Recurrent portal hypertension after composite liver/small bowel transplantation.
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Late technical complications of composite liver/small bowel transplantation procedures are often complex and have not been well defined. Here we describe the unusual presentation and management of two cases of recurrent thrombocytopenia due to hypersplenism resulting from portacaval shunt stenosis. Both patients presented with portal hypertension late after composite liver/small bowel transplantation. One patient presented with recurrent bouts of upper gastrointestinal hemorrhage and was ultimately found to have a stenosis of her native portacaval shunt. After unsuccessful balloon dilatation of the anastomosis, a successful side-to-side distal splenorenal shunt was performed. The second patient presented with severe thrombocytopenia, the etiology of which was determined to be a short segment occlusion of the inferior vena cava between the native portacaval shunt and the piggyback outflow anastomosis of the liver graft. Total caval occlusion prevented balloon dilatation; the patient was relisted for transplantation but died of chronic rejection four months later. Recurrent portal hypertension is challenging in patients who have had combined liver/small bowel transplantation. Surgeons performing intestinal transplantation need to be increasingly aware of these possible late complications. (+info)
Portal hypertension in schistosomiasis: pathophysiology and treatment.
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In heavily infected young patients, there is a "non-congestive" phase of the disease with splenomegaly which can improve after chemotherapy. A strong correlation between hepatosplenic form and worm burden in young patients has been repeatedly shown. The pattern of vascular intrahepatic lesions, seems to depend on two mechanisms: (a) egg embolization, with a partial blocking of the portal vasculature; (b) the appearance of small portal collaterals along the intrahepatic portal system. The role played by hepatitis B virus (HBV) and C virus infections in the pathogenesis of liver lesions is variably considered. Selective arteriography shows a reduced diameter of hepatic artery with thin and arched branches outlining vascular gaps. A rich arterial network, as described in autopsy cases, is usually not seen in vivo, except after splenectomy or shunt surgery. An augmented hepatic arterial flow was demonstrated in infected animals. These facts suggest that the poor intrahepatic arterial vascularization demonstrated by selective arteriography in humans is due to a "functional deviation" of arterial blood to the splenic territory. The best results obtained in treatment of portal hypertension were: esophagogastric devascularization and splenectomy (EGDS), although risk of rebleeding persists; classical (proximal) splenorenal shunt (SRS) should be abandoned; distal splenorenal shunt may complicate with hepatic encephalopathy, although later and in a lower percentage than in SRS. Propranolol is currently under investigation. In our Department, schistosomatic patients with esophageal varices bleeding are treated by EGDS and, if rebleeding occurs, by sclerosis of the varices. (+info)
Selective shunt in the management of variceal bleeding in the era of liver transplantation.
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This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach. (+info)
Functional compartments in the portal system. An experimental study.
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The pressure of the portal trunk, the left gastric vein, the left and right gastroepiploic veins, the mesenteric vein and the abdominal aorta was measured experimentally at the same time in 10 normal dogs. The levels of the raised pressure in the different compartments with their outflow tracts obstructed respectively were observed and the potentials of the functional barriers between these compartments were quantitatively evaluated. The findings showed that the average power of the functional barriers was 45.1 +/- 5.7% between the different compartments in the gastrosplenic area and 74.3% in the mesenteric region. The weakness of the functional barriers' capacity limiting the collateral diversion between the lesser and greater splanchnic systems may be one of the causes making the distal splenorenal shunt lose its selectivity. (+info)
Splenocaval versus mesocaval shunt with artificial vascular graft for the treatment of Budd-Chiari syndrome.
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BACKGROUND: Budd-Chiari syndrome (B-CS) is a disease with a poor prognosis, and the results of medication are not satisfactory. Surgical treatments are widely used to depress portal hypertension and hypertension of the inferior vena cava. Splenocaval shunt is usually applied to treat intrahepatic portal hypertension, but we used this method to treat patients with B-CS successfully. METHODS: The clinical data of 72 B-CS patients (type II), including 26 patients treated with splenocaval shunt (splenocaval group) and 46 patients with mesocaval C-shape shunt (mesocaval group) were analyzed retrospectively. RESULTS: The platelet count of the splenocaval group increased significantly after operation (P<0.05). Free portal pressure (FPP) significantly decreased in both groups after operation (P<0.05), but no significant difference was seen between the two groups (P>0.05). Twenty patients in the splenocaval group and 36 in the mesocaval group were followed up for 6 months to 3.5 years, showing the effective rates of 90.0% and 91.7% respectively in the two groups. The occurrence of hepatic encephalopathy was 5.0% and 5.6% respectively in both groups, but there was no recurrent hemorrhage. CONCLUSIONS: Splenocaval shunt can effectively control B-CS, decrease FPP, prevent upper gastrointestinal hemorrhage, and eradicate hypersplenia. Its efficacy is similar to that of mesocaval shunt in treatment of B-CS. (+info)
Effects of combined splenorenal shunt devascularization and devascularization only on hemodynamics of the portal venous system in patients with portal hypertension.
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BACKGROUND: Shunt and devascularization have totally different effects on hemodynamics of the portal venous system, and the actual results of combined shunt and devascularization should be determined by more clinical observations. This study aimed to evaluate effects on hemodynamics of the portal venous system after conventional splenorenal shunt combined with pericardial devascularization and pericardial devascularization only. METHODS: In 20 patients who had received conventional splenorenal shunt combined with pericardial devascularization(CP) and 18 who had received pericardial devascularization and splenectomy(PCDV), hemodynamic parameters of the portal venous system were studied by magnetic resonance angiography 1 week before and 2 weeks after operation. Free portal pressure was detected continuously by a transducer during the operation. RESULTS: Compared to the preoperative data, a decreased flow of the portal vein(PVF) (563.12+/-206.42 ml/min vs. 1080.63+/-352.85 ml/min, P < 0.05), a decreased diameter of the portal vein (PVD) (1.20+/-0.11 cm vs. 1.30+/-0.16 cm, P < 0.01), a decreased free portal pressure(FPP) (21.50+/-2.67 mmHg vs. 29.88+/-2.30 mmHg, P < 0.01) and an increased flow of the superior mesenteric vein (SMVF) (1105.45+/-309.03 ml/min vs. 569.13+/-178.46 ml/min, P < 0.05) were found in the CP group after operation; a decreased PVD (1.27+/-0.16 cm vs. 1.40+/-0.23 cm, P < 0.05), a decreased PVF(684.60+/-165.73 ml/min vs. 1175.64+/-415.09 ml/min, P < 0.05), a decreased FPP (24.40+/-3.78 mmHg vs. 28.80+/-3.56 mmHg, P < 0.05) and an increased SMVF (697.91+/-121.83 ml/min vs. 521.30+/-115.82 ml/min, P < 0.05) were found in the PCDV group. After operation, the PVF of CP group(563.12+/-206.42 ml/min vs. 684.60+/-165.73 ml/min, P > 0.05) was not decreased significantly while FPP (21.50+/-2.67 mmHg vs. 24.40+/-3.78 mmHg, P < 0.01) was decreased significantly as compared with that of the PCDV group. CONCLUSIONS: PVF and FPP could be decreased by both surgical procedures, but the effect of decreasing FPP is much better in the combined procedures than in PCDV. Since there is no significant difference in PVF between the two groups, the combined procedures could integrate advantages of shunt with those of the devascularization, maintaining the normal anatomy structure of the hepatic portal vein, and should be one of the best choices for patients with PHT when surgical interventions are considered. (+info)
Mesogonadal shunts for extrahepatic portal vein thrombosis and variceal hemorrhage.
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Extrahepatic portal vein thrombosis (EHPVT) may occur in children or adults and usually comes to clinical attention due to complications of portal hypertension such as variceal hemorrhage. A variety of standard surgical techniques exist to manage these patients, but when these fail surgical options are limited. We describe two novel portosystemic shunts that utilize the gonadal vein as an autologous conduit. Four patients were evaluated for EHPVT with variceal bleeding. None of the patients were candidates for a standard splenorenal shunt due to prior surgical procedures. The first patient underwent a left mesogonadal shunt and the remaining 3 patients underwent a right mesogonadal shunt. Postoperative ultrasound or computed tomography (CT) scan confirmed early patency of the shunt in each patient. There have been no further episodes of variceal hemorrhage with follow-up of 3.5 years in the child who underwent the left mesogonadal shunt, and 17, 19, and 20 months in the patients who underwent the right mesogonadal shunt. Three of the 4 shunts remain patent. One shunt thrombosis occurred in a patient homozygous for the Factor V Leiden mutation despite anticoagulation with coumadin. This is the first report of the successful use of the gonadal vein as an in situ conduit for constructing a portosystemic shunt. In conclusion, the right and left mesogonadal shunts may be useful as salvage operations for patients with EHPVT who have failed standard surgical shunt procedures. (+info)
A simplified technique of performing splenorenal shunt (Omar's technique).
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The splenorenal shunt procedure introduced by Robert Linton in 1947 is still used today in those regions of the world where portal hypertension is a common problem. However, because most surgeons find Linton's shunt procedure technically difficult, we felt that a simpler technique was needed. We present the surgical details and results of 20 splenorenal anastomosis procedures performed within a period of 30 months. Half of the patients (Group I) underwent Linton's conventional technique of splenorenal shunt; the other half (Group II) underwent a newly devised, simplified shunt technique. This new technique involves dissection of the fusion fascia of Toldt. The outcome of the 2 techniques was identical with respect to the reduction of preshunt portal pressure. However, our simplified technique was advantageous in that it significantly reduced the duration of surgery (P <0.001) and the amount of intraoperative blood loss (P <0.003). No patient died after either operation. Although Linton's splenorenal shunt is difficult and technically demanding, it is still routinely performed. The new technique described here, in addition to being simpler, helps achieve good vascular control, permits easier dissection of the splenic vein, enables an ideal anastomosis, decreases intraoperative blood loss, and reduces the duration of surgery. Therefore, we recommend the routine use of this simplified technique (Omar's technique) for the surgical treatment of portal hypertension. (+info)