Splenorenal Shunt Research Articles

Immediate and Long-Term Results of Portacaval Shunt Surgeries in Portal Hypertension: 10-Year Clinical Experience of a Regional Vascular Surgery Department

INTRODUCTION: The number of patients with liver cirrhosis (LC) makes 20–40 cases per 100 thousand populations and rises steadily. A five-year survival rate of patients with LC in the compensation stage is 50%–62%, in the decompensation stage — 11%–40%. In the overwhelming majority of patients (80%–90%), LC leads to the compensatory formation of esophageal and gastric varices (EV and GV, respectively), which is further complicated with a life-threatening bleeding in 30% of patients. AIM: To evaluate 5-year results of partial portacaval shunt surgeries. MATERIALS AND METHODS: The paper describes a 10-year clinical experience of the vascular surgery department of Yaroslavl Regional Clinical Hospital in surgical treatment of patients with LC with a clinical presentation of portal hypertension, with recorded esophageal and gastric variceal bleeding. The study included 26 patients (of them 11 men; the mean age 48 ± 7.3 years) with LC (A and B classes on Child-Pugh scale), who underwent planned reconstructive surgery on the portal system. By the type of anastomosis, the patients were divided into 3 groups: group 1 — mesocaval anastomosis (n = 6); group 2 — distal splenorenal anastomosis with preservation of spleen (n = 10); group 3 — splenorenal H-shaped shunt. The primary end points of the study were survival of the patients, rebleeding from EV, shunt patency. Secondary end points were dynamics of EV size, changes in the spleen size, dynamics of the portal and splenic veins size, blood flow directions in the portal system, the presence of hepatic encephalopathy. Postoperative mortality was 3.8%. RESULTS: Survival at 1, 3 and 5 years was 96%, 90% and 58, respectively, and patency of anastomoses was 96%, 96% and 91%, respectively. Rebleeding at 1 year made 4% (n = 1), at 3 years — 0, at 5 years — 17% (n = 2). Changes in the hemodynamics of the portal system were recorded after formation of all types of anastomoses: reduction of the diameter of the portal vein by on average 5 mm, of the splenic vein by 3 mm, of the spleen size by 210 cm3. Shunt thrombosis occurred in two of 26 patients (7.7%) at 1 year (splenorenal H-shaped shunt with use of prosthesis) and 4 years (splenorenal autovenous shunt), respectively. CONCLUSION: The formation of partial portacaval anastomoses in patients with portal hypertension and episodes of bleeding from esophageal varices is a reliable prevention of rebleeding. The first bleeding episode is an indication for an open surgery in case the transjugular intrahepatic stenting is impossible. Survival rate of patients after portacaval shunt surgeries is determined by the initial degree of hepatic failure and patency of the formed anastomoses.

Evaluation of the presence and severity of spontaneous splenorenal or gastrorenal shunts via four-dimensional flow magnetic resonance imaging: a preliminary study.

Four-dimensional phase-contrast magnetic resonance imaging (4D flow MRI) is a relatively new type of MRI acquisition technique that provides a unique and comprehensive set of information within a single acquisition, including hemodynamic and anatomical information. This study was designed to noninvasively evaluate the correlation between the presence and severity of spontaneous splenorenal shunt (SRS) or gastrorenal shunt (GRS) and 4D flow MRI-derived parameters. This retrospective case-control study enrolled 70 patients who were diagnosed with hepatocirrhosis portal hypertension and admitted to the Second Affiliated Hospital of Chongqing Medical University. Patients were divided into three groups according to the diameter of the SRS and GRS. 4D flow MRI-derived parameters, including the turbulent kinetic energy, total volume (TV), flow velocity, blood flow volume (BFV), maximum flow (MF), wall shear stress, and relative pressure, were obtained for eight cut planes: proximal to the splenomesenteric confluence and liver hilum of the portal vein (PV1/PV2); the left/right branch of the bifurcation of the PV (LPV/RPV), at the mesosplenic confluence of the splenic vein (SV1), at the splenic hilum of the SV (SV2); at the proximal to the splenomesenteric confluence of the superior mesenteric vein (SMV1), and 5 cm from the splenomesenteric confluence of the SMV (SMV2). Comparisons among the three groups were based on one-way analysis of variance (ANOVA). Logistic regression was used to identify the risk factors for small SRS/GRS (S-SRS/GRS) and for large SRS/GRS (L-SRS/GRS). Receiver operating characteristic curves were used to evaluate the diagnostic performance of the independent risk factors for SRS and GRS. The associations between the clinical data and the 4D flow MRI-derived parameters of GRS and SRS were assessed via Spearman correlation coefficient analysis. The presence of SRS or GRS was correlated with TVLPV (r=-0.302; P=0.035), TVPV1 (r=-0.385; P=0.001), TVPV2 (r=-0.301; P=0.013), BFVPV1 (r=-0.360; P=0.010), BFVSMV2 (r=0.371; P=0.008), MFPV1 (r=-0.341; P=0.004), and MFPV2 (r=-0.291; P=0.017). Meanwhile, the severity of the SRS or GRS was correlated with alanine aminotransferase level (r=-0.535; P<0.001), BFVLPV (r=-0.560; P=0.008), aspartate aminotransferase level (r=-0.321; P=0.038), and model for end-stage liver disease score (r=0.323; P=0.039). TVPV1, TVPV2, BFVPV1, BFVPV2, and MFSMV2 were found to be independent risk factors for L-SRS/GRS, with intermediate diagnostic efficacy, with the area under the curve (AUC)TV PV1=0.706 [95% confidence interval (CI): 0.519-0.853; sensitivity, 61.54%; specificity, 80.77%; P=0.018], AUCBFV PV1 =0.694 (95% CI: 0.507-0.844; sensitivity, 95.00%; specificity, 63.16%; P=0.035), AUCTV PV2 =0.729 (95% CI: 0.544-0.870; sensitivity, 77.78%; specificity, 66.67%; P=0.016), AUCBFV PV2 =0.718 (95% CI: 0.531-0.862; sensitivity, 60.00%; specificity, 82.35%; P=0.017), and AUCMF SMV2 =0.788 (95% CI: 0.608-0.912; sensitivity, 44.00%; specificity, 84.46%; P=0.005), respectively. As the TV of PV1 and PV2 and the BFV of PV1 and PV2 decreased, the risk of L-SRS/GRS increased. As the MF of SMV2 increased, the risk of the presence of L-SRS/GRS increased. 4D flow MRI-derived parameters correlated with the presence and severity of SRS or GRS. Meanwhile, the independent risk factors for the presence of L-SRS/GRS were the TV of LPV, PV1, and PV2; the BFV of PV1 and SMV2; and the MF of PV1 and PV2.

Comparison of surgical outcomes between shunt surgery and devascularization in non-cirrhotic portal hypertension

Objective: Non-cirrhotic portal hypertension (NCPH) is the most common cause of portal hypertension and upper gastro-intestinal bleeding in children and adolescents in developing nations. It is characterized by features of portal hypertension with preserved liver function. Proximal splenorenal shunt (PSRS) and esophagogastric devascularization are the two most commonly performed surgeries for its management. The present study is aimed at comparison of surgical outcomes between these two procedures. Material and Methods: Between April 2018 and March 2022, prospectively maintained data of consecutive NCPH cases who underwent surgical intervention was reviewed retrospectively. Cases were categorized into two groups- shunt surgery and devascularization. The pre-operative characteristics, peri-operative morbidity and long-term outcomes were compared between the groups. Results: Of 112 cases who were treated during the study period, 54 cases which underwent surgery were included in the study. Of these, 20 cases underwent PSRS, and splenectomy and devascularization was performed in 34 cases. There was no difference in pre-operative variables between the two groups. Patients undergoing PSRS experienced longer duration of surgery (260 vs. 200 minutes, p&lt; 0.001), and those in the devascularization group had significantly greater operative blood loss (350 vs. 455 ml, p&lt; 0.001). Post-operative morbidity was comparable between the two groups. Hypersplenism was corrected in all cases and no cases reported rebleeding after median follow-up of 30 months. Three cases in each group developed features of portal biliopathy in follow up period. Conclusion: Both PSRS and devascularization procedures have comparable efficacy and safety in the management of NCPH.

Imaging and Pathological Feature Analysis of Idiopathic Portal Hypertension

Background: Idiopathic portal hypertension (IPH) is a rare clinical condition often misdiagnosed as cirrhosis. The management of IPH focuses on preventing and treating complications related to portal hypertension, such as bleeding from esophagogastric fundal varices. In contrast, the management of cirrhosis focuses on symptomatic treatment based on etiology, protecting hepatocyte function, and inhibiting hepatic inflammation and fibrosis. Therefore, it is crucial to correctly recognize both diseases and take appropriate therapeutic measures. Objectives: The aim of this study was to summarize and analyze the imaging, pathological, and serological features of idiopathic portal hypertension and cirrhosis to reduce misdiagnosis in clinical practice. Patients and Methods: Pathological, radiological parameters [computed tomography (CT)/magnetic resonance imaging (MRI)], and serological examinations were retrospectively evaluated for 14 patients with IPH and 30 patients with cirrhosis. We analyzed and compared their imaging manifestations in terms of spleen thickness and length, liver morphology, hepatic lobe atrophy, hyperplasia, portal vein thrombosis, arteriovenous phase liver perfusion, regenerative nodules, focal nodular hyperplasia-like lesions of the liver, portal vein morphology, splenorenal shunt, and hepatorenal shunt. The aim was to investigate the correlation between the imaging manifestations and the pathological manifestations. Results: There were significant differences between the IPH and cirrhosis groups in individual indicators of liver function, routine blood tests, and coagulation function (P &lt; 0.05). Significant differences in spleen thickness and length were also observed between the IPH and cirrhosis groups (P &lt; 0.05). Atrophy and hyperplasia of the hepatic lobe differed between the two groups. Changes in liver morphology and parenchyma were observed in both the IPH and cirrhosis groups, with diffuse regenerative nodules and focal nodular hyperplasia-like lesions being significant for distinguishing between IPH and cirrhosis. Focal nodular hyperplasia-like lesions were more common in patients with idiopathic portal hypertension, whereas diffuse regenerative nodules were more common in patients with cirrhosis. All 14 IPH patients had abnormalities in the portal vein system, including main portal vein dilation, stiffness, straightening, and distal branch vein stenosis or occlusion, while 9 cirrhosis patients had portal vein abnormalities, primarily thinning of the portal vein. Pathology revealed that patients in the cirrhosis group had varying degrees of cell necrosis and edema, and pseudolobule formation was observed in all patients. Patients with IPH showed varying degrees of fibrosis in the portal and confluent areas, but lobular inflammation was not evident. Some IPH patients experienced portal vein occlusion and stenosis. Conclusion: Idiopathic portal hypertension is relatively rare in clinical practice and is characterized by mostly normal liver function and hypersplenism, which may lead to a decrease in platelets, red blood cells, and white blood cells. If a giant spleen is found on imaging and the liver surface is smooth, IPH should be considered. Additionally, fibrosis, stenosis, and occlusion of the portal venous system, as well as focal nodular hyperplasia-like lesions, are suggestive of idiopathic portal hypertension. In contrast, diffuse regenerative nodules and pseudolobule formation are often indicative of cirrhosis. Furthermore, atrophy and hyperplasia of the liver are significant in differentiating the two diseases.

Low-dose alcohol exacerbates hyperdynamic circulation and shunting in non-alcoholic cirrhotic rats.

Portal hypertension affects hepatic, splanchnic and portosystemic collateral systems. Although alcohol is a well-known risk factor for liver cirrhosis, it also affects vascular contractility. However, the relevant effects on portal hypertension have not been evaluated in non-alcoholic cirrhosis. The present study aimed to investigate the impacts of low-dose alcohol on portal hypertension-related derangements in non-alcoholic cirrhotic rats. Sprague-Dawley rats received bile duct ligation to induce cirrhosis or sham operation as controls. The chronic or acute effects of low-dose alcohol (2.4 g/kg/day, oral gavage, approximately 1.3 drinks/day in humans) were evaluated. The chronic administration of low-dose alcohol did not precipitate liver fibrosis in the sham or cirrhotic rats; however, it significantly increased splanchnic blood inflow (P=0.034) and portosystemic collaterals (P=0.001). Mesenteric angiogenesis and pro-angiogenic proteins were up-regulated in the alcohol-treated cirrhotic rats, and poorer collateral vasoresponsiveness to vasoconstrictors (P<0.001) was noted. Consistently, acute alcohol administration reduced splenorenal shunt resistance. Collateral vasoresponsiveness to vasoconstrictors also significantly decreased (P=0.003). In non-alcoholic cirrhosis rats, a single dose of alcohol adversely affected portosystemic collateral vessels due to vasodilatation. Long-term alcohol use precipitated splanchnic hyperdynamic circulation, in which mesenteric angiogenesis played a role. Further studies are warranted to evaluate the benefits of avoiding low-dose alcohol consumption in patients with non-alcoholic cirrhosis.

Use of Vascular Shunt at the Time of Pancreatectomy with Venous Resection: A Systematic Review.

The rising diffusion of vascular resections during complex pancreatectomy for malignancy, for both oncological and technical matters, brought with it the use of vascular shunts, either temporary or definitive, to prevent bowel congestion and liver ischemia. This study aimed to systematically review the literature on the technical feasibility of vascular shunts during advanced pancreatic surgery, analyzing intraoperative and postoperative outcomes. A systematic literature search was performed on PubMed, Scopus, Web of Science, and the Cochrane Library Central, according to PRISMA guidelines. Studies published before 2006 were excluded, considering the lack of a standardized definition of locally advanced pancreatic cancer. The main outcomes evaluated were the overall complication rate and shunt patency. Among 789 papers retrieved from the database search, only five fulfilled the inclusion criteria and were included in the review, amounting to a total of 145 patients undergoing a shunt creation at the time of pancreatectomy. Pancreatic adenocarcinoma (PDAC) was found to be the most common diagnosis and pancreaticoduodenectomy was the main surgical procedure, accounting for 88% and 83% of the overall cohort, respectively. The distal splenorenal shunt was the most performed. Overall, 44 out of 145 patients (30%) experienced postoperative complications; the long-term patency of definitive shunts was 83% (110 out of 120 patients). An increasing number of patients with borderline resectable or locally advanced PDAC are becoming amenable to resection and shunt creation may facilitate vascular resection with clear margins, becoming a valid tool of modern pancreatic surgery.

Five years' experience and outcomes in splenorenal shunt

Five years' experience and outcomes in splenorenal shunt

Spontaneous splenic rupture and a congenital splenorenal anomalous shunt.

Atraumatic splenic rupture is rare and not often considered in the differential diagnosis for patients with abdominal pain. This article describes a patient with atraumatic splenic rupture complicated by a congenital splenorenal anomalous shunt. The congenital anomaly increases patient risk and the degree of surgical difficulty, even if it is identified preoperatively.

Clinical outcomes of splenorenal shunts in esophageal varices patients: a literature review

Clinical outcomes of splenorenal shunts in esophageal varices patients: a literature review

Case report on spontaneous remission in paroxysmal nocturnal hemoglobinuria: a rare phenomenon

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder characterized by a deficiency of GPI-anchored proteins in blood cells. It is associated with hemolysis, thromboembolic events, and bone marrow failure. Management includes complement inhibitors, anticoagulation, and stem cell transplantation. Spontaneous remission of PNH is rarely reported. Case Presentation: A 28-year-old male initially diagnosed with aplastic anemia developed portal vein thrombosis and was subsequently diagnosed with PNH. Due to the unavailability of complement inhibitors, anticoagulation therapy and supportive care were employed. Splenectomy with splenorenal shunt was performed for chronic thrombosis and associated complications. The patient achieved spontaneous remission with normalized blood counts and diminished PNH clone. Conclusion: Managing PNH in resource-limited settings presents challenges due to the unavailability of complement inhibitors. Spontaneous remission of PNH is rarely reported and needs further research. A multidisciplinary approach, accessibility to diagnostic tests, and advanced treatments will enhance PNH management in resource-limited settings.

Case report on spontaneous remission in paroxysmal nocturnal hemoglobinuria: a rare phenomenon

Background: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder characterized by a deficiency of GPI-anchored proteins in blood cells. It is associated with hemolysis, thromboembolic events, and bone marrow failure. Management includes complement inhibitors, anticoagulation, and stem cell transplantation. Spontaneous remission of PNH is rarely reported. Case Presentation: A 28-year-old male initially diagnosed with aplastic anemia developed portal vein thrombosis and was subsequently diagnosed with PNH. Due to the unavailability of complement inhibitors, anticoagulation therapy and supportive care were employed. Splenectomy with splenorenal shunt was performed for chronic thrombosis and associated complications. The patient achieved spontaneous remission with normalized blood counts and diminished PNH clone. Conclusion: Managing PNH in resource-limited settings presents challenges due to the unavailability of complement inhibitors. Spontaneous remission of PNH is rarely reported and needs further research. A multidisciplinary approach, accessibility to diagnostic tests, and advanced treatments will enhance PNH management in resource-limited settings.

Prevalence of minimal hepatic encephalopathy in extra hepatic portal venous obstruction patients following proximal splenorenal shunt surgery

Prevalence of minimal hepatic encephalopathy in extra hepatic portal venous obstruction patients following proximal splenorenal shunt surgery

Is there an alternative if splenic vein size is too big for proximal splenorenal shunt (PSRS)

Is there an alternative if splenic vein size is too big for proximal splenorenal shunt (PSRS)

Bleeding Ectopic Varices at Hepaticojejunostomy site after Portal Vein Reconstruction managed by Emergency Proximal Splenorenal Shunt – A case report

Bleeding Ectopic Varices at Hepaticojejunostomy site after Portal Vein Reconstruction managed by Emergency Proximal Splenorenal Shunt – A case report

Outcomes of Portosystemic Shunts in Children with and without Liver Transplantation.

Limited data exist regarding outcome and morbidity associated with portosystemic shunts in the pediatric transplant population. Our study assesses the outcomes of pediatric patients who underwent a portosystemic shunt procedure, both with and without liver transplantation (LT). This study retrospectively reviewed the medical records of pediatric patients aged 0-19 years who underwent shunt placement between 2003 and 2017 at a tertiary care center. The analysis included cases of shunt placement with or without LT. A total of 13 pediatric patients were included in the study with median age of 8.8 years. Among the cases, 11 out of 13 (84.6%) underwent splenorenal shunt, 1 (7.7%) underwent a mesocaval shunt, and another 1 (7.7%) underwent a Modified Rex (mesoportal) shunt. Additionally, 5 out of 13 (38.5%) patients had LT, with 4 out of 5 (80.0%) receiving the transplant before shunt placement, and 1 out of 5 (20.0%) receiving it after shunt placement. Gastrointestinal bleeding resulting from portal hypertension was the indication in all cases. A total of 10 complications were reported in 5 patients; the most common complication was anemia in 3 (23.1%) patients. At the most recent follow-up visit, the shunts were functional without encephalopathy, and no deaths were reported. Shunt placement plays a crucial role in the management of patients with portal hypertension. Our study demonstrates favorable long-term outcomes in pediatric patients who underwent shunt placement. Long term shunt outcomes were similar and unremarkable in patients with LT and without LT.

Successful management of portal hypertension with splenomegaly and cavernous transformation of the portal vein: a rare case report

Abstract Portal hypertension, often stemming from liver cirrhosis or vascular anomalies, can result in cavernous transformation of the portal vein, a rare condition associated with biliary obstruction, variceal hemorrhage, and splenomegaly. This case report details a unique occurrence of portal hypertension, splenomegaly, and cavernous transformation of the portal vein successfully managed through splenectomy and spleno-renal shunt. A 30-year-old female with a history of portal hypertension, portal gastropathy, and splenomegaly presented with left upper quadrant abdominal pain. She had previously undergone esophageal variceal ligation and required intermittent blood transfusions. Additional complications included easy bruising, heavy menstrual bleeding, and a prior episode of hematemesis. Clinical assessment confirmed splenomegaly, while a CT scan confirmed the diagnosis. A tailored surgical approach was chosen, leading to splenectomy and spleno-renal shunt.

Liver Transplant With Double Portal Anastomose: A Case Report

Reno-portal reconstruction is a surgical alternative to achieve enough portal flow in liver transplant when there is a complete portal thrombosis, provided there are collaterals or portosystemic shunt, with or without spleno-renal shunt. We present the case of a 58-year-old man with enolic cirrhosis and a history of gastrointestinal hemorrhage due to esophageal varices and portal thrombosis. The clinical case was discussed in the Transplant Committee, and the patient was included in the surgical waiting list with a Model for End-Stage Liver Disease score of 17 and Child-Pugh score of A6. The preoperative computer tomography scan showed significant collateral circulation with esophageal varices, varices dependent on the inferior mesenteric vein (IMV) and hypoplasic portal vein. During the operation, a large shunt from the IMV to the iliac territory and type II portal thrombosis were observed, which was managed with eversion thrombectomy. A temporary portocaval shunt was performed, showing minimal flow in the portal vein, which did not improve after ligation of the systemic shunt. It was decided to perform a reno-portal anastomosis, after which the portal flow measurement was 600 cc per minute; because of this, it was decided to supplement portal flow with an end-to-side portoportal anastomosis, obtaining a flow of 1300 cc per minute with low resistance (R0.5). The postoperative period was favorable, with good evolution of liver analytical parameters, with permeability of the porto-portal venous anastomoses, reno-portal, arterial, and suprahepatic anastomoses in the imaging tests. If the portal flow is insufficient with a hypoplasic portal vein, a double anastomosis, portoportal, and reno-portal would be a technical resource.

Efficacy, Safety, and Clinical Outcomes of Splenorenal Shunt Surgery as a Therapeutic Intervention for Portal Hypertension Patients

Highlights: 1. This study systematically reviewed the efficacy, clinical outcomes, and safety of the splenorenal shunt procedure with a comprehensive and meticulous approach.2. The splenorenal shunt procedure is an innovative surgical intervention that offers a viable option for the management of portal hypertension. Abstract Portal hypertension is the second most common gastrointestinal bleeding in cirrhosis and non-cirrhosis patients. The splenorenal shunt surgery is a potential intervention that may be considered for portal hypertension patients with clinical symptoms such as upper gastrointestinal bleeding caused by the rupture of gastro-esophageal varices. In this study, the researchers aimed to analyze the efficacy, clinical outcomes, and safety of splenorenal shunt surgery in portal hypertension patients. The sources were obtained from electronic search databases, including PubMed, Google Scholar, and ScienceDirect, using the keywords "Efficacy," "Safety," and "Clinical Outcomes." in relation to splenorenal shunt surgery in portal hypertension patients. The researchers set specific criteria for inclusion and exclusion to select the articles. This systematic review revealed the efficacy of the splenorenal shunt procedure with favorable outcomes. The success rate of splenorenal shunt surgery in reducing the clinical symptoms of portal hypertension varied between 66% and 100%. The prevailing complications observed in this study were shunt thrombosis, rebleeding, and thrombocytopenia. However, notable improvements could be achieved with general treatment. In terms of short- and long-term clinical outcomes, the splenorenal shunt procedure demonstrated favorable results. It can be concluded that splenorenal shunt surgery provides excellent clinical outcomes and should be considered a viable treatment option for patients with both cirrhotic and non-cirrhotic portal hypertension.

The effectiveness of splenorenal shunt in the correction of portal hypertension and hypersplenism in the long-term period

The aim is to evaluate the long-term results of splenorenal anastomosis (SRA) in the treatment of portal hypertension a year or more after surgery. Materials and methods. The long-term results of the imposition of CPA after one to ten years have been studied. Life expectancy, the number of bleeding recurrences, and the severity of thrombocytopenia were assessed based on the results of fibrogastroscopy, duplex scanning (DS), and computed tomography with bolus enhancement. Results. One-year survival rate was 96.77%, three-year - 87.09%, five-year - 74.19%, ten-year - 22.58%. Within three years after bypass surgery, no recurrence of bleeding was observed, while in half of the patients (54.28%) the varicose veins of the esophagus disappeared, in the rest (45.72%) they decreased to grade I. Recurrence of bleeding occurred in six patients (17.14%) after 5-13 years, in one case massive, which was accompanied by shunt thrombosis (2.85%) according to the results of DS. For the rest, its function was preserved. The median platelet count one year and three after CP did not differ and was 110 x109 and 105 x109. It was found that the larger the diameter of the portal vein and the lower the volume velocity of blood flow in it, the smaller was the increase in platelets in the long-term period (r=0.90, p=0.037; r=0.87, p=0.01). Conclusions. After performing splenorenal bypass surgery for portal hypertension for the purpose of primary and secondary prevention of gastric bleeding, its recurrence occurred in 17.14% 5-13 years after surgery. After the correction of portal hypertension, there was a tendency to increase the number of platelets in the long-term postoperative period, which was dependent on the volume velocity of blood flow in the portal vein and the degree of its expansion before surgical treatment.

An Audit of Extrahepatic Portal Vein Obstruction: Experience from Tertiary Referral Center.

Extrahepatic portal vein obstruction (EHPVO) is a common cause of portal hypertension in India. (1) To evaluate the clinical presentation and the natural history of EHPVO; (2) to describe the risk factors, rebleeding rates and development of portal biliopathy on follow-up; and requirement of surgery in EHPVO at a tertiary care center. Data from 318 consecutive patients with EHPVO from June 2012 to October 2020 were analyzed. All patients underwent liver biochemistry, ultrasonography (USG) abdomen, upper gastrointestinal (GI) endoscopy, and viral serology. Color Doppler, computed tomography (CT) abdomen and magnetic resonance cholangiopancreatography (MRCP) were done as indicated. Mean age of presentation was 15.08 years [standard deviation (SD) 12.74; 6 months-60 years; 210 males)]. The presenting features were upper GI bleed (n = 227) (age at first bleed 11 years; 4 months-56 years), left hypochondrium pain or lump (n = 67), and only lower GI bleed (n = 1). Incidentally detected EHPVO on USG was seen in 10.69% (n = 34) patients. Postbleed ascites were seen in 10.69% (n = 34) patients. Six patients had symptomatic portal biliopathy and 14 had hypersplenism. Around 14.77% (n = 47) of patients had a history of being delivered at home, while 3.45% (n = 11) had a history of umbilical sepsis. During follow-up, 35.3% (n = 82) of patients had rebled. On imaging, associated splenic vein (SV) collaterals and superior mesenteric vein (SMV) collaterals were seen in 35.84% (n = 114) and 11.01% (n = 35) patients, respectively. Gallbladder varices were seen in 44.3% (n = 106), while gallstones in 5.66% (n = 18). On endoscopy, 87.42% (n = 278) patients had esophageal varices, 18.86% (n = 60) had isolated fundic varices, and three had ectopic varices. Only two patients had rectal varices and colopathy. Emergency devascularization was required in 3.45% (n = 14) patients for the failure of variceal bleed control, 1.88% (n = 7) underwent splenectomy, and four patients had proximal splenorenal shunt (PSRS) surgery. Extrahepatic portal hypertension (EHPVO) is an important cause of portal hypertension (PHT) in our country. The majority of them present with GI bleed; postbleed ascites were seen only in ~10%. Rebleed occurs in one-third of cases. Gallbladder varices were common; portal biliopathy occurred in 10% and were usually asymptomatic.