Splenorenal Shunt Research Articles

Distal splenorenal and mesocaval shunting at the time of pancreatectomy

BackgroundWhen pancreatic neoplasms occlude or encase the superior mesenteric-portal-splenic vein confluence with abutment of the posterior lateral wall of the superior mesenteric artery, a mesocaval shunt with or without a distal splenorenal shunt allows for safe dissection of the porta hepatis and separation of the pancreatic tumor from the superior mesenteric artery. Herein we report long-term results of the largest known series of portosystemic shunts performed at the time of pancreatectomy. MethodsAll patients who underwent pancreatic resection with a mesocaval shunt or distal splenorenal shunt were identified from our prospective database. Demographics, perioperative treatment, and outcomes were reviewed. ResultsA total of 34 patients underwent mesocaval shunt or distal splenorenal shunt, including 25 at the time of pancreatoduodenectomy, 6 during total pancreatectomy, and 3 after prior pancreatectomy. There were 15 mesocaval shunts, 16 distal splenorenal shunts, 2 combined mesocaval/distal splenorenal shunts, and 1 distal splenoadrenal vein shunt. The mesocaval group included 11 temporary and 6 permanent (3 delayed) shunts. Median operative time was 9 hours (range 6.5–13), median estimated blood loss was 950 mL (range 200–5,000), and median duration of hospital stay was 11 days (range 7–35). Four patients experienced complications that required intervention (Clavien-Dindo grade ≥III), but there were no 90-day mortalities. For patients with adenocarcinoma, median overall survival was 31 months at a median follow-up of 19 months. All but 1 shunt (distal splenorenal) were patent at last follow-up. ConclusionMesenteric venous shunting facilitates a safe and complete tumor resection in patients who require a complex pancreatectomy, many of whom would otherwise be deemed inoperable.

Laparoscopic ligation of a congenital extrahepatic portosystemic shunt for children with hyperammonemia: a single-institution experience.

A congenital extrahepatic portosystemic shunt (CEPS) associated with hyperammonemia requires occlusion of the shunt vessels. We evaluated the effectiveness and safety of laparoscopic ligation of a CEPS in children with hyperammonemia. The subjects of this retrospective study were seven children with hyperammonemia who underwent laparoscopic ligation of a CEPS. Their median age was 5.2years (range 1-16years). Before the laparoscopic procedure, a catheter was inserted through the femoral vein and placed in the portal vein via the shunt vessel. The shunt vessel was dissected and taped laparoscopically. After measuring the portal vein pressure under temporal occlusion, the shunt vessels were ligated. The types of shunts according to location were patent ductus venosus (n = 2), splenorenal shunt (n = 2), gastrorenal shunt (n = 2), and superior mesenteric vein-inferior vena cava shunt (n = 1). Laparoscopic ligation of the shunt vessel was completed uneventfully in all patients. The median portal vein pressure was 19mmHg after ligation. The median preoperative blood ammonia level was 94µg/dL (range 71-259µg/dL), which decreased after ligation in all patients. There was no incidence of postoperative liver failure. Laparoscopic ligation of a CEPS is safe and effective for children with hyperammonemia.

Hepatic arterialization can predict the development of collateral veins in patients with HCV-related liver disease

PurposeArrival time parametric imaging (At-PI) using contrast-enhanced ultrasonography (CEUS) is a procedure for evaluating liver disease progression in chronic hepatitis C infection (CHC). We investigated At-PI diagnostic efficacy in predicting development of collateral veins.MethodsIn total, 171 CHC patients underwent CEUS and upper gastrointestinal (UGI) endoscopy before liver biopsy. Conventional US was performed before CEUS to identify paraumbilical veins (PV) or splenorenal shunts (SRS). After intravenous perflubutane, contrast dynamics of liver segments 5–6 and the right kidney were saved as raw data. At-PI image ratio of red (ROR) pixels to the entire liver was analyzed. Receiver operating characteristic (ROC) curves were generated to investigate the utility of At-PI for collateral vein identification.ResultsConventional US revealed PV in two patients and SRS in five patients; UGI endoscopy detected esophageal varices (EV) in eight patients. Diagnostic capability of At-PI for detecting PV, SRS, and EV was satisfactory, and high for PV and SRS [PV; area under the ROC curve (AUROC) 0.929, cutoff value 77.9%, SRS; AUROC 0.970, cutoff value 82.0%, EV; AUROC 0.883, cutoff value 66.9%].ConclusionsEvaluation of hepatic arterialization by At-PI was useful for predicting collateral vein development in CHC patients.

Rare Complications of Portal Hypertension in a Patient With Underlying Focal Nodular Hyperplasia

Introduction: Esophageal variceal ligation (EVL) and sclerotherapy are both considered standards of care in management of esophageal variceal hemorrhage. Minor complications are not uncommon but occasionally, severe and potentially life-threatening sequelae may develop. Case presentation: Patient is a 30-year-old female with history of variceal bleeding due to portal hypertension secondary to noncirrhotic focal nodular hyperplasia (FNH) and resultant portal vein thrombosis that began at age 13 until she underwent banding at age 20. She was also treated with a splenorenal shunt as well as a superior mesenteric vein to inferior vena cava shunt to help reduce portal venous pressure. Evaluation for anemia with esophagogastroduodenoscopy (EGD) revealed an extremely large esophageal varix in the distal esophagus with active bleeding, which initially improved with sclerotherapy. Ten days after, she vomited blood and fainted. Methods: Repeat EGD noted profuse variceal bleeding, requiring intubation for airway protection. Attempts to band the varices were unsuccessful, requiring repeat sclerotherapy. 27 mL of sodium tetradecyl was injected throughout the esophagus. Post-procedure chest X-ray revealed a large left-sided pneumothorax, requiring a chest tube, and esophageal perforation. Portal venous shunt was attempted; however, the anastomosis was thrombosed, so the cryopreserved vein was ligated. Post-operative esophagram showed no obvious leak. CT chest/abdomen/pelvis showed bilateral pleural effusions. Left pigtail catheter was placed and drained 150 mL and grew E. faecalis as well as Candida kefyr; patient was placed on zosyn and fluconazole. Results: Patient was transferred to medical ICU intubated on CPAP, hemodynamically stable. Patient recovered with all catheters removed following prolonged antimicrobial support. She was stable on discharge and placed on beta blocker therapy without further incident. Conclusion: This case is unusual for many reasons. Firstly, the etiology of portal hypertension secondary to FNH; secondly, the continuous complications of portal hypertension despite previous shunting; and thirdly, her development of a massive upper gastrointestinal bleed a week after successful EVL. Although sclerotherapy is still occasionally used after unsuccessful EVL, we must be cognizant of rare but potentially devastating complications. For this patient, prompt recognition followed by appropriate and aggressive management fortunately resulted in a successful outcome with long-term survival.

Impact of portal vein resection with splenic vein reconstruction after pancreatoduodenectomy on sinistral portal hypertension: Who needs reconstruction?

Resection of the porto-mesenterico-splenic confluence is at times necessary during pancreatoduodenectomy with portal vein resection for pancreatic cancer. Although splenic vein ligation can cause sinistral portal hypertension, the incidence of clinically relevant sinistral portal hypertension remains unknown, and the roles of the preservation of potential collateral veins and splenic vein reconstruction are controversial. Patients with pancreatic cancer who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection were assessed for incidence of development of varices by computed tomography at 6 months after pancreatoduodenectomy. We evaluated the risk factors for sinistral portal hypertension and the impact of splenic vein reconstruction on sinistral portal hypertension. Of the 118 patients who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, 31 (26%) underwent splenic vein reconstruction, 44 patients (37%) developed gastroesophageal varices, and 5 (11%) experienced varix rupture. Sacrifice of all 3 potential collateral veins (what we refer to as the critical veins: left gastric vein, middle colic vein, and superior right colic vein arcade) and absence of any spontaneous splenorenal shunt had a substantial impact on formation of varices. The risk of variceal formation could be stratified based on the number of preserved critical veins, and patent splenic vein reconstruction was associated with a decreased incidence of varices (60% versus 100%, P = .018) among the patients without preservation of the critical veins. In contrast, patients with multiple intact critical veins developed no varices, regardless of splenic vein reconstruction. Sinistral portal hypertension is not uncommon after pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, and the number of preserved critical veins helps to predict the risk of sinistral portal hypertension. Thus, the indication for splenic vein reconstruction should be tailored according to individual risk factors.

Measurement of Inferior Vena Cava to Shunt Distance in Deciding Access Route for Balloon-Occluded Retrograde Transvenous Obliteration Procedure: A Pilot Study

Purpose: Why and how to decide whether femoral or jugular approach should be used for shunt catheterization for a successful balloon-occluded retrograde transvenous obliteration (BRTO) procedure. Materials and Methods: Sixteen patients had undergone BRTO for variceal bleeding (11 cases) and encephalopathy (5 cases) with the femoral (13) and jugular approach (5). In two patients, both femoral and jugular approaches were used. There were four failed shunt catheterizations with the femoral or jugular approach two each. In all patients, the inferior vena cava (IVC) to shunt distance (ISD) was measured on the reformatted coronal computed tomography image. Results: The IVC to shunt distance (ISD) was between 2.0 and 3.5 cm in 13 patients and >3.5 cm in five. Two patients were having both proximal gastrorenal and distal splenorenal shunts. The ISD was >3.5 cm in two patients with failed initial femoral approach and < 3.5 cm in two other patients with failed initial jugular approach. In each of the four failures, the alternative approach resulted in obtaining a successful BRTO. Conclusion: The femoral approach is recommended for catheterization of the gastrorenal shunt for BRTO when the shunt joins the renal vein within 3.5 cm from the IVC. However, when the shunt is farther than 3.5 cm from the IVC, the jugular approach is suitable for a BRTO procedure.

Coronary Renal Shunt with Splenectomy (CRSS) for Selective Variceal Decompression

Distal splenorenal shunt and coronary caval shunt are commonly used for selective decompression of esophagogastric varices, but they may not solve severe hypersplenism and their application may be hampered by the presence of splenic venous thrombosis or a left gastric vein (LGV) situated deeply behind the pancreas. On the other hand, some patients have an LGV entering the splenic vein (SV). We tried to work out a new selective shunt for this group of patients. Sixteen patients with severe hypersplenism and esophagogastric varices received coronary renal shunt using the SV following splenectomy. After splenectomy, the proximal portion of the SV and the LGV was isolated from the pancreas. The isolated SV was divided at a point 3-5cm left to its junction with the LGV. The proximal orifice was anastomosed to the left renal vein, and the distal orifice was ligated. A clip was applied to the SV for occlusion between the portal vein and LGV. The right gastric and gastroepiploic vessels were divided to block backflow from the portal vein and to reduce the arterial inflow of the varices. No operative mortality or procedure-related complications occurred. Postoperative computed tomography and endoscopy showed that all the shunts were patent and that the varices had been obliterated or markedly alleviated. In the 6-36months' follow-up period, no recurrent variceal hemorrhage or encephalopathy occurred. Coronary renal shunt combined with splenectomy can achieve the goal of selective decompression of esophagogastric varices. It would become an alternative means of selective variceal decompression for patients whose LGV enters the SV.

Distal splenorenal and mesocaval shunting at the time of pancreatectomy: an important adjunct to the operative management of selected patients

Background: We previously provided proof that pancreatic resection in the setting of complex vascular involvement can be safely performed. When the tumor involves the portal-superior mesenteric-splenic vein (PV-SMV-SV) confluence with abutment of the SMA, a mesocaval shunt (MCS) may be created with/without distal splenorenal shunt (DSRS). This achieves wide exposure of the vascular structures involved and allows for a safe pancreatectomy. We report our experience with these procedures. Methods: All patients with pancreatic resection and either DSRS and/or MCS were identified from our institutional database. Demographics, stage, neoadjuvant treatment, operative details and outcomes were reviewed. Results: Twenty-eight patients were resected with the aid of shunting procedures (25 adenocarcinomas, 2 neuroendocrine cancers, 1 solid pseudopapillary tumor), including 23 standard or extended pancreaticoduodenectomies and 5 total pancreatectomies. Shunts consisted of 11 MCS, 15 DSRS and 2 MCS/DSRS. Eight MCS were temporary. Median operative time was 8.8 hours (6.3-13), median estimated blood loss was 925 mL (100-3500) and median length of hospital stay was 11.5 days (7-35). Two patients experienced Clavien-Dindo grade III or above complications. No 90-day mortalities or reoperations encountered. Median follow up was 12.2 months (0.5-97). Overall survival was 29 months for patients with adenocarcinoma. Of the permanent shunts performed, all but one DSRS was patent at follow up. Conclusion: Shunting facilitates safe resection in pancreatic tumor patients who may otherwise be deemed inoperable. In the era of more effective systemic therapy, it's critically important to know which patients are candidates for extended resections and how to safely perform them.

Role of ultrasound doppler examination in choice of surgical tactics in portal hypertension

Introduction: Сhoice of surgical tactics in complicated portal hypertension (PH) is actual.More than 400 examinations of hepatic blood flow in patients with complicated PH, including 16 patients, operated by the method of liver tunneling, were fulfilled. Methods: One hundred protocols were chosen randomly. Comparison of distribution indices revealed different occurrence frequency of ultrasound symptoms of PH, having different etiology. Seventy patients with viral etiology of PH prevailed. Varix dilatation of cardia is revealed in 47% of patients. Splenorenal venous shunt (SRVS) is visualized in 43%, recanalization of umbilical vein - in 23% of patients. All types of anhepatic portosystemic shunts are visualized in majority of patients with cirrhosis of ethanol etiology. Liver is always enlarged in fatty hepatosis. In spite of low linear blood flow velocity in PV, its compensatory dilatation is not typical. Damage of PV architectonics is revealed in patients with subhepatic PH, enlargement of PV diameter is naturally absent, splenorenal venous shunt is always observed. Results: Ultrasound Doppler examination is the method of early diagnosis of PH type, its stage and prognosis of bleeding risk. It permits to choose optimal treatment method and evaluate its efficiency by comparison of indices before and after treatment. Conclusion: Indications to application of splenorenal venous anastomosis are doubtful due to natural formation of shunt in 43% of patients with viral hepatitis and 62% - with ethanol liver cirrhosis. Formation of SRVS in anhepatic PH is a compensatory mechanism. In this situation splenectomy or application of splenorenal venous anastomosis can be fatal.

Hemodynamically efficient portal decompression: the concept of competing spontaneous and surgical shunts

Introduction: Temporary portocaval shunt (PCS) has a positive impact on short-term outcomes after liver transplantation (LT). An alternative to this proximal shunt is a distal passive decompression through mesenterico-saphenous shunt (MSS). The goal of this study was to compare the efficiency of spontaneous and surgical distal versus proximal shunts and discuss their respective place during the anhepatic phase in regard to the anatomy of preexisting spontaneous shunts. Method: Patients transplanted in a 2-year period who underwent portal decompression during the anhepatic phase were included. Intraoperative and in-hospital course were compared according to 2 types of surgical decompression techniques: PCS (n = 44) and MSS (n = 77). The impact of spontaneous shunt anatomy on the hemodynamic and metabolic efficiency of surgical shunts using portal pressure and capillary lactate measurements as well as on early graft function were evaluated. Results: MSS and PCS showed a comparable hemodynamic and metabolic efficiency with no significant difference in terms of portal pressure variations and gut lactate production. There was no significant difference in terms of reperfusion syndrome, transfusion rate, renal failure nor early allograft dysfunction (p = 0.956, 0.575, 0.239 and 0.976 respectively). In case of competing shunts (example: PCS and splenorenal shunt or MSS and left gastric shunt), there was a significantly higher rate of EAD (67% vs 13%; p = 0.002). Conclusion: Classical portacaval anastomosis and passive mesenterico-saphenous shunt offer similar hemodynamic and metabolic efficiency without impacting on the outcomes after liver transplantation. Their respective place should be discussed in regard to the anatomy of preexisting portosystemic shunts.

Coronary-renal shunt combined with splenectomy for selective variceal decompression

Instruction: Selective shuns for gastroesophageal varices including distal splenorenal shunt and coronary-caval shunt may not solve the problems of the giant spleen with serious hypersplenism or deep location of the left gastric vein behind the pancreas. A new selective shunt procedure should be explored. Methods: Coronary-renal shunt combined with splenectomy was performed on 16 patients with gastroesophageal varices and serious hypersplenism due to posthepatitic cirrhosis. The patients had the dilated left gastric vein entering the splenic vein by preoperative CT angiorgraphic evaluation. After splenectomy, the proximal part of the splenic vein with a length of 3-5cm and the left gastric vein were freed from the pancreas. The freed splenic vein was divided at the distal side with the proximal orifice anasomosed to the left renal vein. Ligation or division between sutures was applied to the splenic vein between portal vein and left gastric vein. The right gastric and gastro-epiploic vessiles were divided to occlude the back flow from the portal vein. Results: There were no operative motality and no procedure-relative complications. Post-operative CT and endoscopy showed the shunts were patent with reduced or obliterative varices in all sixteen patients. There were no recurrent variceal haemorrhage nor encephalopathy by 6-36 months' follow-up. Conclusion: This procedure can reach the aim of selective variceal decompression when splenectomy is required. Keywords: portal hypertension; coronary-renal shunt; selective variceal decompression; splenectomy

Distal spleno-renal shunt for reconstruction of the gastric and splenic venous drainage during pancreatectomy with resection of the portal venous confluence

Distal spleno-renal shunt for reconstruction of the gastric and splenic venous drainage during pancreatectomy with resection of the portal venous confluence

Comparative study of esophageal devascularisation with splenectomy vs proximal splenorenal shunt in non cirrhotic portal hypertension

Comparative study of esophageal devascularisation with splenectomy vs proximal splenorenal shunt in non cirrhotic portal hypertension

Liver transplantation in patients with spontaneous spleno-renal shunt

Aim: Our aim was to describe the outcomes of liver transplantation (LT) in patients with spontaneous spleno-renal shunt (SSRS) and a defined protocol of mínimum portal flow. Methods: Recipients with SSRS before LT between January 2005 and January 2017 were included in a retrospective study. Our policy was to achieve a final portal flow >80 mL/min/100 gr of liver weight or >1000 mL/min. The primary endpoint was patient survival. Results: Sixty patients comprised the study group. Portal thrombendvenectomy was performed in 15. Portal reconstruction was porto-portal in 56 cases, including 9 cases with left renal vein (LRV) ligation. Reno-portal reconstruction was performed in 4 cases. Median portal flow in those patients with LRV ligation increased from 850 mL/min (266-1419) to 1732 mL/min (1063-3240) after ligation. This was comparable to the patients with porto-portal reconstruction and no need for LRV ligation (1782 mL/min (672-3780)). Moreover, median portal flow/100 gr of liver weight increased from 56 mL (34-79) to 111 mL (61-183) after LRV ligation, also comparable to the patients who did not need LRV ligation (118 mL (69-295)). Mean (SD) portal flow after reno-portal reconstruction was 1372 ± 798 mL/min. Early primary dysfunction was observed in 12 patients (20%). Only 1 patient suffered a primary non-function.1- and 5-year patient survival was 93.3% and 91%. Conclusión: A high patient survival was observed after LT in recipients with pretransplant SSRS when a final portal flow >80 mL/min/100 gr of liver weight or >1000 mL/min was achieved.

Effect of Proximal Splenorenal Shunt on Intraoperative Portal Venous Pressure and Its Correlation with Clinical Outcomes

Proximal splenorenal shunt (PSRS), commonly performed for non-cirrhotic portal hypertension (NCPH), diminishes elevated portal venous pressure (PP) and prevents its sequelae. The change in PP after PSRS and its correlation with clinical outcome is largely unknown. Twenty-four patients who underwent PSRS for NCPH were evaluated prospectively. PP was measured after completion of splenectomy and after PSRS. Follow-up for 3 months was done to assess shunt patency and other relevant clinical variables. Change in PP and shunt patency were correlated with clinical outcome. Seventeen patients had extrahepatic portal vein obstruction (EHPVO) and seven had non-cirrhotic portal fibrosis (NCPF). There was a significant decrease in PP (median10 mmHg) after PSRS (p 0.05). Shunt patency showed significant correlation with splenic vein diameter (p = 0.018), shunt diameter (p = 0.024), blood flow across shunt (p = 0.023), change in variceal grade (p = 0.032), and need for endotherapy (p = 0.002). PP decreases after PSRS in patients with NCPH. However, this does not correlate with clinical outcome. A patent shunt at 3 months correlated with most of these variables.

Surgical portosystemic shunts versus devascularisation procedures for prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

Hepatosplenic schistosomiasis is an important cause of variceal bleeding in low-income countries. Randomised clinical trials have evaluated the outcomes of two categories of surgical interventions, shunts and devascularisation procedures, for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. The comparative overall benefits and harms of these two interventions are unclear. To assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, LILACS, reference lists of articles, and proceedings of relevant associations for trials that met the inclusion criteria (date of search 11 January 2018). Randomised clinical trials comparing surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. Two review authors independently assessed the trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with GRADE and Trial Sequential Analysis. We assessed the certainty of evidence using the GRADE approach. We found two randomised clinical trials including 154 adult participants, aged between 18 years and 65 years, diagnosed with hepatosplenic schistosomiasis. One of the trials randomised participants to proximal splenorenal shunt versus distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy, and the other randomised participants to distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy. In both trials the diagnosis of hepatosplenic schistosomiasis was made based on clinical and biochemical assessments. The trials were conducted in Brazil and Egypt. Both trials were at high risk of bias.We are uncertain as to whether surgical portosystemic shunts improved all-cause mortality compared with oesophagogastric devascularisation with splenectomy due to imprecision in the trials (risk ratio (RR) 2.35, 95% confidence interval (CI) 0.55 to 9.92; participants = 154; studies = 2). We are uncertain whether serious adverse events differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 2.26, 95% CI 0.44 to 11.70; participants = 154; studies = 2). None of the trials reported on health-related quality of life. We are uncertain whether variceal rebleeding differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 0.39, 95% CI 0.13 to 1.23; participants = 154; studies = 2). We found evidence suggesting an increase in encephalopathy in the shunts group versus the devascularisation with splenectomy group (RR 7.51, 95% CI 1.45 to 38.89; participants = 154; studies = 2). We are uncertain whether ascites and re-interventions differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy. We computed Trial Sequential Analysis for all outcomes, but the trial sequential monitoring boundaries could not be drawn because of insufficient sample size and events. We downgraded the overall certainty of the body of evidence for all outcomes to very low due to risk of bias and imprecision. Given the very low certainty of the available body of evidence and the low number of clinical trials, we could not determine an overall benefit or harm of surgical portosystemic shunts compared with oesophagogastric devascularisation with splenectomy. Future randomised clinical trials should be designed with sufficient statistical power to assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisations with or without splenectomy and with or without oesophageal transection.

EFFECTIVENESS OF PROXIMAL SPLENORENAL SHUNT IN THE TREATMENT OF COMPLICATIONS OF PORTAL HYPERTENSION AND HYPERSPLENISM.

22Jul 2018 EFFECTIVENESS OF PROXIMAL SPLENORENAL SHUNT IN THE TREATMENT OF COMPLICATIONS OF PORTAL HYPERTENSION AND HYPERSPLENISM. Vadivelu.P4 , Ilayakumar paramasivam , N.Sritharan , S. Jeyakumar , O. L. Naganath babu , B. Velladurachi , Jayanth v kumar , M. Krishni , I. Devarajan , S. Prathap kumar. MBBS,MS,MCh, Professor, Institute of vascular surgery, Rajiv Gandhi govt. General hospital, Madras medical college, Chennai-3. MBBS, MS.MCh, professor, Department of surgical gastroenterology, Rajiv Gandhi govt. General hospital, Madras medical college, Chennai-3. MBBS,MS.MCh, Assistant professor, Institute of vascular surgery, Rajiv Gandhi govt. General hospital, Madras medical college, Chennai-3. MBBS,MS,MCh(vascular surgery), Post graduate, Institute of vascular surgery, Rajiv Gandhi govt. General hospital, Madras medical college, Chennai-3.

Successful Living Donor Liver Transplantation in a Case of Mean Pulmonary Arterial Pressure of 52 mmHg

Introduction Pulmonary hypertension (PH) is defined as an elevated mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest. The perioperative management can be complicated by hemodynamic instability resulting in severe hypoxemia, acute right heart failure/circulatory collapse and death. Portal hypertension is a curable cause for PH. However, Krowka et al reported that mPAP of 50 mmHg or greater was associated with 100% cardiopulmonary mortality in liver transplantation (LT) setting. Materials and Methods A 45 years old male patient underwent LDLT for HBV + alcoholic cirrhosis and HCC. MELD score was 28. Echocardiography performed 2 months before the operation showed right ventricular systolic pressure (RVSP) 62 mmHg and maximum tricuspid regurgitant jet velocity (TRVmax) 3.8m/sec, suggesting moderate resting PH. During anesthetic induction, pulmonary vascular resistance (PVR) was measured as 246 dynes/sec/cm-5 and mPAP as 52mmHg. One hour later, they were 217 and 40, respectively, with infusion of Isosorbide 1mcg/Kg/min. Vital signs were stable and PaO2 level was 223 mmHg. So we decided to proceed with surgery despite of moderate PH. Results Graft weighed 550g and GRWR was 0.74. The living donor LT procedure was done with modified right lobe graft. Additionally portal vein endthrombectomy, direct ligation of a large splenorenal shunt and splenic artery ligation was done. The operation took 850 minutes and 24 pints of RBC, 16 pints of FFP, 8 pints of PC and 10 pints of cryoprecipitate. PVR and mPAP were in the range of 217~149 and 46~31, respectively. Alprostadil 7mcg/hr was started just after finishing arterial anastomosis and was infused for 7 days thereafter. Extubation was done 9 hours after the operation and liquid diet was begun 2 days after the operation. The day after LT, RVSP was 96 mmHg and TRVmax 4.9m/sec. And 5 days after LT, he complained of dyspnea and Beraprost (prostacyclin pathway agonist) was given orally. Even with mild dyspnea, the patient was discharged on foot 19 days after LT. 6 weeks after LT RVSP was measured as 84 mmHg and TRVmax 4.0m/sec. mPAP was 63 mmHg on right heart catheterization. On CT scan, there was marked hepatic congestion resulting from pulmonary hypertension. Endothelin receptor antagonist Ambrisentan was given orally. The patient's breathing difficulty almost disappeared soon. Now, 3 months after the operation, he returned to work. Conclusion The authors conducted LDLT in a case of severe pulmonary hypertension with mean PAP 50 mmHg successfully by careful intraoperative monitoring and postoperative management. When encountered a case of moderate to severe pulmonary hypertension during LT, initial response to anesthetic management might dictate whether to proceed with LT or not.

Clinical and Imaging Predictors of Surgical Splenorenal Shunt Dysfunction in Pediatric Patients.

Few established criteria exist to prompt angiographic evaluation and intervention for surgically created splenorenal shunts (SRS). Clinical and Doppler ultrasound (DUS) imaging predictors of shunt dysfunction were evaluated in this retrospective study. Consecutive patients undergoing SRS angiography over a 10-year period were retrospectively identified. Preangiography platelet count and DUS measurements of spleen diameter, maximum splenic vein velocity, and maximum shunt velocity were assessed and compared to findings at subsequent catheter angiography. Twenty-six SRS angiograms were performed in 16 patients. Two of the 26 procedures were excluded from analysis due to insufficient baseline preangiography clinical and DUS data. In the remaining 24 cases, significant stenosis/occlusion was confirmed at angiography in 20, whereas wide patency was seen in 4. For the 20 cases of angiographically confirmed significant stenosis/occlusion, when compared to baseline post-SRS creation to immediate preangiography evaluation there was a greater decrease in platelet count (-51.8% vs -19.4%), a greater increase in spleen diameter (+13.4% vs +3.7%), a greater increase in maximum shunt velocity (+74.7% vs +59.7%), and a greater decrease in splenic vein velocity (-25.0% vs -18.5%). Clinical evidence of splenic sequestration and DUS finding of increased maximum shunt velocity correlate with angiographic findings of SRS dysfunction and could be used to help predict the need for shunt intervention.

Ronald W. Busuttil, MD, PhD: William P. Longmire, Jr, Chair of Surgery, Chief of Liver and Pancreas Transplantation, Director, UCLA-Dumont Transplant & Liver Cancer Center.

Ronald W. Busuttil, MD, PhD: William P. Longmire, Jr, Chair of Surgery, Chief of Liver and Pancreas Transplantation, Director, UCLA-Dumont Transplant & Liver Cancer Center.