An evaluation of splenopancreatic disconnection as a modification of the distal splenorenal shunt, studied in nonalcoholic patients by sequential angiography

To evaluate the validity and complications of modifying the distal splenorenal shunt (DSRS) by performing splenopancreatic disconnection (SPD), hemodynamic changes in the portal system were assessed by visceral angiography in 93 patients with nonalcoholic portal hypertension during early postoperative follow-up after DSRS. There were 40 patients who underwent DSRS alone and 53 who underwent DSRS plus SPD. Early follow-up angiography showed that portal vein perfusion was well maintained, and that the diameter of the portal vein had decreased significantly by the same degree in both groups. Hepatofugal collaterals for the shunt had developed to a greater extent in the DSRS group, while they were almost completely absent in the DSRS with SPD group. Nevertheless, partial portal vein thrombosis was not detected in the DSRS group, although it was seen in seven (13.2%) of the patients who underwent DSRS plus SPD, in whom the left proximal splenic vein was not visible. The proximal splenic vein was seen in significantly less of the DSRS with SPD patients (47.2%) than the DSRS group patients (85%). In conclusion, SPD more effectively prevented the early postoperative development of collateral pathways for the shunt compared with standard DSRS; however, the possible stagnation of blood flow in the left proximal splenic vein may predispose to a risk of partial portal vein thrombosis developing during the early postoperative period after DSRS with SPD.     

Splanchnic hemodynamic changes after the distal spleno renal shunt

Marked changes in preoperative to postoperative corrected sinusoidal pressures (CSP) occurred in 51 per cent of a series of 51 patients undergoing the distal splenorenal shunt. Twenty patients who had the highest incidence of partial portal vein thrombosis, (48%--Group I), showed minimal pre- to postoperative changes in CSP. Twelve patients (Group II) who increased their CSP to 4 mm Hg or greater had marked postoperative hyperbilirubinemia and decreased portal blood flow. Fourteen patients who decreased their CSP 4 mm Hg or more postoperatively also showed moderate portal blood flow decrease without significant changes in liver enzymes. Morbidity and mortality were not significantly different among the three groups. The significance of these hemodynamic changes is not known.     

The incidence and natural history of thrombus in the portal vein following distal splenorenal shunt.

The incidence of thrombus formation in the portal vein following distal splenorenal shunt was 4% occlusive and 14% nonocclusive from 1974 to 1977, and 6% occlusive and 22% nonocclusive in 1980. The increased incidence was probably due to more aggressive ligation of collaterals on the portal vein. Ten patients with this complication were evaluated prospectively with clinical and biochemical parameters, angiography, and nutrient hepatic perfusion. In this group, one thrombus was occlusive immediately after operation, and nine were nonocclusive: eight of the latter resolved by six months, but one progressed to total thrombosis. There were no demonstrable adverse clinical or biochemical sequelae. Angiography showed continuing portal perfusion in the face of nonocclusive thrombus, but at six months there was increased collateral formation and significant (p less than 0.05) reduction in portal vein diameter, from 20 +/- 4 mm to 14 +/- 5 mm. Nutrient hepatic perfusion at six months, 896 +/- 257 ml/min, was not significantly different from that seen prior to operation, 848 +/- 92 ml/min. It is concluded that the natural history of nonocclusive portal vein thrombus after distal splenorenal shunt is resolution, and management should be expectant.     

肝硬化门静脉高压症不同手术方式与血栓形成

目的分析肝硬化门静脉高压症患者不同手术方式与血栓形成部位及发生率的关系,探讨血栓形成的机制。方法回顾性分析2011年1月至2012年12月间收治的资料完整的72例肝硬化门静脉高压症患者术前术后的临床资料,脾切除＋断流手术25例,选择性断流术15例,脾切除脾肾静脉分流＋断流的联合手术32例,分析术前术后患者的血小板数量、凝血功能、门静脉血流动力学状况与血栓形成的关系。结果①术前在有无门静脉系统血栓形成的两组问各项凝血功能参数差异均无统计学意义,唯门静脉血流速度在血栓组较无血栓组显著减慢（P〈0．05）。②术后有无血栓形成的两组间血小板数量无明显差异,D-二聚体均较正常值为高,但两组间差异无统计学意义。③行断流术的25例患者,在术后2周和2个月时,血栓形成率可达100％,主要为脾静脉血栓,其中12例（48％）合并门静脉主干及分支血栓。④选择性断流术后以脾静脉血栓为主,部分可向门静脉主干或分支蔓延,将胃冠状静脉一食管旁静脉闭塞;部分患者仅显示肠系膜上静脉-胃冠状静脉-食管旁静脉,门静脉主干、分支及脾静脉均闭塞。⑤脾肾静脉分流加断流的联合手术后2个月时血栓形成率最高（75％）,至6个月时下降至41％,为3组中最低（P〈0．01）。主要为门静脉主干和（或）分支血栓,除1例外,肠系膜上静脐-脾静脉-吻合口血流通畅。结论肝硬化门静脉高压症患者的术前、术后门静脉系统血栓形成与凝血功能改变无明显关系。无论何种手术,术后门静脉系统均有血栓形成可能,术式不同其血栓发生的部位可不同,血栓形成主要与门静脉系统血流动力学改变有关。联合手术后,虽门静脉主干及分支内可有血栓形成,但吻合口通畅,基本上无术后再出血,且肝性脑病发生率低、易被处理,应成为首选。     

Hyperbilirubinemia following distal splenorenal shunt

To assess the incidence, pathogenesis, and associated morbidity and mortality of hyperbilirubinemia following the distal splenorenal shunt, hepatic hemodynamics, liver function, and clinical course were evaluated before and after this procedure in 78 cirrhotic patients. Individuals with a peak postoperative bilirubin level greater than 5 mg/dL had a higher preoperative bilirubin concentration, worse Child's score, longer hospital stay, and higher mortality than patients with a peak postoperative bilirubin level less than 5 mg/dL. Mean preoperative and postoperative hepatic portal perfusion and sinusoidal pressure were similar in both groups. When only patients with minimally elevated preoperative bilirubin levels (less than 2 mg/dL) were analyzed, 83% of individuals who developed postoperative hyperbilirubinemia (level, greater than 5 mg/dL) had a major alteration in hepatic hemodynamics as manifested by either complete portal vein thrombosis or a marked change in sinusoidal pressure (greater than 4 mm Hg). Although preoperative hepatic functional reserve is the major determinant of postoperative bilirubin concentration, alterations in hepatic hemodynamics secondary to the distal splenorenal shunt may also play a role.     

门静脉高压症联合手术前后血流动力学变化的临床意义

目的探讨门静脉高压症患者在联合手术前后血流动力学变化的临床意义。方法回顾性分析45例脾切除、贲门周围血管离断加脾肾静脉分流(简称联合手术)患者术前、术中、术后血流动力学的变化及其对临床疗效的影响。结果本组无手术死亡。术后门静脉自由压从(37±8)cmH_2O降至(30±4)cmH_2O,两者相比差异有统计学意义(P<0.05);门静脉入肝血流量从(1098±338)ml/min减至(995±293)ml/min,两者相比差异有统计学意义(P>0.05);肠系膜上静脉血流量从(605±288)ml/min增至(735±293)ml/min,两者相比差异有统计学意义(P<0.05)。42例(93%)患者得到随访,平均随访时间2年6个月,再出血发生率为4%,其中1例死亡。门静脉高压性胃病得到明显缓解,肝性脑病发生率为4%,未发现脾静脉血栓形成,肝功能得到一定程度的改善。结论联合手术是治疗门静脉高压症较为理想的有效术式。     

Hemodynamic Patterns in Human Hepatic Cirrhosis: A Prospective Randomized Study of the Hemodynamic Sequelae of Distal Splenorenal (Warren) and Mesocaval Shunts

Increasingly successful operative management of gastroesophageal variceal hemorrhage has been achieved by newer techniques of portal venous reconstruction. Although it is postulated that the clinical success may be due to more selectivity in portal venous shunting, direct determination of the effect of portasystemic shunt on portal vein blood flow has not been possible. Direct determinations of portal vein blood flow were performed preoperative on unanesthetized, hemodynamically stable cirrhotic patients by observation of radiopaque water-insoluble droplets. Patients were then randomized into elective distal splenorenal (Warren) or mesocaval shunt and determinations were performed postoperatively under similar conditions when clinically possible. Although portal vein blood flow was not significantly different before (929 +/- 147 ml/min) or after 899 +/- 271 ml/min) distal splenorenal shunt, there was a large change in portal vein blood flow after mesocaval shunt, decreasing from 772 +/- 177 ml/min (hepatopetal) to -1021 +/- 310 ml/min (hepatofugal) p < 0.01). After either procedure total hepatic blood flow (as determined by cardiac green clearance) was not significantly changed, nor was renal blood flow; however, cardiac output was significantly increased after mesocaval shunt. Thus the theoretical hemodynamic goals of the selective distal splenorenal shunt, i.e., preservation of the hepatopetal flow within the portal vein, is achieved as determined in the early postoperative period. The correlation between these changes and the eventual clinical outcome remains to be determined.     

Posttransplantation portal thrombosis secondary to splenorenal shunt persistence

Purpose

The aim of this study was to analyze our experience with portal vein thrombosis after liver transplantation with a persistent splenorenal shunt.

Materials and methods

The study population included 780 liver transplantations from 1990 to 2009. We analyzed the existence of portal vein thrombosis in the immediate posttransplant period, selecting cases with a persistent splenorenal shunt requiring surgery.

Results

The incidence of posttransplant portal vein thrombosis was 1.41% (n = 11), of which 3 (27%) had a splenorenal shunt as a possible cause (0.38% of the total). Two cases required liver retransplantation due to portal vein thrombosis, and the third a thrombectomy. In all cases the shunt was also closed. During the early postoperative follow-up of these 3 patients, 2 needed repeat surgeries because of a new portal vein thrombosis (thrombectomy) in one and a bilioperitoneum in the other. After a median follow-up of 11 months, the patients showed a good evolution with no primary graft dysfunction.

Discussion

The portal steal phenomenon secondary to persistence of a splenorenal shunt promotes the occurrence of portal vein thrombosis. Although it is a rare cause of graft dysfunction, it must be treated early, because it can lead to a small-for-size syndrome.     

Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation.

In an attempt to prevent portoprival malcirculation after distal splenorenal shunt (DSRS), a splenic hilar renal shunt (HRS) with proximal flush ligation of splenic vein was designed. To accomplish this procedure, two methods were compared: HRS alone (Group A) and HRS plus proximal flush ligation of the splenic vein (Group B). In Group A, which included 20 cirrhotic patients with esophageal varices, angiographic as well as pulsed Doppler flowmetric follow-up study revealed a portal thrombosis in two patients and severe narrowing of a portal vein in another two. Considerable stealing flow was observed in these four patients. In the Group B series, which included 33 cirrhotic patients, there were no gross changes in the portal hemodynamics. Normal prograde portal flow was confirmed by Doppler flowmeter in this series including 14 patients of more than 8 months after surgery. When the amount of nonisolated splenic vein embedded in the pancreas is minimized, portal malcirculation after distal splenorenal shunt can, to a great extent, be prevented.     

Portosystemic shunt for the treatment of portal vein thrombosis following orthotopic liver transplantation

Abstract The efficacy of the portosystemic shunt operation for the treatment of portal vein thrombosis following orthotopic liver transplantation was demonstrated. From 1 July 1988 to 31 December 1991 42 portosystemic shunt operations were performed at our centre. In six of these cases portal vein thrombosis after orthotopic liver transplantation (OLT) was the indication for the procedure. All the patients retained adequate liver function but they demonstrated manifestations of significant portal hypertension, mainly variceal rebleeding. Two of the patients were children. Three patients underwent distal splenorenal shunt (DSRS), one mesocaval and one side-to-ide splenorenal shunt and the last one side-to-ide splenorenal shunt which was converted to DSRS 2 weeks later. All these patients were doing well after 30 months mean follow-up time without rebleeding or other signs of portal hypertension and none had so far required retransplantation.     

Splenic artery ligation in distal splenorenal shunts

Splenic artery ligation, a simple surgical procedure expected to decrease splenic flow and portal pressure in patients with cirrhosis of the liver, was performed concomitantly with a distal splenorenal shunt procedure in six patients and as the main surgical procedure in two patients. Immediate cessation of bleeding was achieved in the four patients in whom the splenic artery was ligated to reduce intraoperative bleeding. However, three of the seven patients with previous gastroesophageal hemorrhage rebled from various postoperatively. Symptoms of splenic infarction were observed in six patients, resulting in thrombosis of the splenic vein and/or of the distal splenorenal shunt in four patients and necessitating splenectomy in one. This incidence of thrombosis of the distal splenorenal shunt is much higher than the overall incidence of 5 per cent observed at our institution. It is thus concluded that the splenic artery should not be ligated in cirrhotic patients with patent distal splenorenal shunts, since splenic arterial collateral vessels have already been reduced by the gastric devascularization, an integral component of the distal splenorenal shunt.     

Acute portal vein thrombosis secondary to donor/recipient portal vein diameter mismatch after orthotopic liver transplantation: a case report

The incidence of portal vein thrombosis in end-stage liver disease is estimated as varying between 5% and 21%, whereas in candidates undergoing liver transplantation, this is 3-13%. Portal vein thrombosis occurring after liver transplantation can be managed surgically by thrombectomy, retransplantation, splenorenal shunt, or Wall-stent placement, or nonsurgically by angioplasty, local high-dose infusion of thrombolytic agents, combination of portal thrombolysis, or embolization of a pre-existing spontaneous splenorenal shunt. We report a case of portal vein thrombosis after liver transplantation diagnosed on postoperative day 1 in a 57-year-old patient who received a liver from an 8-year-old donor. The patient was successfully treated surgically with portal vein thrombectomy and systemic anticoagulation. Portal vein thrombosis, in this case, was considered to be secondary to size discrepancy between the donor and the recipient portal veins. Routine use of daily Doppler ultrasound was the key factor in early diagnosis.     

Cause and management of upper gastrointestinal bleeding after distal splenorenal shunt.

BACKGROUND. The aims of this study were to determine the causes of recurrent upper gastrointestinal hemorrhage (UGH) after distal splenorenal shunting (DSRS) and to summarize our experience in the prevention and management of this complication. METHODS. This study is based on a retrospective review of 145 consecutive patients undergoing DSRS from 1978 through 1991. RESULTS. Recurrent UGH developed in 19 patients (13%), most frequently secondary to residual portal hypertension (84%). Eight patients had shunt thrombosis and 11 had patent shunts. The incidence of shunt thrombosis was significantly greater in patients whose splenic vein was less than or equal to 8 mm in diameter (44%) than those whose splenic vein was greater than 8 mm (7%, p less than 0.001). The frequency of shunt failure from 1985 through 1991 was significantly lower (2%) than from 1978 through 1984 (10%, p less than 0.05). Five patients, all with occluded shunts, underwent surgical treatment for recurrent UGH and three died (60%). Fourteen patients were managed nonoperatively, with a mortality rate of 38%. CONCLUSIONS. Recurrent UGH after DSRS occurs in patients with patent shunts and in those with occluded shunts; DSRS thrombosis is more frequent when the splenic vein diameter is less than or equal to 8 mm; DSRS thrombosis decreases with operative experience; and the mortality rate for this complication is high with both operative and nonoperative management.     

Modeling splanchnic hemodynamics after distal splenorenal shunt: a computer simulation and sensitivity analysis

The distal splenorenal shunt operation was specifically designed to preserve portal flow and maintain elevated portal pressure. However, although this goal is met in the immediate postoperative period, flow decreases over time, and in as many as 75% of alcoholic patients, portal flow is lost in the first year. Various explanations have been offered for this observation, and modifications of the original operation have been proposed (splenopancreatic disconnection). Although other portacaval shunts have been successfully modeled as electrical circuits, this approach has never been described for the distal splenorenal shunt. In this study we developed a computer program that modeled the distal splenorenal shunt as an electrical circuit. We performed an analysis to determine the sensitivity of portal flow to changes in each resistance element and then performed a series of simulation experiments to critically examine the various explanations offered for the gradual changes in hepatic hemodynamics. We found that portal flow was most sensitive to resistance in the renal vein followed by resistance in the anastomosis. The simulation experiments suggested a new alternative to splenopancreatic disconnection--restricting the ability of the splenic vein, anastomosis, or renal vein to dilate. Additional clinical studies will be needed to test these predictions.     

The selective shunt for variceal bleeding: a personal perspective

It has been proved that selective decompression of esophageal varices can occur by way of the left gastric venous route or the transsplenic route. The left gastric venacaval shunt functions well over a long postoperative period, if the shunt is technically satisfactory; however, the distal splenorenal shunt (DSRS) can be problematic. Unless the proximal and distal portions of the splenic vein are both entirely isolated from the pancreas, blood flow will be diverted from the portal vein to the distal splenic vein, where the pressure has been lowered by the shunt. This portal malcirculation may lead to portal thrombosis or stenosis on occasion. To prevent this adverse effect, complete isolation of the splenic vein (splenopancreatic disconnection) is necessary. Extensive gastric disconnection is irrelevant in this regard. Although the conventional DSRS has been viewed with disfavor, we must realize that splenopancreatic disconnection makes the DSRS a satisfactory technique. The clinical evidence and theoretic basis of the selective shunt for esophageal varices are described herein.     

Selective distal splenorenal shunt versus side-to-side portacaval shunt. Clinical results of a prospective, controlled study

A prospective, controlled study comparing the clinical results of the selective distal splenorenal shunt procedure and the side-to-side portacaval shunt procedure was undertaken in 1980. Ninety-three cirrhotic patients with previous episodes of bleeding from esophageal varices underwent a distal splenorenal shunt procedure (47 patients). The operative mortality rate was 2 percent in both groups. The intraoperative decrease of portal hypertension after the portacaval shunt procedure was higher than after the distal splenorenal shunt procedure (p less than 0.05), and in those with patent shunts, there was a 0 percent incidence of early variceal rebleeding after the portacaval shunt procedure compared with a 9 percent incidence after the distal splenorenal shunt procedure (p less than 0.05). Both shunts, however, had similarly satisfactory results in preventing long-term variceal rebleeding (portacaval shunt 2 percent and distal splenorenal shunt 0 percent). Postoperative ascites was more common after the distal splenorenal shunt procedure (58 percent versus 24 percent; p less than 0.01). Analysis of actuarial survival curves showed no difference between the two procedures. The incidences of long-term episodes of chronic encephalopathy were not statistically different after both procedures. The only three instances of severe encephalopathy occurred in patients with the portacaval shunt (p less than 0.05). The distal splenorenal shunt also seemed to have a less negative effect on postoperative liver function than the portacaval shunt. These data suggest that the selective shunt should be viewed as a first choice strategy in the treatment of portal hypertension.     

TIPS联合搅拌溶栓治疗肝硬化急性门静脉血栓的临床疗效分析

目的探讨经颈静脉肝内门体分流术(TIPS)联合搅拌溶栓治疗肝硬化急性门静脉血栓的临床疗效。方法回顾性分析2014年1月至2017年12月河南科技大学第一附属医院连续收治的37例肝硬化急性门静脉血栓患者资料,其中男性20例,女性17例,年龄29~71岁。按治疗方案不同分为联合组5二15)与抗凝组5=22)。联合组接受TIPS联合搅拌溶栓以及抗凝药物治疗。抗凝组仅接受抗凝药物治疗。比较两组肝功能、门静脉血流动力学等变化。随访患者术后门静脉通畅、出血以及生存情况等。结果联合组术后门静脉压力和门静脉最大负荷低于术前,门静脉最大血容量和门静脉血流速度髙于术前,差异有统计学意义(均P<0.05)。联合组术后2周、6个月.12个月门静脉最大负荷分别为(13.9±5.4)%、(16.1±5.5)%、(13.8±6.2)%,低于抗凝组的(84.1±31.3)%、(85.9±27.6)%、(88.2±39.5)%,差异有统计学意义(均P<0.05)。联合组术后2周、6个月、12个月门静脉血流速度分别为(21.6±5.7cm/s、(16.1±6.3)cm/s、(17.6±4.9)cm/s,高于抗凝组的(9.7±4.6)cm/s、(8.1±4.3)cm/s、(8.2±3.5)cm/s,差异有统计学意义(均P<0.05)。联合组术后3例患者门静脉血栓复发,其余患者门静脉及分流道血流通畅。抗凝组仅3例门静脉血流通畅。联合组累积无消化道出血率优于抗凝组。联合组累积生存率优于抗凝组,差异有统计学意义(P<0.05)。结论TIPS联合搅拌溶栓治疗肝硬化急性门静脉血栓的疗效尚可,且优于传统抗凝治疗。     

Loss of selectivity of warren shunt in long-term observation

Sixty patients who underwent distal splenorenal shunt were followed up from one to ten years, with an average of 5.6 years. Postoperative portography through the superior mesenteric artery was carried out in 58 of these patients and the remaining two were studied at autopsy. The diameter of the portal vein was unchanged in 65 per cent of the patients within 30 postoperative days, but it decreased remarkably in size one year after the surgery in one third of the patients, and it was observed in about half of the patients at 5 years after the surgery. Numerous collaterals had developed around the pancreas and stomach in the majority of cases presenting narrowing of the portal vein. Enormously dilated pancreatic veins directed to non-isolated distal splenic vein were identified in the autopsied cases. These findings strongly suggest that pancreatic veins connecting to the distal vein may play a leading role in production of malcirculation of the portal system after distal splenorenal shunt.     

Noncirrhotic portal vein thrombosis. Physiology before and after shunts.

Controversy exists concerning the proper therapy for bleeding gastroesophageal varices secondary to noncirrhotic portal vein thrombosis. Disparity of opinion exists regarding the significance of hepatic portal blood flow and the consequences of total portal-systemic shunts in this condition. One patient is presented who developed severe, crippling encephalopathy 20 years after a central splenorenal shunt. This was associated with loss of portal flow to the liver and marked nitrogen intolerance. Closure of the shunt resulted in restoration of hepatic portal flow via collateral veins (HPI 0.36), clearance of encephalopathy and return to near normal protein tolerance. An additional patient was studied with hyperammonemia and early suggestive signs of encephalopathy eight years following a mesocaval shunt. Four patients were evaluated before and after selective distal splenorenal shunts. All had "cavernous transformation" of the portal vein with angiographic evidence of portal flow to the liver. Postoperative angiograms revealed continued hepatic portal perfusion and a patent shunt in each patient. Radionuclide imaging postoperatively gave an estimated portal fraction of total hepatic blood flow (HPI) of .39 and .60 in two of the four patients. We conclude that 1) there is significant hepatic portal perfusion in noncirrhotic portal vein thrombosis (cavernous transformation), 2) loss of this hepatic portal flow following total shunts can lead to severe encephalopathy, 3) the selective distal splenorenal shunt maintains hepatic portal perfusion and is the procedure of choice when there is a patent splenic vein and surgical intervention is indicated.     

Living-related liver transplantation with renoportal anastomosis for a patient with large spontaneous splenorenal collateral

BACKGROUND: A large splenorenal collateral must be interrupted during liver transplantation to secure adequate portal perfusion. However, this process increases the complexity of the operative procedure and may cause hazardous bleeding. Recently, renoportal anastomosis in portal reconstruction was reported in cadaveric liver transplantation for patients with surgically created splenorenal shunts. We used this technique in a living-related liver transplantation. METHODS: A 29-year-old female with a large spontaneous splenorenal collateral and a portal venous thrombus underwent a living-related liver transplantation. At surgery, the left renal vein was divided and the distal stump was anastomosed to the portal vein of the graft without interrupting collaterals. RESULTS: Adequate portal venous blood flow was maintained throughout the postoperative course. The patient was discharged 9 weeks after transplantation and remains well. CONCLUSION: The renoportal anastomosis could be used for portal reconstruction in living-related liver transplantation for patients with a large splenorenal collateral. It provides adequate portal perfusion without interrupting collateral circulation.