A selective portacaval shunt

Makeshift Shunts in Extrahepatic Portal Vein Obstruction in Pediatric Population

Background and Objectives

More than 20% of patients with extrahepatic portal vein obstruction (EHPVO) may be deemed as nonshuntable due to lack of a suitable vein. The role of "makeshift shunts" or "lesser shunts" assumes importance in such cases. In this report, the authors have shared their experience with the makeshift shunts in the management of portal hypertension in children with emphasis upon anatomic considerations, resolution of symptoms, outcomes after surgery, and shunt patency.

Materials and Methods

During the period 1983-2018, 138 children with portal hypertension were managed under the care of a single surgeon (VB). Of them, 134 were EHPVO. Children with EHPVO were treated with splenectomy and proximal lienorenal shunt (n = 107), splenectomy and devascularization (n = 21), and makeshift shunts (n = 6). Makeshift shunts comprised (i) side-to-side right gastroepiploic vein (Rt-GEV) to left renal vein (LRV) shunt (n = 1), (ii) superior mesenteric vein (SMV) to inferior vena cava (IVC) shunt using a spiral saphenous venous graft (n = 1), (iii) side-to-side inferior mesenteric vein (IMV) to LRV shunt (n = 2), (iv) side-to-side IMV to IVC shunt (n = 1), (v) end-to-side IMV to IVC shunt (n = 1), and (vi) side-to-side IMV to LRV shunt (n = 1) in a case of crossed fused renal ectopia.

Results

Following the creation of portosystemic shunt, a decline in portal pressure was demonstrated in all six patients. There was resolution of symptoms including hematemesis, melena, and anorectal variceal bleed. None of the patients demonstrated the features of hepatic encephalopathy. The associated portal cavernoma cholangiopathy (n = 1) also resolved following Rt-GEV to LRV shunt. Shunt patency was documented for the entire duration of follow-up (1.5-4 years) in five of six patients; the sixth patient demonstrated shunt block at 6-month follow-up but without recurrence of symptoms.

Conclusions

Makeshift shunts offer a viable alternative to standard portosystemic shunting in pediatric patients with a nonshuntable vein. The selection of such shunts is, however, subject to surgeon's preferences and has to be individualized to local anatomy.

Management of portal hypertension based on portal hemodynamics

Portal hypertension is most commonly caused by chronic liver disease. As liver damage progresses, portal pressure gradually elevates and hemodynamics of the portal system gradually change. In normal liver, venous returns from visceral organs join the portal trunk and flow into the liver (hepatopetal blood flow). As portal pressure increases due to liver damage, congestion of some veins of the visceral organ occurs (blood flow to and from). Finally, the direction of some veins (the left gastric vein in particular) of the visceral organ change (hepatofugal blood flow) and develop as collateral veins (portosystemic shunt) to reduce portal pressure. Therefore, esophagogastric varices serve as drainage veins for the portal venous system to reduce the portal pressure. In chronic liver disease, as intrahepatic vascular resistance is increased (backward flow theory) and collateral veins develop, adequate portal hypertension is required to maintain portal flow into the liver through an increase of blood flow into the portal venous system (forward flow theory). Splanchnic and systemic arterial vasodilatations increase the blood flow into the portal venous system (hyperdynamic state) and lead to portal hypertension and collateral formation. Hyperdynamic state, especially around the spleen, is detected in patients with portal hypertension. The spleen is a regulatory organ that maintains portal flow into the liver. In this review, surgical treatment, interventional radiology, endoscopic treatment, and pharmacotherapy for portal hypertension (esophagogastric varices in particular) are described based on the portal hemodynamics using schema.

Gastric cancer surgery for patients with liver cirrhosis

AIM

To elucidate the influence of liver cirrhosis (LC) on the prognosis of patients with gastric cancer (GC).

METHODS

Of the 1347 GC patients who underwent curative gastrectomy for GC between January 1984 and June 2007, 25 patients (21 men and 4 women with a median age of 67 years; range 54-77 years) with LC were enrolled in this study. Using the Child-Pugh classification, 15 patients were evaluated as grade A and 10 patients as grade B. No grade C patient underwent gastrectomy in this series. Clinical outcomes, including postoperative morbidity and survival, were retrospectively analyzed based on medical records and surgical files.

RESULTS

There was no significant difference in operative blood loss and perioperative blood transfusion between the two groups. The most common postoperative complication was intractable ascites, which was the single postoperative morbidity noted more frequently in grade B patients (40.0%) than in grade A patients (6.7%) with statistical significance (P = 0.041). Operative mortality due to hepatic failure was seen in one grade A patient. Three patients had hepatocellular carcinoma (HCC) at presentation and two patients developed HCC after surgery. Overall 5-year survival rate was 58.9% in patients with early GC and 33.3% in patients with advanced GC (P = 0.230). GC-specific 5-year survival rate of early GC patients was 90.0% while that of advanced GC patients was 58.3% (P = 0.010). Four patients with early GC died of uncontrolled HCC, of which two were synchronous and two metachronous.

CONCLUSION

The risk of postoperative intractable ascites is high, particularly in grade B patients. Early detection and complete control of HCC is vital to improve a patient's prognosis.

New trends in surgical treatment for portal hypertension

A number of surgical procedures have been developed to manage esophageal varices. Broadly, these can be classified as shunting and non-shunting procedures. While total shunt effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. The distal splenorenal shunt (DSRS), a selective shunt, was developed by Warren in 1967 to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. The DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection (SPD, i.e. skeletonization of the splenic vein from the pancreas to its bifurcation at the splenic hilum) and gastric transection (GT, i.e. transection and anastomosis of the upper stomach with an autosuture instrument). An alternative to shunting was developed by Sugiura and Futagawa in 1973. Esophageal transection (ET) divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. DSRS was more effective than ET in preventing recurrence of esophageal varices, but was associated with a higher incidence of hyperammonemia. The incidence of hyperammonemia in patients who underwent DSRS with SPD plus GT was significantly lower than that in patients who underwent DSRS alone or those who underwent DSRS with SPD. In conclusion, there are various surgical treatments for esophagogastric varices. Distal splenorenal shunt with SPD plus GT is considered an adequate treatment for patients with esophagogastric varices.

Clinical analysis of surgical treatment of portal hypertension

AIM: To review the experience in surgery for 508 patients with portal hypertension and to explore the selection of reasonable operation under different conditions.

METHODS: The data of 508 patients with portal hypertension treated surgically in 1991-2001 in our centers were analyzed. Of the 508 patients, 256 were treated with portaazygous devascularization (PAD), 167 with portasystemic shunt (PSS), 62 with selective shunt (SS), 11 with combined portasystemic shunt and portaazygous devascularization (PSS+PAD), 9 with liver transplantation (LT), 3 with union operation for hepatic carcinoma and portal hypertension (HCC+PH).

RESULTS: In the 167 patients treated with PSS, free portal pressure (FPP) was significantly higher in the patients with a longer diameter of the anastomotic stoma than in those with a shorter diameter before the operation (P<0.01). After the operation, FPP in the former patients markedly decreased compared to the latter ones (P<0.01). The incidence rate of hemorrhage in patients treated with PAD, PSS, SS, PSS+PAD, and HCC+PH was 21.09% (54/256), 13.77 (23/167), 11.29 (7/62), 36.36% (4/11), and 100% (3/3), respectively. The incidence rate of hepatic encephalopathy was 3.91% (10/256), 9.58% (16/167), 4.84% (3/62), 9.09% (1/11), and 100% (3/3), respectively while the operative mortality was 5.49% (15/256), 4.22% (7/167), 4.84% (3/62), 9.09% (1/11), and 66.67% (2/3) respectively. The operative mortality of liver transplantation was 22.22% (2/9).

CONCLUSION: Five kinds of operation in surgical treatment of portal hypertension have their advantages and disadvantages. Therefore, the selection of operation should be based on the actual needs of the patients.

Review: surgical shunts and encephalopathy

Historically, surgical shunts have played an important role in the treatment of patients with portal hypertension associated with ascites and/or variceal esophageal bleeding. Today, in the era of liver transplantation most patients with end-stage liver disease and concomitant portal hypertension and associated problems are best treated by liver grafting. The successful introduction of transjugular intrahepatic portosystemic shunting (TIPS), performed by radiologists and gastroenterologists, provides a very effective alternative to surgical shunt procedures. One advantage of TIPS is that this procedure does not interfere with subsequent liver grafting. Today, surgical shunts have clearly lost ground to the less invasive TIPS procedure. Surgical shunts still maintain a role: as a salvage procedure in selected cases and in emergency situations. Surgical shunts are associated with a high rate of encephalopathy. In most cases selective surgical shunts should be preferred to nonselective surgical shunts. The role of partial surgical shunts versus selective surgical shunts remains to be determined. Hepatic encephalopathy is a common complication of all shunt procedures and is dependent on the shunt volume. Liver grafting is able to reverse encephalopathy because of a shunting procedure. In our institution, we prefer TIPS over surgical shunts as a bridging procedure before liver transplantation.

Surgery in portal hypertension

The role of surgery in portal hypertension remains a topic of debate. For the past 100 years, various surgical procedures have been used to treat variceal bleeding, refractory ascites, and end-stage liver disease. The past decade has seen significant advances in pharmacotherapy, endoscopy, interventional radiology, and surgery for the management of patients with portal hypertension. Liver transplantation has come of age in the 1990s and is now an accepted therapy for patients with end-stage liver disease. The wide array of management options can complicate the decision making process and defines the need to evaluate these patients fully. Factors such as the aetiology and extent of liver disease, response to prior medical, endoscopic, and other interventional treatments, and possibility of future liver transplantation must be considered. This manuscript will review the history of surgical treatments of portal hypertension, describe the surgical procedures with their advantages and disadvantages, and evaluate their role in the elective and emergent settings.

The role of surgery in the treatment of portal hypertension

The role of surgery in the treatment of portal hypertension continues to evolve. Pharmacologic and endoscopic therapies are the primary treatment modalities for the prophylaxis and treatment of variceal bleeding and ascites. Failure of these therapies is the indication for invasive intervention such as TIPS, surgical shunt, or devascularization. Distal splenoreal shunting provides selective variceal decompression with less encephalopathy and accelerated hepatic failure than portal decompression. Liver transplantation remains the treatment of choice for patients with poor hepatic function.

Surgical emergencies in liver disease

In this chapter the surgical management of bleeding oesophageal varices, ruptured hepatocellular carcinoma and fulminant liver failure have been discussed. Bleeding oesophageal varices can usually be successfully treated with vasopressin, balloon tamponade and injection sclerotherapy. Emergency surgery should be considered if two courses of injection sclerotherapy have failed to achieve haemostasis. Stapled oesophageal transection and portosystemic shunting are currently the two most popular procedures. The former is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. Ruptured hepatocellular carcinomas are usually associated with liver cirrhosis and impaired liver function. Selective coeliac axis cannulation followed by embolization of the hepatic artery branches supplying the tumour is an effective method of achieving haemostasis and is associated with a lower morbidity and mortality than emergency hepatic artery ligation or liver resection. If haemostasis is achieved by embolization the patient may subsequently be assessed for an elective resection of the tumour. Fulminant liver failure may be managed by supportive medical therapy or orthotopic liver transplantation. Patients whose liver failure is graded as mild (grade I) should be treated by medical therapy, whereas those with severe liver damage (grades III and IV) should be assessed for transplantation. Accurate monitoring of the patient's clinical progress and prognostic indicators are vital in deciding whether conservative treatment should be continued or liver transplantation performed.

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.

Current strategy for esophageal varices in Japan

Management of bleeding esophageal varices in Japan includes tamponade, sclerotherapy, devascularization, and shunt procedures. Sclerotherapy is the most widely used treatment in both acute and chronic management. The Japanese Research Society for Sclerotherapy of Esophageal Varices monitors and surveys this treatment method at 152 institutions. Extensive devascularization operations now include a thoracotomy less frequently than previously, and they have a 6.6% rebleeding rate in elective patients. Shunt operations are applied in 20% of cases of bleeding esophageal varices in Japan. Effective medical and surgical treatments have led to changes in management strategy and to diversity in treatment during the last decade. The timing of treatment, the nature of the disease, the patient's liver function, and the distribution of collaterals should all be considered in selecting treatment.

Definitive therapy for variceal bleeding: a personal view

Definitive therapy for variceal hemorrhage has evolved during the past half century. Only completely decompressing shunts (nonselective shunts) were available before 1967. Additional options now include selective shunts, devascularization procedures, endoscopic sclerotherapy, pharmacotherapy, and hepatic transplantation. Although drug treatment is experimental at the present time, the remaining therapeutic options are applicable to various subgroups of patients and in certain clinical settings. At the University of Nebraska, patients with variceal bleeding are first grouped based on their candidacy for transplantation. Transplantation candidates with advanced (Child's class C) or symptomatic liver disease undergo transplantation as soon as possible. Future transplantation candidates with stable, asymptomatic liver disease undergo either long-term sclerotherapy or a distal splenorenal shunt if sclerotherapy fails or if they have poor access to tertiary medical care. These patients are carefully monitored so that they can undergo transplantation before they become high-operative risks. Patients who are not candidates for transplantation receive chronic variceal sclerotherapy as initial therapy so long as shunt surgery is readily available if sclerotherapy fails. When surgery is indicated, the distal splenorenal shunt is preferred to nonselective shunts because several controlled and uncontrolled series have demonstrated a lower frequency of encephalopathy after selective variceal decompression.

Selective shunts: the Johannesburg experience

My personal 15-year experience with 141 selective shunts (127 elective, 14 emergency) for portal hypertension is reported. Alcoholic cirrhosis comprised 54% of elective operations, and of the nonalcoholic patients, 22% were cirrhotic and 24% were noncirrhotic. Adequate and, if necessary, prolonged (mean 6 weeks) in-hospital preparation resulted in Hospital mortality and long-term actuarial survival were better in nonalcoholics compared with alcoholics, but there was no significant difference between cirrhotic nonalcoholics and alcoholics. Variceal rebleeding was rare (4% of Warren procedures) and, when present, was usually related to shunt failure. Gastric fundal variceal rebleeding did not occur in 44 patients undergoing splenopancreatic disconnection. Postoperative encephalopathy occurred in 13% of patients; however, it did not occur at all in noncirrhotic patients. Prograde portal venous perfusion was preserved in 77% of patients. Fifteen alternate selective operations to the Warren shunt were performed, usually because of antecedent splenectomy. Shunt failure and variceal rebleeding occurred more frequently with these more vulnerable shunts, but 66% had a satisfactory outcome. Selective shunts have produced highly satisfactory results in appropriately selected patients.

A prognostic evaluation of endoscopic intravariceal injection sclerotherapy for esophageal varices

Eighty cases of endoscopic injection sclerotherapy for esophageal varices were retrospectively studied to evaluate their prognoses. These cases were evaluated in terms of post-therapeutic bleeding, survival rates and causes of death. Post-therapeutic bleeding occurred in 50% of the emergency cases (26 cases), 25% of the elective cases (16 cases) and 23.7% of the prophylactic cases (38 cases). The frequency of post-therapeutic bleeding was significantly lower in cases with variceal obliteration than in cases without obliteration. An evaluation of the survival rates by the Kaplan-Meier method revealed that poor prognostic factors in sclerotherapy cases were emergency cases, Child's C group, post-therapeutic cases with unsuccessfully obliterated varices, and cases with post-therapeutic bleeding. Concerning early death within 7 days after sclerotherapy, 4 emergency cases died from initial variceal bleeding despite sclerotherapy. Three of these 4 were hepatocellular carcinoma cases, and all 3 cases had tumor thrombi of the portal vein. We recommend prophylactic sclerotherapy from the standpoint of the prognosis after sclerotherapy. However, in the bleeding cases of hepatocellular carcinoma in Child's C group complicated by tumor thrombi of the portal vein, overly enthusiastic application of the therapy should be avoided.

Bilateral gastric venous decompression by a modified Warren shunt

A new modification of the Warren shunt by which the coronary and short gastric venous systems can be simultaneously decompressed was carried out on two patients with oesophagogastric varices due to liver cirrhosis. One was an elective and the other an emergency operation. The left gastric vein entering the splenic vein was also drained through a Gore-Tex graft between the splenic and left renal veins. The proximal end of the splenic vein was ligated at its junction to the superior mesenteric vein. Porta-azygos disconnection was achieved by ligating the right gastric and gastro-epiploic veins. The shunt was patent and its effect on the varices was immediate with good decompression in both patients. The patients have had no recurrent variceal haemorrhage or postshunt encephalopathy. This modification may be indicated for selected patients with portal hypertension for both elective and emergency operations.

Clinical experiences with left gastric vena caval shunt in patients with esophageal varices

Left gastric vena caval shunt (Inokuchi) was performed in four patients with liver cirrhosis; electively in two and prophylactically in two cases. The overall results have been satisfactory in terms of the effect on esophageal varices and postoperative complications. This procedure appeared to be superior to distal splenorenal shunt or other direct surgical procedures in several aspects. Since left gastric vena caval shunt does not require particularly elaborate surgical techniques and can be performed safely even in patients with considerably impaired hepatic function, it can be recommended as an ideal surgical procedure to be performed in elective and prophylactic surgical candidates.

Transthoracic cardiectomy with infraesophago-supragastric devascularization for bleeding esophageal varices

Based on the thoughts that transthoracic approaches give less load to liver than transabdominal ones, and that effectiveness for bleeding esophageal varices is secured by cardiectomy with complete devascularization of lower esophagus and upper stomach, a new operative procedure for esophageal varices is described which is more safely applicable to the risky patients. Twenty cases with portal hypertension were operated, including eight cirrhotic patients with severe hepatic dysfunction, six cases of emergency bleeding and six reoperated cases. No operative death was encountered, but three cirrhotic patients died during the late follow up period. The remaining 17 patients had uneventful postoperative courses without recurrence esophageal bleeding during 20 months follow up period. Thus this operation may eliminate the shortcoming of previous operative methods for portal hypertension.