Repeated Shunt Surgery in a Patient with Portal Hypertension

Summary: A 45-year-old male with chronic active hepatitis and portal hypertension had a mesocaval interposition graft performed because of repeated uncontrolled bleeding from oesophageal varices. Acute hepatocellular failure, manifested by Grade IV encephalopathy and severe coagulopathy, developed early in the post-operative course despite the absence of hepatic necrosis or other precipitating factors. Both encephalopathy and coagulopathy resolved rapidly following ligation of the shunt. Variceal bleeding recurred and nine months later an emergency distal lienorenal shunt was performed. Post-operatively the shunt was shown to be patent and there has been no encephalopathy or recurrence of variceal bleeding. It is concluded that (1) the splanchnic haemodynamic effects of a mesocaval interposition graft can result in severe hepatocellular failure and this can be reverted by shunt ligation and (2) the distal lienorenal shunt, while effectively reducing the risk of haemorrhage from varices, may be less likely to result in post-operative encephalopathy than more conventional forms of portal decompressive surgery.     

Closure of Interposition Mesocaval Shunt in a Case of Idiopathic Portal Hypertension

Interposition mesocaval shunt for hemorrhagic esophageal varices was carried out in a patient with idiopathic portal hypertension without preoperative hepatic dysfunction. The esophageal varices were controlled, but the hemodynamics of the portal vein subsequently underwent gradual change and attacks of hepatic encephalopathy occurred frequently the following year. Therefore, the shunt was closed after about 2 yr. Hepatic encephalopathy disappeared after this surgery, but the varices obviously worsened on the 5th postoperative day and bled spontaneously on the 33rd postoperative day. A distal splenorenal shunt constructed 35 days after the operation resulted in the reduction, but not the complete disappearance, of esophageal varices. Episodes of hepatic encephalopathy or bleeding from the esophageal varices were not observed in the 24 months following the second shunt surgery.     

Hepatic encephalopathy verified by psychometric testing and EEG in cirrhotic patients: effects of mesocaval interposition shunt or sclerotherapy

Background. The aim of this randomised prospective study was to evaluate hepatic encephalopathy after mesocaval interposition shunt operation and after repeated endoscopic sclerotherapy. Methods. Forty-five patients with bleeding oesophageal varices due to liver cirrhosis were randomised to the two treatment groups, 24 to the shunt group and 21 to the sclerotherapy group. The patients were evaluated preoperatively regarding blood tests, hepatic encephalopathy as measured by electroencephalogram with spectral analysis and by a battery of psychometric tests. The direction of portal flow in the shunt group was investigated by shunt phlebography and ultrasonography with Doppler. During follow-up the same investigations were performed twice at median 6.7 and 14.7 months after operation. Results. No statistically significant difference was found during follow-up regarding blood tests and electroencephalography with spectral analysis. Although the preoperative psychometric tests showed that the shunt group performed significantly better than the sclerotherapy group, the first follow-up showed that the shunt group performed statistically worse than the sclerotherapy group in seven of the tests: Synonyms (measuring verbal ability), Block Design Test (measuring visuo-spatial ability), Memory for Design Test, Error Score (measuring memory function), Revised Visual Retention Test, correct answers and the same test error answers (measuring visuo-spatial memory, ability and immediate memory), Digit Symbol Test (measuring perceptual ability) and Trial Making Test B (measuring cognitive motor abilities). Conclusions. Patients treated by mesocaval interposition shunt showed a progressive general reduction in psychometric performance compared with patients treated with repeated sclerotherapy, in whom a general intellectual improvement was observed. This finding corresponds to the reverse direction of the preoperative portal flow to a hepatofugal pattern at first follow-up and at 12 months among two-thirds of the patients.     

Complications and limitations of injection sclerotherapy in portal hypertension.

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.     

Inferior mesocaval shunt for bleeding anorectal varices and portal vein thrombosis

Intractable bleeding from anorectal varices is a serious and often misdiagnosed complication of portal hypertension and no agreement has been reached on which could be the optimal diagnostic and therapeutic strategy. Indeed, fatal outcome has been often reported resulting from delayed diagnosis and improper treatment. The case of a 67-year-old gentleman with life-threatening bleeding from anorectal varices who successfully underwent inferior mesocaval shunt is reported, and surgical technique for establishing a shunt between the inferior mesenteric vein and inferior vena cava is described. A review of other therapeutic options is presented and results are discussed and compared to those obtained with this novel form of treatment. In our experience, immediate control of recurrent bleeding from anorectal varices was obtained with inferior mesocaval shunt. Technical ease, promptness of action and effectiveness, low procedure-related morbidity are the main features of the shunt. With the introduction of new promising second-line treatment modalities to primary and metastatic liver tumors, like percutaneous radiofrequency thermal ablation, and improvement in outcome of portal vein thrombosis, the inferior mesocaval shunt may represent a sound alternative for patients who are ineligible for transjugular intrahepatic portosystemic shunt or presenting with clotted shunt.     

Encephalopathy following portal shunting in nodular regenerative hyperplasia of the liver

Two patients with nodular hyperplasia of the liver developed a chronic disabling encephalopathy after an interposition mesocaval shunt. Both had a low total hepatic blood flow-rate postoperatively. Encephalopathy disappeared following surgical occlusion of the shunt. These observations emphasize the risk of postshunt encephalopathy in patients with non-cirrhotic intrahepatic portal hypertension.     

Selective transplenic decompression of oesophageal varices by distal splenorenal and splenocaval shunt

The usefulness of selective transplenic decompression of oesophageal varices by distal splenorenal shunt and splenocaval shunt was evaluated in the control of gastrointestinal haemorrhage in patients with portal hypertension of varied aetiology. (Decompression was successful in 69 out of 78 cases.) It was shown that it is superior to total portosystemic shunts, as the incidence of encephalopathy was very low compared with the data from our series of portocaval shunts. The operative mortality has been progressively lowered and has now reached levels comparable with portocaval shunt. Distal splenorenal shunt when performed as an emergency procedure to arrest bleeding has limited usefulness but when performed as an elective or prophylactic procedure its results are comparable with those of portocaval shunt without the untoward complications such as encephalopathy. A modified selective decompression of varices has been described in which the distal end of the splenic vein is anastomosed to the inferior vena cava. Though no long term follow-up studies are available, we believe that this shunt is likely to prove superior to distal splenorenal shunt as it has both the advantages of the distal splenoral and the haemodynamic advantage of end-to-side portocaval shunt. We conclude that in patients with portal hypertension of varied aetiology, who have not had a haemorrhagic episode but in whom varices have been demonstrated or who have had one episode of haemorrhage from varices, the splenocaval shunt when feasible or the distal splenorenal shunt offers the optimal method of management at present in India.     

Subtotal Splenectomy and Central Splenorenal Shunt for Treatment of Bleeding from Roux En Y Jejunal Loop Varices Secondary to Portal Hypertension

Purpose To present subtotal splenectomy and splenorenal shunt as a surgical option to treat severe bleeding from a Roux en Y jejunal loop varices secondary to portal hypertension. Method A 64-year-old white woman presented severe episodes of bleeding from varices inside a Roux en Y jejunal loop secondary to portal hypertension due to cirrhosis. Subtotal splenectomy was performed with preservation of the upper splenic pole supplied by the splenogastric vessels. This procedure was combined with a central splenorenal shunt to divert part of portal blood to systemic flow. Results This procedure was safely performed with no complications. A 2-year post-operative follow-up of the patient has been uneventful. No re-bleeding occurred during this period and she returned to her normal life. Conclusion Subtotal splenectomy combined with central splenorenal shunt seems to be a safe procedure useful for the treatment of enteral bleedings due to portal hypertension.     

Management of rectal varices in portal hypertension

Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.     

Thrombin Injection for Bleeding Duodenal Varices

Bleeding from duodenal varices, although rare, is often massive and life threatening. Duodenal varices are more common in extrahepatic portal venous obstruction. We report a patient with recurrent bleeding from duodenal varices, secondary to thrombosed portal vein, splenic vein, and mesocaval shunt, who was successfully managed by injection of thrombin.     

Treatment of hepatocellular carcinoma occurring after distal splenorenal shunt for esophagogastric varices

BACKGROUND/AIMS: Whereas endoscopic therapy is hardly effective, distal splenorenal shunt is expected to have permanent hemostatic effects on the esophagogastric varices complicated with hepatocellular carcinoma and to sustain favorable general condition of the patient. In this study, we examined the effects of the shunt in the patients who developed hepatocellular carcinoma during the follow-up of the shunt operation. METHODOLOGY: Among the patients who had undergone distal splenorenal shunt operation for portal hypertension caused by cirrhosis, we selected only those who developed hepatocellular carcinoma during the follow-up, and then we reviewed our treatment of hepatocellular carcinoma. RESULTS: Hepatocellular carcinomas developed postoperatively in 12 out of 59 patients with the shunt operation. At onset of the carcinomas, the varices were well controlled with no risk of bleeding; and the liver function was reasonably maintained and pancytopenia was alleviated, compared to those at shunt operation. We performed hepatectomy in 4 cases and nonoperative therapies in 8 cases. After the therapies, no variceal bleeding occurred. Those therapies caused minor complications but no death. CONCLUSIONS: Distal splenorenal shunt is a useful therapy for postcirrhotic esophagogastric varices as it enables us to safely perform therapies for the hepatocellular carcinomas that develop during the follow-up period.     

Prophylactic surgery in non-cirrhotic portal fibrosis:is it worthwhile?

BACKGROUND: In cirrhotic patients with portal hypertension prophylactic portasystemic shunts have been found to be ineffective as deaths from post-shunt liver failure exceed those from bleeding. However, in patients with non-cirrhotic portal hypertension, variceal bleeding rather than liver failure is the common cause of death. In developing countries shortage of tertiary health-care facilities and blood banks further increases mortality due to variceal bleed. AIM: To study the results of prophylactic operations to prevent variceal bleeding in patients with portal hypertension due to non-cirrhotic portal fibrosis (NCPF). METHODS: Between 1976 and 2001, we performed 45 prophylactic operations in patients with NCPF, if the patients had high-risk esophagogastric varices or symptomatic splenomegaly and hypersplenism. Proximal lienorenal shunt was done in 41 patients and the remaining underwent splenectomy with (2 patients) or without (2 patients) devascularization. RESULTS: There was no operative mortality. Thirty-eight patients were followed up for a mean 49 (range, 12-236) months. Three patients bled - one was variceal and two due to duodenal ulcers; none died of bleeding. There were 2 late deaths (6 weeks and 10 years after surgery), one from an unknown cause and one due to chronic renal failure. The delayed morbidity was 47%. This included 7 patients who developed portasystemic encephalopathy, 4 glomerulonephritis, 2 pulmonary arteriovenous fistulae and 5 ascites requiring treatment with diuretics. Thus only 20 (53%) patients were symptom-free on follow up. CONCLUSIONS: Prophylactic surgery is safe and effective in preventing variceal bleeding in NCPF but at the cost of high delayed morbidity.     

Recurrent bleeding from cutaneous venous collaterals in portal hypertension

In portal hypertension, three types of cutaneous portosystemic collaterals may develop: the 'classical' caput Medusae, enterostomal varices and scar or adhesion-related abdominal collaterals. Two patients were treated with severe and recurrent bleeding from adhesion-related collaterals, a complication not reported previously. In the first patient bleeding was only controlled by mesocaval shunt operation; the second patient suffered no further recurrence after local sclerotherapy.     

Portale Hypertension

Bleeding of gastro-oesophageal varices is one of the most serious complications of portal hypertension. An early endoscopic examination of patients with cirrhosis has become standard practice because direct measurement of portal pressure is not universally available. If varices are present prophylaxis to prevent bleeding can be achieved by non-selective betablocker therapy. In the face of contraindications or intolerance to this therapy, endoscopic band ligation is an alternative prevention strategy for high-risk patients. Acute variceal haemorrhaging can be controlled in about 90% of the cases by endoscopic sclerotherapy or band ligation. In addition, vasoactive drugs like octreotide or terlipressin can be used to reduce portal pressure and to control haemorrhaging. Prevention of recurrent bleeding can be achieved through a consistent band ligation. The most promising therapy for gastric variceal bleeding is the injection of histoacryl. In cases of endoscopic treatment failure, a balloon tamponade or a portosystemic shunt are rescue treatment options.     

Clinical significance and prediction factors of gastric varices in patients with hepatocellular carcinoma

BACKGROUND/AIMS: Hepatocellular carcinoma is part of the natural history of liver cirrhosis. Gastrointestinal bleeding and hepatic failure are the leading causes of death in hepatocellular carcinoma patients. With gastrointestinal bleeding, variceal bleeding is the most prominent, and most variceal bleeding is of esophageal origin. Gastric varices bleeding is often a massive and severe bleeding episode. The role of gastric varices among patients with hepatocellular carcinoma remains to be clarified. In this study, we aimed to evaluate the prevalence, clinical significance and prediction of gastric varices in patients with hepatocellular carcinoma. METHODOLOGY: From 1998 to 2000, we reviewed 304 patients with hepatocellular carcinoma receiving upper gastrointestinal endoscopic examinations. Patients' clinical characteristics, physical findings, laboratory data, image studies, endoscopic examinations and treatment were reviewed. RESULTS: Among 304 patients with HCC, twenty-one (6.9%) had gastric varices among 304 patients with hepatocellular carcinoma. The location of gastric varices were the posterior wall in 12 (57%), the lesser curvature in 1 (5%), the greater curvature in 4 (19%) and the fundus in 4 (19%). Three (14%) of these 21 patients with hepatocellular carcinoma and gastric varices had clinical evidence of bleeding. One of them died due to uncontrollable bleeding. Child-Pugh classification, hepatic encephalopathy, portal vein or splenic vein dilatation, ascites, splenomegaly, albumin level, prothrombin time and platelet count were significantly different between hepatocellular carcinoma patients with gastric varices and without gastric varices under the univariate analysis. Ascites (Odds ratio: 5.45; 95% confidence interval: 2.12-14.01) and portal vein or splenic vein dilatation (Odds ratio: 4.38; 95% confidence interval: 1.77-10.86) were the two most important predictors under the stepwise logistic regression analysis. CONCLUSIONS: The prevalence of gastric varices in patients with hepatocellular carcinoma is 6.9% and the risk of bleeding is low in this study. The Predictors of gastric varices among hepatocellular carcinoma are related to liver cirrhosis, Child-Pugh classification, hepatic encephalopathy, portal vein or splenic vein dilatation, ascites, splenomegaly, albumin level, prothrombin time and platelet count.     

Diagnosis and management of ectopic varices

Abstract   Ectopic varices are dilated portosystemic venous collateral vessels that may occur anywhere in the gastrointestinal tract. Ectopic varices account for approximately 5% of all hemorrhages from varices. Ectopic varices may occur as a result of portal hypertension from any cause but are more common (particularly duodenal and biliary varices) in patients with extrahepatic portal vein thrombosis. Ectopic varices may also develop following successful endoscopic obliteration of gastroesophageal varices. With the exception of isolated gastric fundal varices, ectopic varices have relatively low risk for bleeding. Diagnosis is often made by endoscopy; however, computed tomography, magnetic resonance imaging and portal venography may be needed in some cases. Endoscopic treatment is successful in many cases and is the safest option provided bleeding is definitively controlled. Surgical options are now reserved for treatment of life-threatening bleeding or for shunt insertion in patients who are not candidates for transjugular intrahepatic portosystemic shunt (TIPS) as a result of portal vein thrombosis. Portal decompression using TIPS, in spite of the risk for encephalopathy, is the treatment of choice for bleeding from ectopic varices that cannot be successfully managed endoscopically.     

Hemodynamic tolerance and rapid hypertrophy of a hepatic graft corresponding to less than 30% of the ideal mass in pigs

BACKGROUND AND OBJECTIVE: Evaluation of a new pig liver transplantation technique for survival and hypertrophy of a small-sized graft by providing adapted and controlled venous portal flow. MATERIAL ET METHODS: Twenty Large-White pigs underwent heterotopic liver transplantation after a mesocaval shunt and ligation of the superior mesenteric vein downstream from the shunt. The donor-to-recipient weight ratio was below 30%. Furthermore, recipient's biliary duct and portal vein into the hilum were tied. In a control group, no mesocaval shunt was performed and the graft received the entire splanchnic venous flow. RESULTS: The mesocaval shunt provided diversion of 60% of the splanchnic blood flow. The median survival of study pigs was 39 days (range: 8-98). Median serum bilirubin levels at 1 week were 12 micromol/L (range: 4-59). At autopsy, graft weight was increased to 2.7 times the initial weight and histological findings were normal. In the control group, all pigs died quickly from acute splanchnic congestion. CONCLUSION: In a model of heterotopic liver transplantation using small-sized grafts, complete diversion of mesenteric blood flow through a mesocaval shunt resulted in hemodynamic tolerance and hypertrophy of a graft corresponding to less than 30% of the ideal mass.     

Pattern of Serum Amino Acids in Patients with Liver Cirrhosis

The serum amino acid pattern was studied in 30 patients with alcoholic liver cirrhosis, in 15 patients with non-alcoholic cirrhosis, and in nine healthy controls. Patients with alcoholic liver cirrhosis had significantly increased serum levels of aspartic acid, proline, methionine, tyrosine, phenylalanine, and tryptophan compared with controls. Valine was significantly decreased. Patients with non-alcoholic liver cirrhosis differed from patients with alcoholic liver cirrhosis only in having significantly greater serum levels of glycine. The serum amino acid pattern of nine cirrhotic patients who underwent mesocaval interposition shunt surgery because of bleeding esophageal varices was prospectively compared with that of nine matched patients treated with transesophageal sclerotherapy. A further significant increase in methionine and tyrosine serum levels was noted after shunt surgery. It is concluded that sclerotherapy influences serum amino acids less, which might be an advantage in relation to the development of hepatic encephalopathy.     

Transjugular intrahepatic portasystemic stent shunting for control of acute and recurrent upper gastrointestinal haemorrhage related to portal hypertension.

The insertion of a transjugular intrahepatic portasystemic stent shunt (TIPSS) was evaluated in 22 patients with recurrent upper gastrointestinal haemorrhage related to portal hypertension (bleeding from oesophageal varices 10, gastric varices six, portal hypertensive gastropathy six). TIPSS was successfully performed electively in 15 patients and as an emergency in three patients. Twelve patients have had no further admissions with bleeding after TIPSS. Single episodes of bleeding were noted in six patients after TIPSS associated with shunt thrombosis (two), intimal hyperplasia within the shunt (two), and shunt migration (one). Another patient presented with reaccumulated ascites suggesting poor shunt function but died from massive variceal haemorrhage before further assessment could be performed. There was one death related to the procedure. Two patients developed encephalopathy after TIPSS, in one patient this was controlled by the insertion of a smaller diameter stent within the existing TIPSS. Several complications arose in earlier patients that have not recurred after modification of the initial technique. TIPSS can be life saving and is effective in controlling variceal haemorrhage and rebleeding from oesophageal or gastric varices and portal hypertensive gastropathy. Larger and longer term studies are required, however, to define the role of TIPSS in the overall management of such patients.     

Analysis of hepatofugal flow in portal venous system using ultrasonic Doppler duplex system

Blood flow directions of the portal trunk, splenic vein, and superior mesenteric vein were studied using an ultrasonic Doppler duplex system in 146 healthy adults, 132 patients with liver cirrhosis, 76 with hepatocellular carcinoma, 32 with idiopathic portal hypertension, 134 with chronic hepatitis, 18 with acute hepatitis, and 142 with other diseases. Spontaneous hepatofugal flow in one or more of the three vessels examined was detected in 14 patients. Spontaneous hepatofugal flow in the portal trunk was detected in three patients with liver cirrhosis. In two of these three patients, the hepatofugal flow in the portal trunk disappeared after medication. This is interesting, since hepatofugal flow may, in fact, be more common than we suspected in patients who, because of the severity of their disease, are not able to undergo invasive examination. Postoperative hepatofugal flow in the portal system was detected in 20 of 71 cases: 15/17 patients after interposition mesocaval shunting, 2/17 after distal splenorenal shunting, 2/31 after splenectomy, and 1/6 after splenic artery occlusion with steel coils. In more than half the cases of interposition mesocaval shunting (9/17 patients), blood flow in the portal trunk was hepatofugal. However, hepatopetal blood flow in the portal trunk was maintained in most cases of distal splenorenal shunting (13/17), showing the merits of this technique as a selective portosystemic shunt operation.