Surgical Portosystemic Shunts Research Articles

Does depressurization of the portal vein before liver transplantation affect the recurrence of HCC? A nested case-control study

BackgroundPortal hypertension (PHT) has been proven to be closely related to the development of hepatocellular carcinoma (HCC). Whether PHT before liver transplantation (LT) will affect the recurrence of HCC is not clear.Methods110 patients with depressurization of the portal vein (DPV) operations (Transjugular Intrahepatic Portosystemic Shunt—TIPS, surgical portosystemic shunt or/and splenectomy) before LT from a HCC LT cohort, matched with 330 preoperative non-DPV patients; this constituted a nested case-control study. Subgroup analysis was based on the order of DPV before or after the occurrence of HCC.ResultsThe incidence of acute kidney injury and intra-abdominal bleeding after LT in the DPV group was significantly higher than that in non-DPV group. The 5-year survival rates in the DPV and non-DPV group were 83.4% and 82.7% respectively (P = 0.930). In subgroup analysis, patients in the DPV prior to HCC subgroup may have a lower recurrence rate (4.7% vs.16.8%, P = 0.045) and a higher tumor free survival rate (88.9% vs.74.4%, P = 0.044) after LT under the up-to-date TNMI–II stage, while in TNM III stage, there was no difference for DPV prior to HCC subgroup compared with the DPV after HCC subgroup or the non-DPV group.ConclusionCompared with DPV after HCC, DPV treatment before HCC can reduce the recurrence rate of HCC after early transplantation (TNM I-II). DPV before LT can reduce the recurrence of early HCC.

Endovascular Alternatives to Transhepatic Shunt Creation.

Portomesenteric decompression is often necessary to treat patients with refractory symptoms of portal hypertension. When transjugular or direct intrahepatic portosystemic shunt creation is not feasible or is inadequate, surgical portosystemic shunt creation is considered, which carries significant morbidity and mortality in these high-risk patients. Surgery is further complicated in patients with portomesenteric thrombosis who require concurrent thrombectomy and long-term anticoagulation. In this article, we outline the technique for performing advanced endovascular alternatives to intrahepatic portosystemic shunt creation including mesocaval and splenorenal shunting. We will also discuss some of the clinical considerations for treating these patients with symptomatic portal hypertension and portomesenteric thrombosis.

Portal Hypertension: Current Surgical Management

AbstractPortal hypertension occurs due to multiple disorders of the liver and its circulation. It is defined as an elevated pressure gradient between the portal circulation and the systemic circulation. The primary clinical consequences of portal hypertension are ascites and the development of portosystemic varices, which may cause life threatening hemorrhage. Modern management of portal hypertension includes medical, endoscopic therapy and transjugular intrahepatic portosystemic shunt placement by interventional radiology. Historically, portal hypertension was treated through the creation of surgical portosystemic shunts. In this chapter, the physiology of portal hypertension and the approaches to its management will be discussed. Specifically, the chapter will focus on indications, technical considerations, and types of surgical shunts used to treat portal hypertension, as well as literature supporting these procedures. Three case reports describing recent successful surgical shunt creation will be presented. Although portosystemic surgical shunt creation is performed far less frequently as medical, endoscopic and radiologic interventions have improved, this chapter illustrates that this procedure is a vital tool to be used in the treatment of portal hypertension.

Don’t Shun the Shunt: Surgical Portosystemic Shunts in the Era of TIPS and Liver Transplantation

Don’t Shun the Shunt: Surgical Portosystemic Shunts in the Era of TIPS and Liver Transplantation

Modulating hepatocarcinogenesis by porto-systemic vein shunting in a high-fat diet mouse model

Abstract Objective Non-alcoholic fatty liver disease (NAFLD) is an increasingly common disease, which can lead to hepatocellular carcinoma (HCC). It is associated with an increased portal pressure, which can alter the intestinal barrier, increase the translocation of bacterial products, and further worsen NAFLD. We hypothesized that this vicious circle can be broken by surgical porto-systemic vein shunting (PSVS), and previously demonstrated that PSVS can decrease the histological features of NAFLD in a high-fat diet (HFD) mouse model. We now test whether PSVS can also impact de-novo hepatocarcinogenesis. Methods C57BL/6 mice received HFD starting from 4 weeks of age. HCC was induced by intraperitoneal injection of DEN at 25mg/kg on week 2 and PSVS (n = 18) (or sham surgery (n = 18)) are created at 8 weeks. HCC burden was assessed by MRI and, finally, by macroscopic and histomorphology assessments. HCC features of aggressiveness, including solid growth pattern and fat component have been also evaluated. Results At 40 weeks of HFD feeding, tumors were identified in all the animals. Shunted HFD mice showed a reduced number of tumor nodules compared to sham (median nodules 8 vs 14, -42.9%; p = 0.0471) while associated to a greater average total tumor volume (709.3 vs 197 mm3, +258,6%; p = 0.0245). This correlated with an increased median tumor volume in shunted mice (16.30 vs 72.45 mm3, +344,5%; p = 0.0011). Notably, HCC histology of shunted mice was hallmarked by accentuated trend concerning HCC fatty change combined to a less pronounced solid growth pattern (p = 0.193). Conclusion PSVS leads to the presence of larger HCCs, potentially linked to the proportionally increased arterial supply of the liver. However, it demonstrates a protective effect on HCC carcinogenesis (< number of tumors). Collectively, this data suggests that portal pressure could represent a potential therapeutic target to attenuate liver steatosis and NAFLD-related HCC carcinogenesis.

Surgical Portosystemic Shunts - Still an Important Tool in the Current Management of Portal Hypertension

Surgical Portosystemic Shunts - Still an Important Tool in the Current Management of Portal Hypertension

Porto Systemic Shunt Surgery - Case Series of 40 Cases Performed at a Single Tertiary Care Centre

Introduction: Portal hypertension is seen when there is pathological increase in hepatic venous pressure gradient. Portal hypertension is seen in a number of conditions like extra-hepatic portal venous obstruction, cirrhosis of liver, non cirrhotic portal fibrosis, portal vein thrombosis from various causes. Surgical Porto systemic shunts are a time proven modality for treating portal hypertension. These patients present as recurrent variceal bleeding, ascites, encephalopathy. This is a case series on Porto systemic shunting done in patients in a single tertiary care centre. Method: Retrospective study of 40 cases performed in a single tertiary care centre performed over 5 years from 2012 to 2016, along with comparison with the existing data on Porto systemic shunt surgeries. Results: From amongst the 40 patients cases of extra-hepatic portal venous obstruction were 75%, non cirrhotic portal fibrosis were 15%, portal vein thrombosis were 5%, cirrhotic patients were 5%. There was no immediate peri-operative mortality. 4 year shunt patency was 97%. Recurrent variceal bleeding was seen in 5%. Encephalopathy was seen in 1%. Re-intervention was required in 3%. 4 year survival was 96%. Conclusions: Surgical Porto systemic shunts remain time tested efficacious modality in management of portal hypertension. Porto systemic shunts have good long term survival benefit with symptomatic relief and improvement of quality of life.

An Update on the Management of Budd-Chiari Syndrome.

Budd-Chiari syndrome (BCS) is an uncommon condition, caused by obstruction to hepatic venous outflow. It is largely underdiagnosed, and a high index of suspicion is required for any patient with unexplained portal hypertension. The understanding of its etiology and pathology is improving with advances in diagnostic techniques. Recent studies reported an identifiable etiology in > 80% of cases. Myeloproliferative neoplasm (MPN) is the most common etiology, and genetic studies help in diagnosing latent MPN. Better cross-sectional imaging helps delineate the site of obstruction accurately. The majority of BCS patients are now treated by endovascular intervention and anticoagulation which have improved survival in this disease. Angioplasty of hepatic veins/inferior vena cava remains under-utilized at present. While surgical porto-systemic shunts are no longer done for BCS, liver transplantation is reserved for select indications. Some of the unresolved issues in the current management of BCS are also discussed in this review.

Surgical intervention for portal hypertension caused by oxaliplatin-based chemotherapy: a case report and a review of literature regarding radiological and/or surgical interventions for oxaliplatin-associated portal hypertension

A 63-year-old man showed massive ascites, massive pleural effusion, severe lower-extremity edema, and repeated esophageal variceal bleeding. Two-year previously, he received 13-courses of oxaliplatin-based chemotherapy (OBC) followed by associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for multiple colorectal cancer liver metastases but developed a solitary remaining liver metastasis and multiple lung metastases 2 months after the ALPPS, for which multiple regimens of chemotherapy were conducted. The symptoms were considered attributable to the OBC-associated portal-hypertension. Water-retention symptoms were mitigated by the use of tolvaptan but the variceal bleeding necessitated frequent endoscopic treatments and disallowed restarting antineoplastic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) was considered undesirable because TIPS in this patient might have prohibited future repeat hepatectomy. Thus, the patient underwent splenectomy and surgical portosystemic shunting. Since then, the portal-hypertension symptoms were completely resolved. Thereafter, chemotherapy was able to be recommenced. Moreover, repeat hepatectomy was performed. A literature review demonstrated that radiological and/or surgical interventions for the OBC-associated portal-hypertension have been reported in 31 cases to date. However, this report is the first to show a case of successful treatment of the OBC-associated portal-hypertension with splenectomy and surgical portosystemic shunting, which allowed subsequent chemotherapy followed by repeat hepatectomy.

Surgical Portosystemic Shunts: History, Evolution, and Current Applications

AbstractMechanical obstruction, thrombus, intrinsic liver disease causing fibrosis or cirrhosis, or an outflow obstruction at the level of the sinusoids or hepatic venous obstruction can cause an increase in pressure or resistance, or both, leading to portal hypertension (PH). Portosystemic shunts (PSS) are usually performed to relieve the congestion that inevitably occurs in the setting of PH. Since their introduction, surgical PSS were often the treatment of choice to prevent recurrent bleeding in patients with clinically significant PH. Development of novel pharmacological therapies, continuous improvement of endoscopic approaches, the introduction of transjugular intrahepatic portosystemic shunt, and advancements in transplantation has provided an evolution in the approach for PH and has precipitated the steady decrease in the proportion of patients needing surgical shunts. Despite this, PSS remain important tools in the surgeon's armamentarium, as they are often employed in the pediatric population with extrahepatic portal vein obstruction and are frequently being used for portal inflow modulation to achieve better portal hemodynamics in resections and transplantation. This has become of great relevance to decrease the risk of small-for-size syndrome and portal hyperperfusion in liver transplantation, and to decrease the risk of posthepatectomy liver dysfunction after major resections in hepatobiliary surgery.

Current Indications and Long-Term Outcomes of Surgical Portosystemic Shunts in Adults

BackgroundSurgical portosystemic shunts are rare. We reviewed indications, operative details, and outcomes of patients undergoing surgical portosystemic shunt procedures. MethodsWe retrospectively reviewed clinical data of consecutive patients between 1997 and 2018 from a single institution. Clinical characteristics and outcomes were compared between two groups: patients with portomesenteric venous thrombosis (PMVT) vs those with cirrhosis. Endpoints included 30-day mortality, shunt-related complications, patency, and survival. ResultsThere were 99 patients, 45 male and 54 female, with a mean age of 46 ± 18 years, enrolled in the study. There were 63 patients (63%) with PMVT and 36 patients (36%) with cirrhosis. Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for more diabetes among those with cirrhosis (p < 0.05). There were no significant differences in procedural metrics and intra-procedure complications between groups, except that patients with PMVT underwent more non-selective shunts than those with cirrhosis (63% vs. 30%, p < 0.001). There were two 30-day deaths (2%), with no difference in mortality and MAEs between groups. On univariate analysis, cholangiopathy and PMVT were associated with graft thrombosis (HR = 9.22, 95% CI 1.22–70.27) while race, smoking, cardiac comorbidity, type of operative shunt, configuration of the shunt, and use of conduit were not (p > 0.05). Patients with PMVT had significantly lower 1-, 5-, and 10-year primary (77%, 71%, and 71% vs. 97%, p = 0.009) and secondary patency (88%, 76%, and 72% vs. 96%, p = 0.027) compared with those with cirrhosis. The 1-, 5-, and 10-year survival rates were 94%, 84%, and 61% for patients with PMVT compared with 88%, 58%, and 26% for those with cirrhosis (non-adjusted HR 0.40, 95% CI 0.19–0.84, p = 0.01, age-adjusted HR 0.51, 95% CI 0.24–1.09, p = 0.08). The survival of patients with PMVT without liver disease trended higher than those with liver disease; however, when adjusted for age, the survival gap narrowed, and the difference was not statistically significant (p = 0.19), survival being lowest for those with PMVT and liver disease. ConclusionsSurgical portosystemic shunts are safe and effective for symptom relief in selected patients with portal hypertension. The odds of graft thrombosis is 9 times higher in patients with PMVT. Overall survival is similar in patients with PMVT or cirrhosis.

Long-term Outcome of Transjugular Intrahepatic Portosystemic Shunt in Children With Portal Hypertension.

A proportion of children with chronic liver disease have severe portal hypertension (PH) and a preserved synthetic and biliary function. In our institution these children have been managed with transjugular intrahepatic portosystemic shunts (TIPS). We aimed to evaluate the long-term patency of TIPS placed in pediatric patients with PH. Retrospective study of children who underwent TIPS in the last 15 years. We compared patients with cirrhotic PH to those with noncirrhotic PH, and all with an historical cohort of children who underwent a surgical portosystemic shunt. Kaplan-Meier analysis measured long-term shunt patency. Twenty-nine patients were recorded (cirrhotic PH = 11, noncirrhotic PH = 18, mean age 10.3 years[±4.3], mean weight 36.7 kg [±20.1], mean pediatric end-stage liver disease score 4.1 [±7.1]); in 5 TIPS was placed after split liver transplantation. Indication for TIPS was variceal bleeding in 18, refractory ascites in 11. Primary patency rates at 6 months and at 1, 2, and 4 years were 91%, 83%, 60%, and 46%, respectively. At last follow-up (mean of 2.8 years [±2.4, range 0.1-8.1 years]) secondary patency (after radiological revision) was 100%. The patency rate of the historical cohort of patients who underwent a surgical portosystemic shunt was 26 of 31 (82%) at a median follow-up of 12.5 years (1.6-25.8). TIPS appears to have a high mid-term patency rate, especially if monitored and revised. Its high clinical success rate, along with a minimally invasive approach, suggests that in this setting TIPS should not be regarded only as a bridge to liver transplantation.

Spleen stiffness measurement as a non-invasive test to evaluate and monitor portal hypertension in children with extrahepatic portal vein obstruction.

The aim of the study was to test the feasibility of spleen stiffness measurement (SSM) by two-dimensional shear wave elastography (2D-SWE) and compare data on its diagnostic use with upper gastrointestinal endoscopy in children with extrahepatic portal hypertension (EHPH) before and after surgery. A total of 44 children were included in this study [34 children with EHPH (main group)] and 10 controls (7.57 ± 1.22years), who underwent ultrasonography including SSM by 2D-SWE. Patients in the main group also underwent upper gastrointestinal endoscopy (UGE) and CT angiography. The main group was divided into three subgroups: Group A: patients with EHPH without large spontaneous portosystemic shunts (n = 15); Group B: patients with EHPH with large spontaneous portosystemic shunts (n = 9); Group C: patients with EHPVO and after surgical portosystemic shunts (n = 10). According to UGE, children in group A had significantly higher grades of esophageal varices (EV) (2.3 ± 0.14; p < 0.001) compared to those in groups B and C. After surgical shunting procedures (in group C), the grade of EV declined to 0.37 ± 0.14. There was significant difference (p < 0.001) in the mean SS of children in group A (70 ± 4.64kPa) compared to those in group B (37.04 ± 4.62kPa) and group C (26.3 ± 2.9kPa). After surgery, SS decreased but remained elevated compared with controls (26.3 ± 2.9 vs 17.85 ± 1.3kPa; p = 0.016). The SS showed a small but significant correlation with grades of EV (r = 0.56, p = 0.002). The SS measured by 2D-SWE is feasible in children with EHPH and the results reflect the presence or degree of EV, thus elastography of spleen is useful in monitoring portal hypertension before and after shunt surgeries.

The effect of neuraxial morphine on postoperative pain in dogs after extrahepatic portosystemic shunt attenuation

ObjectiveTo investigate the analgesic effect of epidural morphine after surgical extrahepatic portosystemic shunt (EHPSS) attenuation. Study designRandomized clinical trial. AnimalsA total of 20 dogs with a congenital EHPSS. MethodsDogs were randomly allocated to be given either a single epidural dose of 0.2 mg kg–1 preservative-free morphine (group M) or not (group C) before surgery. All dogs were administered 0.3 mg kg–1 methadone intravenously (IV) as preanaesthetic medication. Pain scores were determined every 2 hours for the first 24 hours postoperatively using the short-form Glasgow Composite Measure Pain Scale (GCMPS-SF). Dogs with a GCMPS-SF pain score >4/20 or >5/24 received 0.1 mg kg–1 methadone IV as rescue analgesia and were reassessed 30 minutes later. If more than three doses of methadone were administered in a 2 hour period, alternative pain relief was provided and a treatment failure recorded. The GCMPS-SF pain scores and number of rescue analgesia injections were analysed over 24 hours. The last observation carried forward method was applied in case of treatment failure. Food consumption and time to first urination were recorded. Data were analysed using a Mann–Whitney U test and presented as median (minimum–maximum range), with significance set at p < 0.05. ResultsGroup M showed lower GCMPS-SF pain scores [15 (11–41) versus 31 (11–86); p = 0.023] and lower postoperative methadone requirements [0 (0–0.2) versus 0.25 (0–0.5) mg kg–1; p = 0.029] than group C. There were three treatment failures in group C only. Food consumption and time to first urination did not differ between groups. Conclusions and clinical relevanceEpidural morphine reduced the requirement for postoperative analgesia in this study population.

Surgical Mesoportal Bypass and Portosystemic Shunt Interventions

AbstractExtrahepatic portal vein obstruction is defined by obstruction of the extrahepatic portal vein with or without involvement of the intrahepatic veins and does not include isolated thrombosis of the splenic vein or superior mesenteric vein. The etiology may be congenital versus acquired and acute versus chronic. Historically, surgical intervention has been reserved for patients with symptoms refractory to medical or endoscopic management. Over time, however, advances in surgical technique and research have caused a shift in practice. The interventionalists' role is primarily to address clinically significant shunt dysfunction, including shunt stenosis and thrombosis. In this article, the authors discuss the classification and indications of surgical portosystemic conduits, pre-and postoperative imaging, and clinical signs, and endovascular techniques to address shunt dysfunction.

Endovascular treatment of surgical mesoportal and portosystemic shunt dysfunction in pediatric patients

Published data describing the endovascular treatment of dysfunctional mesoportal and portosystemic shunts in the pediatric population are limited. We sought to describe the treatment and follow-up of such shunts managed by interventional radiology at a single pediatric hospital. We hypothesized that stenotic and occluded pediatric portosystemic and mesoportal shunts can be maintained patent by interventional radiology in the moderate term. We conducted a single-center retrospective study at a tertiary pediatric hospital. We included children with surgical mesoportal (meso-Rex) or portosystemic (mesocaval, splenorenal or splenocaval) shunts treated with attempted angioplasty or stenting from 2010 to 2018. Technical success was defined as catheterization and intervention upon the shunt with venographic evidence of flow improvement. The primary outcome variables were shunt patency at 1month, 6months, 12months and 24months post-procedure and freedom from reintervention. Twenty pediatric patients (11 boys, 9 girls; mean age 8.25years, range 1.3-17years) met inclusion criteria. Fifty-two interventions (primary and reintervention) on 13 splenorenal, 3 meso-Rex, 2 mesocaval and 2 splenocaval shunts were performed because of evidence of shunt failure, including gastrointestinal bleeding, hypersplenism, or radiographic evidence of a flow defect. The 11 stenotic shunts were treated with 100% technical success, while the remaining 9 occluded shunts were treated with 66.7% technical success. The mean number of reinterventions was 1.9 (standard deviation [SD] = 3.1) per child, which did not differ between stenotic and occluded shunts (P=0.24). Primary patency at 1-month, 6-month, 12-month and 24-months follow-up visits was 17/17 (100%), 10/16 (62.5%), 7/15 (46.7%) and 4/10 (40%), respectively. However, 100% of shunts were either primary patent or primary-assisted patent by endovascular reintervention. There were no cases of shunt occlusion following initial technical success. Finally, the median freedom from reintervention duration was 387days (SD=821days). Dysfunctional portosystemic surgical shunts are effectively managed by endovascular methods. While many shunts require reintervention, combined primary patency and assisted primary patency rates are excellent.

Comparision between portosystemic shunts and endoscopic therapy for prevention of variceal re-bleeding

Background:Portosystemic shunts, including surgical portosystemic shunts and transjugular intra-hepatic portosystemic shunt (TIPS), may have benefit over endoscopic therapy (ET) for treatment of variceal bleeding in patients with cirrhotic portal hypertension; however, whether there being a survival benefit among them remains unclear. This study was to compare the effect of three above-mentioned therapies on the short-term and long-term survival in patient with cirrhosis.Methods:Using the terms “variceal hemorrhage or variceal bleeding or variceal re-bleeding” OR “esophageal and gastric varices” OR “portal hypertension” and “liver cirrhosis,” the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the references of identified trials were searched for human randomized controlled trials (RCTs) published in any language with full texts or abstracts (last search June 2017). Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated using random effects model by Review Manager. The quality of the included studies was evaluated using the Cochrane Collaboration's tool for the assessment of the risk of bias.Results:Twenty-six publications comprising 28 RCTs were included in this analysis. These studies included a total of 2845 patients: 496 (4 RCTs) underwent either surgical portosystemic shunts or TIPS, 1244 (9 RCTs) underwent either surgical portosystemic shunts or ET, and 1105 (15 RCTs) underwent either TIPS or ET. There was no significant difference in overall mortality and 30-day or 6-week survival among three interventions. Compared with TIPS and ET, separately, surgical portosystemic shunts were both associated with a lower bleeding-related mortality (RR = 0.07, 95% CI = 0.01–0.32; P < 0.001; RR = 0.17, 95% CI = 0.06–0.51, P < 0.005) and rate of variceal re-bleeding (RR = 0.23, 95% CI = 0.10–0.51, P < 0.001; RR = 0.10, 95% CI = 0.04–0.24, P < 0.001), without a significant difference in the rate of postoperative hepatic encephalopathy (RR = 0.52, 95% CI = 0.25–1.00, P = 0.14; RR = 1.09, 95% CI = 0.59–2.01, P = 0.78). TIPS showed a trend toward lower variceal re-bleeding (RR = 0.46, 95% CI = 0.36–0.58, P < 0.001), but a higher incidence of hepatic encephalopathy than ET (RR = 1.78, 95% CI = 1.34–2.36, P < 0.001).Conclusions:The overall analysis revealed that there seem to be no short-term and long-term survival advantage, but surgical portosystemic shunts are with the lowest bleeding-related mortality among the three therapies. Surgical portosystemic shunts may be the most effective without an increased risk of hepatic encephalopathy and TIPS is superior to ET but at the cost of a higher incidence of hepatic encephalopathy. However, some of findings should be interpreted with caution due to the lower level of evidence and the existence of significant heterogeneity.

For adults with cirrhosis and variceal hemorrhage, how do surgical and transjugular intrahepatic portosystemic shunts compare?

For adults with cirrhosis and variceal hemorrhage, how do surgical and transjugular intrahepatic portosystemic shunts compare?

Current clinical indications and midterm outcomes of surgical portosystemic shunts in adults

Background: Portosystemic shunts were originally described for the management of bleeding varices due to cirrhosis. However, in the era of transjugular intrahepatic portosystemic shunts and liver transplant, these procedures are increasingly rare. We reviewed indications, operative details and outcomes of patients undergoing surgical portosystemic shunt procedures. Methods: Clinical and procedural details of consecutive patients undergoing creation of a portosystemic shunt from Jan 1997 to August 2018 were reviewed retrospectively. Endpoints were mortality, primary patency, secondary patency and shunt-related complications. Clinical success was defined as postoperative resolution of the primary symptoms for which the shunt was performed. Univariate Cox regression analysis was performed to search for risk factors for graft thrombosis (loss of primary patency). Subsequently, we compared patency and survival in subgroups: Group I: patients with cirrhosis vs those with non-cirrhotic portal hypertension and Group II: patients with computed tomography signs of portomesenteric venous thrombosis (PMVT) vs those without PMVT. Results: Surgical portosystemic shunts were performed in 99 patients (54 female, mean age 46 years). Indications were refractory gastrointestinal bleeding in 75; ascites in 24; secondary to PMVT in 63 (portal n = 46, hepatic n = 15, splenic n = 17, superior mesenteric vein n = 16) and cirrhosis in 36. PMVT was unprovoked in 45 patients (thrombophilia identified in 17). Comorbidities included hypertension (21), diabetes (16), hyperlipidemia (8), coronary artery disease (5) and smoking (16); average MELD score was 8. Shunts were nonselective in 45 (portocaval n = 25, mesocaval n = 17, mesorenal n= 2, rex n = 1) and selective in 50 (distal n = 6, central n = 48). Procedural success was 99%; average length of stay was 8 (3–122) days. Complications occurred in 55% [hematoma (23), bowel ischemia in (3), encephalopathy in (19), new PMVT (10)]. Early mortality was 2% (1 pulmonary embolism, 1 coagulopathy). Early graft thrombosis occurred in 9; 7 underwent re-intervention (1 endovascular, 6 open- patency restored in 3). Symptom relief was not achieved in 6 with early graft thrombosis. It was complete in 76; partial in 6 (3 patent, 2 thrombosed) and recurrent in 3 (graft thrombosis). Therapeutic anticoagulation was prescribed in 35. The median clinical follow-up was 3.2 (1-20) years and imaging follow-up 1 (1–20) years. On Kaplan-Meier analysis, overall survival was 90%, 73% and 49%; primary patency 84%, 82% and 82%; secondary patency 90%, 85% and 82% at 1, 5 and 10 years respectively. The risk of loss of primary patency [HR of 9.22 (95% CI 1.22–70.27, p = 0.032] but not secondary patency was higher in Group II (Fig 1) with no difference in age adjusted survival in either group. No other predictive factors for shunt thrombosis were identified. Conclusion: Surgical portosystemic shunts are safe and effective for symptom relief in selected patients with portal hypertension. The risk of graft thrombosis is 9-times higher in patients with PMVT and is not influenced by use of therapeutic anticoagulation. Overall survival is similar in those with/without cirrhosis or PMVT. Rethrombosis is associated with symptom recurrence; open re-intervention is advisable for symptom relief when suitable targets are available.

Passive mesenterico-saphenous shunt: An alternative to portocaval anastomosis for tailored portal decompression during liver transplantation

Temporary portocaval shunt has a positive impact on short-term outcomes after liver transplantation. An alternative to temporary portocaval shunt is a distal passive decompression through mesenterico-saphenous shunt. The purpose of this study was to compare outcomes of these two types of surgical portosystemic shunt and discuss their respective place during the anhepatic phase. Patients transplanted with portal decompression during a 4-year period were included. Patients were compared according to two types of surgical decompression techniques: temporary portocaval shunt (n = 44) and mesenterico-saphenous shunt (n = 77). Spontaneous >5-mm portosystemic shunts were described as absent, nonpersistent, distal, or proximal. Intraoperative portal pressure variations and inhospital course were compared between the two groups, with special attention on the impact of competing spontaneous and surgical shunts. Mesenterico-saphenous shunt and temporary portocaval shunt showed a comparable hemodynamic efficiency, with no significant difference in terms of portal pressure variations. We found no significant difference in terms of reperfusion syndrome (P = .956), transfusion rate (P = .575), renal failure (P = .239) nor early allograft dysfunction (P = .976). There was a significantly higher risk of early allograft dysfunction when competing surgical and spontaneous shunts were used (P = .002) with a lesser hemodynamic efficiency (analysis of variance test; P = .04). Portacaval or mesenterico-saphenous shunts offer similar hemodynamic efficiency without impacting the outcomes after liver transplantation. Their respective place and the place of portal decompression should be discussed regarding the presence of portal thrombosis and pre-existing portosystemic shunts. Evaluation of the anatomy and the efficiency of these shunts may guide tailored portal decompression.