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Nayak HK, Pattnaik B, Mohakud S, Mitra JK, Krishna EV, Sethi S, Samal SC. Rescue Devascularization in Coronavirus Disease 19 (COVID-19) Induced Early Shunt Thrombosis After Emergency Proximal Spleno-renal Shunt for Extrahepatic Portal Vein Obstruction. J Clin Exp Hepatol 2022; 12:721-722. [PMID: 34226804 PMCID: PMC8241577 DOI: 10.1016/j.jceh.2021.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Hemanta K Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Bramhadatta Pattnaik
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Sudipta Mohakud
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Jayanta K Mitra
- Department of Anaesthesiology and Critical Care Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Edla V Krishna
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Shivam Sethi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Subash C Samal
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
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Gupta S, Pottakkat B, Kalayarasan R, Senthil G, Nitesh PNB. Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study. Ann Hepatobiliary Pancreat Surg 2022; 26:178-183. [PMID: 35193996 PMCID: PMC9136421 DOI: 10.14701/ahbps.21-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Backgrounds/Aims Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis. Methods This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ2 test. Results Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group. Conclusions CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.
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Affiliation(s)
- Shahana Gupta
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Gnanasekaran Senthil
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Pagadala Naga Balaji Nitesh
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Unconventional Shunts in Extrahepatic Portal Venous Obstruction-A Retrospective Review. J Clin Exp Hepatol 2022; 12:503-509. [PMID: 35535107 PMCID: PMC9077177 DOI: 10.1016/j.jceh.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/22/2021] [Indexed: 12/12/2022] Open
Abstract
Background Proximal splenorenal shunt (PSRS) is one of the most commonly performed portosystemic shunt (PSS) in extrahepatic portal venous obstruction (EHPVO) for portal decompression. Sometimes various anatomical and surgical factors related to the splenic vein and/or left renal vein may make the construction of a PSRS difficult or impossible. Unconventional shunts are required to tide over such conditions. Methods From January 2008 to December 2018, 189 patients with EHPVO underwent PSS, of which, the 10 patients who underwent unconventional shunts form the study group of this paper. Results The ten unconventional shunts included 8 proximal splenoadrenal shunts, one collateral-renal shunt, and one inferior mesenteric vein to inferior vena cava (IMV-Caval) shunt. The mean percentage drop in omental pressure was 34.2% post-shunt with a mean anastomotic diameter of 13.7 ± 3.1 mm. Three patients experienced some form of postoperative complication. With a mean follow-up period of 32.3 months (maximum of 111 months) all patients had patent shunts on follow-up Doppler. None of the patients had variceal bleed, or features of biliopathy and hepatic encephalopathy in follow-up. Conclusion Unconventional shunts can be used safely and effectively with good postoperative outcomes in EHPVO.
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Key Words
- BDI, Bile duct injury
- EHPVO
- EHPVO, Extrahepatic portal venous obstruction
- EVL, endoscopic variceal ligation
- IMV, Inferior mesenteric vein
- LRV, Left renal vein
- PHG, Portal hypertensive gastropathy
- PHT, Portal hypertension
- PSRS, Proximal splenorenal shunt
- PSS, portosystemic shunt
- SMV, Superior mesenteric vein
- SV, Splenic vein
- UGI, Upper gastrointestinal
- make-shift shunts
- unconventional shunts
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Voskanian SÉ, Shabalin MV, Voevodin AL, Artem'ev AI, Kolyshev II, Naĭdenov EV, Bashkov AN. H-shaped partial splenorenal shunting with the use of a reinforced graft made of porous polytetrafluoroethylene. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:103-112. [PMID: 32240144 DOI: 10.33529/angio2020116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM The study was aimed at improving the immediate and remote results of splenorenal bypass grafting. PATIENTS AND METHODS A total of 57 patients presenting with hepatic cirrhosis, portal hypertension, and recurrent haemorrhage from oesophageal varices underwent an H-shaped partial splenorenal shunt procedure using an externally reinforced 1.5-2.0-cm-long synthetic graft with a diameter equalling half of that of the splenic vein in an end-to-side fashion. Assessment of efficacy of shunting was based on intraoperative measurement of venous pressure in the portal system before and after shunting, the findings of Doppler ultrasonography of the linear velocity of blood flow in the portal, splenic, and left renal veins in the early postoperative period, as well as computed tomography, esophagogastroscopy, and assessment of the degree of hepatic encephalopathy in the remote postoperative period. RESULTS The findings of intraoperative measurement of venous pressure in the portal vein system before and after shunting demonstrated a statistically significant decrease in (normalization of) portal pressure in all patients after bypass grafting (p≤0.05). There were no severe postoperative complications, in-hospital mortality, nor events of decompensation of hepatic insufficiency. According to the findings of Doppler ultrasonography of the linear velocity of blood flow and control computed tomography after surgery, the splenic vein, left renal vein and the conduit between them remained patent at all terms of postoperative follow up. The findings of control esophagogastroscopy revealed a statistically significant decrease in the degree of oesophageal varices at 3, 6, and 9 months after shunting (p≤0.05). There was no statistically significant difference in the change of the degree of hepatic encephalopathy at 3, 6, and 9 months after shunting (p=0.853, p=0.712, and p=0.581, respectively). At various terms after surgery, nine patients underwent deceased donor liver transplantation, with the splenorenal shunt ligated intraoperatively. CONCLUSION This method of splenorenal shunting makes it possible to decrease the risk of bleeding from oesophageal varices and venous thromboses in vascular anastomoses, as well as complications resulting from using autovenous conduits, to decrease the risk of decomposition of hepatic insufficiency and the frequency of the development of encephalopathy in the postoperative period. Besides, this method makes it possible to easily dismantle the previously created artificial portocaval shunt in the process of liver transplantation.
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Affiliation(s)
- S É Voskanian
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
| | - M V Shabalin
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
| | - A L Voevodin
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
| | - A I Artem'ev
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
| | - I Iu Kolyshev
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
| | - E V Naĭdenov
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
| | - A N Bashkov
- A.I. Burnasyan Federal Medical and Biophysical Center of FMBA, Moscow, Russia
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Abstract
Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are prototype noncirrhotic causes of portal hypertension (PHT), characterized by normal hepatic venous pressure gradient, variceal bleeds, and moderate to massive splenomegaly with preserved liver synthetic functions. Infections, toxins, and immunologic, prothrombotic and genetic disorders are possible causes in IPH, whereas prothrombotic and local factors around the portal vein lead to EHPVO. Growth failure, portal biliopathy, and minimal hepatic encephalopathy are long-term concerns in EHPVO. Surgical shunts and transjugular intrahepatic portosystemic shunt resolve the complications secondary to PHT. Meso-Rex shunt is now the standard-of-care surgery in children with EHPVO.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India.
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Mohapatra N, Sandhyav R, Agrawal N, Arora A, Chattopadhyay TK. Effect of Proximal Splenorenal Shunt on Intraoperative Portal Venous Pressure and Its Correlation with Clinical Outcomes. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1803-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Woerner A, Shivaram G, Koo KSH, Hsu EK, Dick AAS, Monroe EJ. Clinical and Imaging Predictors of Surgical Splenorenal Shunt Dysfunction in Pediatric Patients. J Pediatr Gastroenterol Nutr 2018; 66:e139-e145. [PMID: 29470285 DOI: 10.1097/mpg.0000000000001931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE Few established criteria exist to prompt angiographic evaluation and intervention for surgically created splenorenal shunts (SRS). Clinical and Doppler ultrasound (DUS) imaging predictors of shunt dysfunction were evaluated in this retrospective study. MATERIALS AND METHODS Consecutive patients undergoing SRS angiography over a 10-year period were retrospectively identified. Preangiography platelet count and DUS measurements of spleen diameter, maximum splenic vein velocity, and maximum shunt velocity were assessed and compared to findings at subsequent catheter angiography. RESULTS Twenty-six SRS angiograms were performed in 16 patients. Two of the 26 procedures were excluded from analysis due to insufficient baseline preangiography clinical and DUS data. In the remaining 24 cases, significant stenosis/occlusion was confirmed at angiography in 20, whereas wide patency was seen in 4. For the 20 cases of angiographically confirmed significant stenosis/occlusion, when compared to baseline post-SRS creation to immediate preangiography evaluation there was a greater decrease in platelet count (-51.8% vs -19.4%), a greater increase in spleen diameter (+13.4% vs +3.7%), a greater increase in maximum shunt velocity (+74.7% vs +59.7%), and a greater decrease in splenic vein velocity (-25.0% vs -18.5%). CONCLUSION Clinical evidence of splenic sequestration and DUS finding of increased maximum shunt velocity correlate with angiographic findings of SRS dysfunction and could be used to help predict the need for shunt intervention.
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Affiliation(s)
| | | | | | | | - Andre A S Dick
- Department of Pediatric Transplantation, Seattle Children's Hospital and University of Washington, Seattle, WA
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Khanna R, Sarin SK. Idiopathic portal hypertension and extrahepatic portal venous obstruction. Hepatol Int 2018; 12:148-167. [PMID: 29464506 DOI: 10.1007/s12072-018-9844-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/19/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are non-cirrhotic vascular causes of portal hypertension (PHT). Variceal bleed and splenomegaly are the commonest presentations. AIM The present review is intended to provide the existing literature on etiopathogenesis, clinical profile, diagnosis, natural history and management of IPH and EHPVO. RESULTS IPH and EHPVO are both characterized by normal hepatic venous pressure gradient, moderate to massive splenomegaly with preserved liver synthetic functions. While the level of block in IPH is presinusoidal, in EHPVO it is at prehepatic level. Infections, autoimmunity, drugs, immunodeficiency and prothrombotic states are possible etiological agents in IPH. Contrastingly in EHPVO, prothrombotic disorders and local factors around the portal vein are the incriminating factors. Diagnosis is often clinical, supported by simple radiological tools. Natural history is defined by episodes of variceal bleed and symptoms related to enlarged spleen. Growth failure, portal biliopathy and minimal hepatic encephalopathy are additional concerns in EHPVO. Long-term survival is reasonably good with endoscopic surveillance; however, parenchymal extinction leading to decompensation is seen in a minority of patients in both the disorders. Surgical shunts revert the complications secondary to PHT. Meso-Rex shunt has become the standard surgery in children with EHPVO. CONCLUSION This review gives a detailed summary of these two vascular conditions of liver-IPH and EHPVO. Further research is needed to understand the pathogenesis and natural history of these disorders.
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Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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Mishra PK, Patil NS, Saluja S, Narang P, Solanki N, Varshney V. High patency of proximal splenorenal shunt: A myth or reality ? - A prospective cohort study. Int J Surg 2016; 27:82-87. [PMID: 26804351 DOI: 10.1016/j.ijsu.2015.12.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/29/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Proximal splenorenal shunt (PSRS) is a well-accepted surgical procedure for non-cirrhotic portal hypertension (NCPH). Though a patent shunt is important for good long term outcome, there are very few studies on patency of these shunts. We analysed shunt patency using dynamic computed tomographic (CT) portography and compared it with other modalities. METHODS From 2004 to 2014, 50 patients with PSRS were evaluated prospectively for shunt patency using dynamic CT portography, clinical parameters and ultrasound Doppler. RESULTS The causes of NCPH were extrahepatic portal vein obstruction (EHPVO) in 38 patients and non-cirrhotic portal fibrosis (NCPF) in 12 patients. The shunt patency rate using clinical parameters, ultrasound Doppler and dynamic CT portography were 70%, 40% and 60% respectively. Clinical parameters overestimated while ultrasound Doppler underestimated the shunt patency rate. Dynamic portography had 100% correlation with conventional angiography in the five patients when this was done. The site of shunt could be demonstrated convincingly by dynamic CT portography. The shunt patency rate decreased over time. It was 64%, 60% and 43% in <1 year, 1-5 years and >5 years respectively. Our NCPF patients had a greater shunt patency rate compared to EHPVO patients (9/12 vs. 21/38) though the difference was not significant. Only size of the splenic vein had a significant impact on the shunt patency rate on statistical analysis. CONCLUSIONS Dynamic CT portography is useful for evaluation of shunt patency. Proximal splenorenal shunts have a high blockage rate which has hitherto not been reported.
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Affiliation(s)
- Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India.
| | - Nilesh Sadashiv Patil
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Sundeep Saluja
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Poonam Narang
- Department of Radio Diagnosis, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Nisha Solanki
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
| | - Vaibhav Varshney
- Department of Gastrointestinal Surgery, G B Pant Institute of Post Graduate Medical Education and Research and Maulana Azad Medical College, India
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