13 cm before the treatment to 14 × 12 × 10 cm after the surgical procedure.Clinical discussionThe most relevant aspect of this communication is the reduction of the huge splenomegaly to a normal size spleen after detorsion of the splenic vessels and splenopexy to the left diaphragm. Reduction of the splenic size is well-known after distal splenorenal shunt, but this is the first publication of a spontaneous splenic size reduction after treating a congestive wandering splenomegaly by detorsion of the spleen pedicle.ConclusionEctopic congestive splenomegaly due to the splenic pedicle rotation is adequately treated by splenic detorsion and splenopexy in its proper subdiaphragmatic site, which reduces the splenic size to normal.

Collaterals in portal hypertension: anatomy and clinical relevance.

Portal hypertension is a key pathophysiology of chronic liver diseases typified with cirrhosis or noncirrhotic portal hypertension. The development of collateral vessels is a characteristic feature of impaired portal hemodynamics. The paraumbilical vein (PUV), left gastric vein (LGV), posterior gastric vein (PGV), short gastric vein (SGV), splenorenal shunt (SRS), and inferior mesenteric vein (IMV) are major collaterals, and there are some rare collaterals. The degree and hemodynamics of collateral may affect the portal venous circulation and may compensate for the balance between inflow and outflow volume of the liver. Additionally, the development of collateral shows a relation with the liver function reserve and clinical manifestations such as esophageal varices (EV), gastric varices, rectal varices and the other ectopic varices, hepatic encephalopathy, and prognosis. Furthermore, there may be an interrelationship in the development between different collaterals, showing additional influences on the clinical presentations. Thus, the assessment of collaterals may enhance the understanding of the underlying pathophysiology of the condition of patients with portal hypertension. This review article concluded that each collateral has a specific function depending on the anatomy and hemodynamics and is linked with the relative clinical presentation in patients with portal hypertension. Imaging modalities may be essential for the detection, grading and evaluation of the role of collaterals and may help to understand the pathophysiology of the patient condition. Further investigation in a large-scale study would elucidate the basic and clinical significance of collaterals in patients with portal hypertension and may provide information on how to manage them to improve the prognosis as well as quality of life.

Renoportal anastomosis in adult-to-adult living donor liver transplantation for patients with portal vein thrombosis in single center experience

The anastomosis between the left renal vein and graft portal vein is one of the crucial options in patients with end-stage liver disease with portal venous thrombosis and a previous splenorenal shunt. However, especially in living donor liver transplantation (LDLT) practice, limited cases are published in the literature. Between January 2006 and December 2019, a total of 14 patients underwent adult LDLTs with renoportal anastomosis (RPA). The long-term outcomes were evaluated by reviewing the medical records of the 14 patients. Of the 14 patients who received adult LDLTs with RPA, 2 patients underwent end-to-end (E-to-E) RPA using left renal vein (LRV), 5 patients underwent side-to-end (S-to-E) RPA, and the rest underwent E-to-E RPA using LRV connected IVC cuff. Except two patients who died from cerebral hemorrhage and graft failure came from acute cellular rejection, twelve patients has maintained normal graft function and a patent RPA at a median follow-up of 42 months (range, 1-155 months). RPA can be performed safely and effectively in LDLT as an acceptable and life-saving procedure for patients with end-stage liver disease with portal venous thrombosis and a previous splenorenal shunt. According to our experience, E-to-E RPA using LRV connected IVC cuff is the best option considering feasibility and safety.

Unconventional Shunts in Extrahepatic Portal Venous Obstruction—A Retrospective Review

Proximal splenorenal shunt (PSRS) is one of the most commonly performed portosystemic shunt (PSS) in extrahepatic portal venous obstruction (EHPVO) for portal decompression. Sometimes various anatomical and surgical factors related to the splenic veinand/or left renal veinmay make the construction of a PSRS difficult or impossible. Unconventional shunts are required to tide over such conditions. From January 2008 to December 2018, 189 patients with EHPVO underwent PSS, of which, the 10 patients who underwent unconventional shunts form the study group of this paper. The ten unconventional shunts included 8 proximal splenoadrenal shunts, one collateral-renal shunt, and one inferior mesenteric vein to inferior vena cava (IMV-Caval) shunt. The mean percentage drop in omental pressure was 34.2% post-shunt with a mean anastomotic diameter of 13.7±3.1mm. Three patients experienced some form of postoperative complication. With a mean follow-up period of 32.3 months (maximum of 111 months) all patients had patent shunts on follow-up Doppler. None of the patients had variceal bleed, or features of biliopathy and hepatic encephalopathy in follow-up. Unconventional shunts can be used safely and effectively with good postoperative outcomes in EHPVO.