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Purpose: To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS)., Methods: This is a single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts were performed, 15 MRS and 7 DSRS, over an 18-year period. Patients were followed up for a mean of 11 years (range 2-18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalised ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2 years after shunt surgery., Results: One MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration., Conclusion: In EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails., (© 2023. Crown.)

Objective: The aim of the present study is to evaluate efficacy and safety of proximal splenic vein embolization (PSVE) for liver transplant recipients having complicated large splenorenal shunts (SRS)., Background: In adult living donor liver transplantation for a patient who has large splenorenal shunts (SRS), their interruption is utmost important to maintain adequate portal flow by avoidance of portal flow steal through the preexisting SRS. We effectively managed most of the recipients with surgical ligation and/or additional radiologic embolization using by intraoperative cine-portogram. However, when complete interruption is not achieved in a few recipients having complicated large SRS, it may leave a chance of lethal portal flow steal in the recipient afterward., Methods: PSVE was performed in 13 patients between April 2014 and November 2017. We performed a retrospective analysis of preoperative images, postoperative graft and recipient outcomes, and presence of isolated portal hypertension., Results: Ten patients underwent PSVE as an additional secondary method because of portal steal syndrome through the remaining SRS after surgical interruption and/or embolization, and 3 patients underwent PSVE only as a primary method of SRS interruption. In all 13 patients, portal steal on the final intraoperative cine-portogram completely disappeared after PSVE. All patients recovered with satisfactory regeneration of the partial liver graft without the reappearance of portosystemic collaterals, and there were no procedure-related complications., Conclusions: PSVE is an effective and safe procedure to secure adequate portal flow without portal steal for patients with complicated large SRS arising from multiple sites of the splenic vein or escaping to multiple terminal ends., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical shunts are commonly used to manage complications resulting from extrahepatic portal vein thrombosis (EHPVT) in children. We describe a single-center experience utilizing a functional Side-to-Side Splenorenal Shunt (fSRS), created using either an enlarged inferior mesenteric vein (IMV) or left adrenal vein (LAV)., Methods: Pediatric patients with isolated EHPVT who were poor candidates for a Rex shunt and who underwent a fSRS procedure at our institution between 2003 and 2020 were reviewed. The pre/post shunt portosystemic gradient change, rates of early and late complications, postoperative shunt patency, and mortality were evaluated., Results: Twelve EHPVT patients (mean age of 6.1 years) underwent a fSRS procedure. The mean portosystemic gradient change for the cohort was -11.7 mmHg (±4.9). There were no cases of recurrent variceal bleeding or episodes of shunt thrombosis reported after fSRS procedures., Conclusions: Surgical shunts continue to be an important adjunct in the treatment of complications related to EHPVT. The functional Side-to-Side Splenorenal Shunt is a safe alternative that is easy to perform, involves minimal dissection and requires only a single anastomosis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Portal hypertension (PH) is infrequent in children as compared to adults. Currently, repetitive endoscopic ablation of varices is standard treatment. However, endoscopic facilities are not readily available in resource-limited settings. We reviewed the indications, operative morbidity, mortality, shunt patency and re-bleeding episodes in nine patients (age range 6-16 years, M:F 6:3) who had DSRS for recurrent GI bleeding not responding to endoscopic treatment and hypersplenism. DSRS is a safe and effective treatment alternative in resource limiting setting for preventing bleeding and improving hypersplenism in children with extrahepatic portal hypertension.

Rationale: Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking., Patient Concerns: A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion., Diagnoses: Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis., Interventions: To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis., Outcomes: After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up., Lessons: The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.

A 70-year-old woman with hepatitis C cirrhosis underwent balloon-occluded retrograde transvenous obliteration for hepatic encephalopathy due to spleno-renal shunt. Because the shunt was thick, long, and winding, we used a coaxial and double interruption system, which enables the effective occlusion of the drainage route, and shape-memory coils, which are more physically stable than conventional metallic coils because they form three-dimensional loops. The patient was successfully treated with the combined usage of these devices, resulting in a normal serum ammonia level. Thereafter, the patient was treated with direct-acting antivirals, and a sustained virological response was achieved.

Patients with large spontaneous splenorenal shunts (SRSs) prove challenging during liver transplantation (LT), regardless of organizing portal vein (PV) thrombosis. Here, we detail the clinical outcomes of 26 patients who underwent direct ligation of large SRSs during LT. Direct ligation of large SRS was applied in poor portal flow during LT. We performed temporary test clamping of the SRS before direct ligation and applied PV pressure monitoring in patients who showed signs of portal hypertension, such as bowel edema. We retrospectively reviewed and evaluated their clinical outcomes. Among 843 patients who underwent LT between 2010 and 2015, 26 (3.1%) underwent direct ligation of SRS without any intraoperative event. Mean preoperative Model for End-Stage Liver Disease score was 16.7 ± 9.0. The main PV diameter on preoperative computed tomography was 8.3 ± 3.4 mm (range, 3.0-14.0 mm). SRS was easily identified at just below the distal pancreas and beside the inferior mesenteric vein in all patients. Accompanying PV thrombectomy was done in 42.3% of patients. Among 26 patients, massive and prolonged ascites was evident in 15.4% (n = 4) postoperatively. They were all living donor LT recipients with a small PV diameter (4.0-6.7 mm). Except for 1 patient who underwent splenic artery embolization, ascites was tolerable and well controlled by conservative management. There was a 7.7% rate of major complications related to direct ligation, including reoperation due to combined ligation of SRS along with a left renal vein at the confluence. Except for 1 hospital mortality due to sepsis, 25 patients (96.2%) are alive with no evidence of further PV complications. In conclusion, direct ligation of large SRS during LT is a safe and feasible method to overcome the effects of a large SRS. Liver Transplantation 23 899-906 2017 AASLD., (© 2017 by the American Association for the Study of Liver Diseases.)

Introduction: The concept of magnetic compression technique (MCT) has been accepted by surgeons to solve a variety of surgical problems. In this study, we attempted to explore the feasibility of a splenorenal shunt using MCT in canine and cadaver., Material and Methods: The diameters of the splenic vein (SV), the left renal vein (LRV), and the vertical interval between them, were measured in computer tomography (CT) images obtained from 30 patients with portal hypertension and in 20 adult cadavers. The magnetic devices used for the splenorenal shunt were then manufactured based on the anatomic parameters measured above. The observation of the anatomical structure showed there were no special structural tissues or any important organs between SV and LRV. Then the magnetic compression splenorenal shunt procedure was performed in three dogs and five cadavers. Seven days later, the necrotic tissue between the two magnets was shed and the magnets were removed with the anchor wire., Results: The feasibility of splenorenal shunt via MCT was successfully shown in both canine and cadaver, thus providing a theoretical support for future clinical application.

The management of LSRS is a crucial problem to ensure a sufficient PV flow during pediatric LT. Although several techniques have been indicated to solve this problem, a more appropriate approach to LSRS is still needed in pediatric LT. We herein present a modified surgical approach to the ligation of LSRS via the left side of the IVC for a nine-month-old boy with severe portal hypertension and a history of Kasai portoenterostomy. LSRS was identified and exposed through the left side of the IVC and the dorsal surface of the pancreas from the superior side of the body of the pancreas. The post-operative course was uneventful with an excellent PV flow. The central approach for the ligation of LSRS is worth considering as an alternative procedure for a patient with collateral vessels and a history of multiple laparotomies., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Extra-hepatic portal vein obstruction (EHPVO) is one of the most often causes of portal hypertension in children., Objective: Establishing the importance of shunt surgery in combination with partial spleen resection in selected pediatric patients with EHPVO, enormous splenomegaly and severe hypersplenism., Methods: Distal splenorenal shunt (DSRS) with partial spleen resection was performed in 22 children age from 2 to 17 years with EHPVO. Indications for surgery were pain and abdominal discomfort caused by spleen enlargement, as well as symptomatic hypersplenism with leucopenia, thrombocytopenia and anemia. The partial spleen resection was performed by ligation of blood vessels to caudal two thirds of the spleen. After ischemic parenchymal demarcation transection with electrocautery LigaSure was performed with preservation of 20-30% of spleen tissue, and then Warren DSRS was created. Platelet and leucocytes counts and liver function tests were obtained before, one month and one year after surgery. Growth was assessed with SD scores (Z scores) for height, weight and body mass index at the time of surgery and one year later., Results: In all patients postoperative period was without significant complications. Platelets and leucocytes counts were normalized. Patency rate of shunts was 100%. Two significant shunts stenosis were observed and successfully treated with percutaneous angioplasty. During the follow-up period (1 to 9 years) all patients were asymptomatic, with improved quality of life and growth., Conclusion: Results of our study indicate that shunt surgery with a partial spleen resection is an effective and safe procedure for patients with enormous splenomegaly and severe hypersplenism caused by EHPVO.

Background: Vascular resection/reconstruction at the time of pancreatectomy is performed when limited vascular involvement is the only barrier to complete resection. Splenic vein (SV) ligation facilitates resection/reconstruction of the superior mesenteric vein (SMV)-portal vein (PV) confluence and widely exposes the superior mesenteric artery and celiac origin. If the inferior mesenteric vein does not provide for retrograde decompression, SV ligation may result in sinistral portal hypertension; creation of a distal splenorenal shunt (DSRS) can prevent this complication. Additional complexity occurs in the setting of cavernous transformation of the PV. A mesocaval shunt (MCS) can be utilized to temporarily divert portal flow allowing for a safe portal dissection. Herein we report our initial experience utilizing DSRS and MCS at the time of pancreatectomy for cancer., Methods: We reviewed all patients who underwent pancreatic resection for cancer and had either a DSRS and/or MCS performed between January 1, 2009 and February 1, 2012., Results: Of 11 patients identified, 10 had adenocarcinoma, 9 underwent standard or extended pancreaticoduodenectomy, and 2 underwent total pancreatectomy. Median operative time was 9.5 hours, median blood loss was 1,000 mL and median duration of stay was 10 days. There were no mortalities. There was 1 Clavien grade III complication during the index admission and 3 others were readmitted. No patient required reoperation., Conclusion: We provide proof of concept that extended pancreatic resection in the setting of limited vascular involvement can be safely performed. This is the first report utilizing MCS and DSRS to facilitate resection of the SMV-PV confluence in the setting of cavernous transformation of the PV., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Purpose: To establish the importance of shunt surgery combined with partial resection of the spleen for selected pediatric patients with extra-hepatic portal vein obstruction (EHPVO), enormous splenomegaly and severe hypersplenism. Severe hypersplenism is often refractory to treatment with endoscopic sclerotherapy or band ligation and shunt surgery; however, to our knowledge, this is the first such study to be published., Methods: Distal splenorenal shunt with partial resection of the spleen was performed in 16 of 60 children treated for EHPVO in the Gastroenterology Department of our hospital. Upper gastrointestinal endoscopy had shown esophageal varices of varying grade in all patients and band ligation or endoscopic sclerotherapy had been done for children with a history of bleeding. The indications for surgery were pain and discomfort caused by a large spleen (5-15 cm below the costal margin) and symptomatic hypersplenism with leucopenia, thrombocytopenia, and anemia. Partial resection of the spleen was performed, starting with ligation of the branches and tributaries of the caudal two-thirds. When an ischemic line demarcated the splenic parenchyma, it was transected using electrocautery or LigaSure, leaving 20-30 % of splenic tissue. After the spleen resection, a Warren shunt was performed. Platelet and white blood cell counts and liver function tests were performed before and after the operation. Growth was assessed using SD scores (z scores) for height, weight, and body mass index at the time of surgery and 1 year later., Results: Postoperative recovery was uneventful and the leukocyte and platelet counts normalized. The shunt patency rate was 100 %. Two cases of shunt stenosis were treated successfully with percutaneous angioplasty. There was no postoperative mortality. During the follow-up period, from 1 to 7 years, all 16 children were asymptomatic, with improved quality of life, growth, and nutrition. No episodes of variceal bleeding, sepsis or encephalopathy occurred., Conclusion: Our results demonstrate that shunt surgery with partial resection of the spleen is effective and safe for pediatric patients with massive splenomegaly and severe hypersplenism secondary to EHPVO.

Introduction: The management of a large splenorenal shunt is important because it affects recipient outcome, particularly in living donor liver transplantation., Methods: To manage large splenorenal shunts in living donor liver transplantation, we diverted superior mesenteric vein and splenic portal vein blood flow by ligation at the root of the splenic portal vein., Result: This procedure was applied for five patients in whom superior mesenteric vein blood flow had been completely stolen by a splenorenal shunt preoperatively. Postoperative course was excellent in all cases., Conclusion: This technique completely prevents morbidity related to large splenorenal shunts after living donor liver transplantation.

Objectives: Spontaneous splenorenal shunts cause significant vascular steal from the liver. There is no accepted algorithm for treating spontaneous splenorenal shunts before, during, or after liver transplant, and evidence for efficacy of treatments remains limited., Materials and Methods: We reviewed the literature, and our institution's experience regarding spontaneous splenorenal shunts, including a case series of 6 patients with spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts, a case of intraoperative ligation of a large spontaneous splenorenal shunts during transplant, and 1 patient requiring multiple endovascular interventions to embolize recurrent spontaneous splenorenal shunts after orthotopic liver transplant., Results: Small spontaneous splenorenal shunts may not need intervention, as involution after liver transplant is well known. Transjugular intrahepatic porto-systemic shunts may decrease the porto-systemic gradient in patients with large spontaneous splenorenal shunts, as shown in our review of 6 patients with large spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts. We have demonstrated re-establishment of physiologic flow after ligation of a large spontaneous splenorenal shunt at the time of transplant, supporting operative ligation may be justified if intraoperative compression of the spontaneous splenorenal shunts demonstrates significant improvement of allograft portal venous flow. Ligation of the left renal vein for large spontaneous splenorenal shunts is a safe and effective method of preventing portal venous steal. For concomitant spontaneous splenorenal shunts and portal vein thrombosis, renoportal anastomosis can be performed. We report transient success with endovascular embolization of large spontaneous splenorenal shunts in a patient posttransplant who required multiple interventions., Conclusions: Experience in the approach to and treatment of spontaneous splenorenal shunts in liver transplant recipients is limited. Further investigation into the best approach to treat spontaneous splenorenal shunts is warranted as the presence and persistence of spontaneous splenorenal shunts can lead to allograft dysfunction and possible allograft loss.

Background: Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension (NCPH). While a splenectomy alone can effectively relieve the hypersplenism, it does not address the underlying portal hypertension. The present study was undertaken to analyze the impact of shunt and non-shunt operations on the resolution of hypersplenism in patients with NCPH. The relationship of symptomatic hypersplenism, severe hypersplenism and number of peripheral cell line defects to the severity of portal hypertension and outcome was also assessed., Methods: A retrospective analysis of NCPH patients with hypersplenism managed surgically between 1999 and 2009 at our center was done. Of 252 patients with NCPH, 64 (45 with extrahepatic portal vein obstruction and 19 with non-cirrhotic portal fibrosis) had hypersplenism and constituted the study group. Statistical analysis was done using GraphPad InStat. Categorical and continuous variables were compared using the chi-square test, ANOVA, and Student's t test. The Mann-Whitney U test and Kruskal-Wallis test were used to compare non-parametric variables., Results: The mean age of patients in the study group was 21.81+/-6.1 years. Hypersplenism was symptomatic in 70.3% with an incidence of spontaneous bleeding at 26.5%, recurrent anemia at 34.4%, and recurrent infection at 29.7%. The mean duration of surgery was 4.16+/-1.9 hours, intraoperative blood loss was 457+/-126 (50-2000) mL, and postoperative hospital stay 5.5+/-1.9 days. Following surgery, normalization of hypersplenism occurred in all patients. On long-term follow-up, none of the patients developed hepatic encephalopathy and 4 had a variceal re-bleeding (2 after a splenectomy alone, 1 each after an esophago-gastric devascularization and proximal splenorenal shunt). Patients with severe hypersplenism and those with defects in all three peripheral blood cell lineages were older, had a longer duration of symptoms, and a higher incidence of variceal bleeding and postoperative morbidity. In addition, patients with triple cell line defects had elevated portal pressure (P=0.001), portal biliopathy (P=0.02), portal gastropathy (P=0.005) and intraoperative blood loss (P=0.001)., Conclusions: Hypersplenism is effectively relieved by both shunt and non-shunt operations. A proximal splenorenal shunt not only relieves hypersplenism but also effectively addresses the potential complications of underlying portal hypertension and can be safely performed with good long-term outcome. Patients with hypersplenism who have defects in all three blood cell lineages have significantly elevated portal pressures and are at increased risk of complications of variceal bleeding, portal biliopathy and gastropathy.

Aim: To investigate recurrent variceal hemorrhage and long-term survival rates of patients treated with partial proximal splenorenal venous shunt., Methods: Patients with variceal hemorrhage who were treated with small-diameter proximal splenorenal venous shunt in Ruijin Hospital between 1996 and 2009 were included in this study. Shunt diameter was determined before operation using Duplex Doppler ultrasonography. Peri-operative and long-term results in term of rehemorrhage, encephalopathy and mortality were followed up., Results: Ninety-eight patients with Child A and B variceal hemorrhage received small-diameter proximal splenorenal venous shunt with a diameter of 7-10 mm. After operation, the patients' mean free portal pressure (P < 0.01) and the flow rate of main portal vein (P < 0.01) decreased significantly compared with that before operation. The rates of rebleeding and mortality were 6.12% (6 cases) and 2.04% (2 cases), respectively. Ninety-one patients were followed up for 7 mo-14 years (median, 48.57 mo). Long-term rates of rehemorrhage and encephalopathy were 4.40% (4 cases) and 3.30% (3 cases), respectively. Thirteen patients (14.29%) died mainly due to progressive hepatic dysfunction. Five- and ten-year survival rates were 82.12% and 71.24%, respectively., Conclusion: Small-diameter proximal splenorenal venous shunt affords protection against variceal rehemorrhage with a low occurrence of encephalopathy in patients with normal liver function.

Background: Although significant advances are expected to be made in the assessment of the portal hypertension-related complications, the prognostic role of spleno-renal shunts has not been fully explored so far. Clarifying this aspect could help tackle the life-treating events occurring in patients suffering from liver cirrhosis. The aim of the study was to analyze the relationships between the spleno-renal shunts presence at doppler ultrasound and the liver cirrhosis complications., Design: eighty one patients out of 129 formed the study population (35 females). Chronic liver damage in these patients was caused by HCV (66), HBV (2), alcohol abuse (2) or unknown etiology, likely non-alcoholic steatohepatitis (11)., Setting: two Liver Units of university/primary hospitals in Southern Italy., Main Outcome Measures: grading of esofageal varices; detection of ascites: assessment of hepatic encephalopathy; evaluation of liver cirrhosis severity; tracking hepatocellular carcinoma; doppler features of spleno-renal shunts and splenic flow velocity; spleen longitudinal diameter at sonography., Results: The prevalence of spleno-renal shunts was 18.5%, without no difference concerning the etiology (HCV versus non-HCV, p = 0.870); the prevalence of hepatocellular carcinoma in patients with spleno-renal shunts was superior to that of patients without them (Pearson Chi-square, p = 0.006, power of sample size 74%), also after adjustment for liver decompensation (p = 0.024). The median score of hepatic encephalopathy in patients with and without spleno-renal shunts was similar, i.e., 0 (range, 0-2) versus 0 (0 - 3), p = 0.67. The median splenic vein flow velocity in patients with spleno-renal shunts was significantly inferior to that of patients without them, i.e., 13 cm/sec (95% confidence intervals, 6-18) versus 21 cm/sec (17-24), p < 0.0001. By far the largest percentage of large esophageal varices was in patients without spleno-renal shunts (p = 0.005). In contrast, the frequency of ascites and hepatic encephalopathy severity was overlapping in the two groups. BMI values but not Child-Pugh's classification predicted spleno-renal shunts (Ors = 1.84, 95% confidence intervals = 1.28-2.64, p = 0.001 and 1.145, 95% confidence intervals = 0.77-1.51, p = 0.66)., Conclusion: Taking into consideration the relatively small sample size, patients with spleno-renal shunts are burdened by an increased incidence of hepatocellular carcinoma. BMI predicted the spleno-renal shunts presence.

Background: In the current era of transplantation and therapeutic endoscopy, the role of the distal splenorenal shunt (DSRS) for portal hypertension (PH) has diminished. We reviewed the outcome of the use of DSRS in children to determine the usefulness of this operation., Methods: In the follow-up course for PH from 1987 to 2006, 15 patients who developed severe thrombocytopenia (platelet count <50 x 10(3)/mm(3)) and/or leukopenia (WBC count <3000/mm(3)) with normal liver function were referred for DSRS. Primary diagnosis was portal vein thrombosis (N=10) and congenital hepatic fibrosis (N=5). Platelet, WBC count, liver function test, and spleen size were checked before and after DSRS. Shunt patency was accessed postoperatively. Operative morbidity, mortality, and long-term outcomes were measured., Results: Platelet count and WBC count increased in individual patients. Mean value of each count increased significantly after DSRS (p=0.002, .004, respectively). Spleen size decreased significantly (N=7, p=0.018). Shunt patency rate was 100%. There was one postoperative complication and no postoperative mortality. Two patients developed portopulmonary hypertension. No patients underwent subsequent transplantation or endoscopic treatment for gastroesophageal varices after DSRS., Conclusions: DSRS is an effective and reliable procedure for children with PH and is still useful for selected pediatric patients.

The secondary hypersplenism appears from 30-50% in liver cirrhosis with portal hypertension. The mechanism of the complication is the splenic congestion as the result of the progress of the portal hypertension. Between 1997-2005, 16 patients with hypersplenism due to liver cirrhosis were operated in the service. The aim of the operation was to decompress the portal hypertension, by spleno-renal shunt (Warren), in 6 patients, truncular shunts in 2 patients, and splenectomy with spleno-renal shunts in 8 patients. No postoperative death was noted on the series. The platelets number and the white blood cells, destroyed by the reticuloendothelial system of the spleen, were counted in the first month and the first year, as well as the spleen volume. In patients with non-splenectomy operations the improvement of the blood elements number was remarked in the first week, but the volume of the spleen remained increased during 1-6 month. In patients with splenectomy the platelets and the white cells dramatically increased, with the risk of coagulation disfunction. The survival rate at five years was 12 patients.

Background: Bleeding from esophagogastric varices is the worst and most lethal complication of cirrhotic portal hypertension. Distal splenorenal shunt (Warrens surgery) is used in the therapeutic of this patients, Child A and B, with rebleeding after clinical endoscopic therapy. The portal vein congestion index is elevated in cirrhotic portal hypertension and could predict rebleeding after Warrens surgery in these patients., Aim: To verify if the portal vein congestion index or liver function (Child-Pugh) at preoperative are predictive factors of rebleeding after Warrens surgery., Methods: Sixty-two cirrhotic patients were submitted to Warrens surgery at "Santa Casa" Medical School and Hospital - Liver and Portal Hypertension Unit, São Paulo, SP, Brazil. Fifty-eight were analyzed for Child-Pugh class and 36 for portal vein congestion index, divided in two groups: with or without rebleeding and statistical analysis was performed., Results: In the rebleeding group, 69% were Child B, with portal vein congestion index = 0.09. The group without rebleeding show us 62% patients Child A with portal vein congestion index = 0.076. The difference was significant for Child-Pugh class but not to portal vein congestion index., Conclusion: Portal vein congestion index was not predictive of rebleeding after Warrens surgery, but cirrhotics Child B have more chance to rebleed after this surgery than Child A.

Aim: To compare endoscopic sclerotherapy (ES) with distal splenorenal shunt (DSRS) in the prevention of recurrent variceal bleeding in cirrhotic patients during a long-term follow-up period., Methods: In 1984 we started a prospective, controlled study of patients with liver cirrhosis. Long-term follow-up presents a natural history of liver cirrhosis complicated by advanced portal hypertension. In this study the effects of 2 types of treatment, DSRS or ES, were evaluated. The study population included 80 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1991. These patients were drawn from a pool of 282 patients who underwent either elective surgery or ES during the same period of time. Patients were assigned to one of the 2 groups according to a random number table: 40 to DSRS and 40 to ES using polidocanol., Results: During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS and another patient suffered duodenal ulcer rebleeding. Eight ES patients suffered at least one episode of gastrointestinal bleeding: 4 from varices and 4 from esophageal ulcerations. Eight ES patients developed transitory dysphagia. Long-term follow-up was completed in all patients except for 5 cases (2 DSRS and 3 ES patients). Five-year survival rates for shunt (73%) and ES (56%) groups were statistically different: in this follow-up period and in subsequent follow-ups this difference decreased and ceased to be of statistical relevance. The primary cause of death became hepatocellular carcinoma (HCC). Four DSRS patients rebled due to duodenal ulcer, while eleven ES patients had recurrent bleeding from esophago-gastric sources (seven from varices, three from hypertensive gastropathy, one from esophageal ulcerations) and two from unknown sources. Nine DSRS and 2 ES patients developed a chronic encephalopathy; 13 DSRS and 5 ES patients suffered at least one episode of acute encephalopathy. Five ES patients had esophageal stenoses, which were successfully dilated., Conclusion: In a subgroup of patients with good liver function, DSRS with a correct portal-azygos disconnection more effectively prevents variceal rebleeding than ES. However, this positive effect did not influence the long-term survival because other factors (e.g. HCC) were more important in deciding the fate of the cirrhotic patients with portal hypertension.

Portal hypertension with variceal bleed and a well functioning liver is an indication for shunt surgery. The commonly performed procedure is the lieno-renal shunt. When the left adrenal vein is long enough, and of healthy diameter a spleno-adrenal shunt is possible. Most of the reported cases are of distal spleno-adrenal type. A case of proximal spleno-adrenal patent shunt with a follow-up two years is presented along with review of literature.

Background & Aims: Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding., Methods: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 +/- 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated., Results: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different., Conclusions: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.

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.

Background: Establish the predictive factors of rebleeding in cirrhotic patients submitted to the Warren's surgery., Methods: 57 cirrhotic patients with good hepatic functional reserve and previous variceal bleeding that had not responded to clinical, endoscopic treatment were submitted to the Warren's surgery (distal splenorenal shunt). They were divided in two groups: I (31 had presented rebleeding at postoperative care) and II (26 had not presented new bleeding). Group I was again divided into 2 groups according to time of rebleeding: Group I.A (12 that presented rebleeding until hospital discharge) and Group I.B (19 that presented rebleeding after hospital discharge). We analyzed the clinical, endoscopic, laboratorial and Doppler-ultrasound information at the pre- and postoperative moments and also intrasurgery data that were compared between the established groups., Results: Serum albumin and bilirubins were 3.33 mg% and 1.7 mg% in group I, 3.56 mg% and 1.16 mg% in group II. Portal flow and diameter were 0.24 cm/s and 1.34 cm in group I, and 0.18 cm/s and 1.21 cm in group II, respectively. In group I.A the volume of crystalloid given during surgery was 3.692 ml against 2.166 ml in group I.B., Conclusion: Albumin and total bilirubins dosages in the preoperative period, added to the value of the flow and portal diameter were predictive factors for rebleeding in cirrhotic patients submitted to the Warren's surgery. The volume of crystalloid given during the surgery was a predictive factor for early rebleeding.

Idiopathic portal hypertension (IPH) requires invasive measures to prevent rupture and bleeding of esophagogastric varices. However, the long-term results of shunt surgery for IPH have not been reported. In particular, the pros and cons of surgery that preserves the spleen and its long-term hematologic effects have not been described. The records of 15 patients who underwent distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for IPH between 1983 and 1998 was reviewed retrospectively. One patient died within 3 years of surgery, for a 3-year survival rate of 93%; the 10-year survival rate was 64%. Three patients (18%) suffered rebleeding from esophagogastric varices. The white blood cell and platelet counts were higher 3-5 years and 7-13 years postoperatively compared with preoperative values. Four of five patients who underwent postoperative computed tomography had a smaller spleen postoperatively. DSRS with SPGD provides long-term hemostasis for esophagogastric variceal bleeding in IPH and alleviates hypersplenism. DSRS with SPGD is an effective treatment for patients with IPH in whom long-term survival is expected.

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

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.

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.

Some of serious hepatic diseases with cirrhosis may be complicated by portal hypertension, splenomegaly and hypersplenism. Splenomegaly inhibits regenerative processes of the liver, and also intensifies sequestration of the cellular components of blood up to hypersplenism. Cytopenia caused by hypersplenism is aggravated by negative hepatic influence on bone marrow activity-hemathopoesis, and also by recurrent bleeding from oesophageal varices, and from the other site of gastrointestinal tract. This circle of pathologic conditions may be interrupted only by liver transplantation, until which patients are jeopardized by acute bleeding and chronic anemia. Partial resection of the spleen and splenorenal shunt may correct portal hypertension and hypersplenism, prevent gastrointestinal bleeding, and alleviate hepatic regenerative processes inhibition. In this study, 51 patients with partial resection of the spleen and splenorenal shunt, were analyzed.

Background/aims: Distal splenorenal shunt with splenopancreatic disconnection (DSRS + SPD) evolved to prevent the development of a pancreatic siphon, to improve maintenance as well as quality of portal perfusion and to achieve better long-term survival. We report several cases of postoperative pancreatitis in DSRS + SPD. Recently, oxygen-derived free radicals have been reported to play an important role in pathogenesis of acute pancreatitis., Methodology: In this study, ten cases of DSRS + SPD were examined intraoperatively. The local changes in oxygen-derived free radicals were obtained by measuring lipid peroxide and an endogenous scavenger (SOD) in the development of DSRS + SPD-induced pancreatitis., Results: Lipid peroxide activity as the offense system was not changed before or after SPD. However, SOD activity as a defense system was significantly lowered after SPD compared to before SPD., Conclusions: These results indicate that an imbalance of both systems might be the cause of postoperative pancreatitis.

Objective: To study the prevention method for thrombosis after porta-azygous devascularization for portal hypertension., Methods: 71 patients with portal hypertension due to cirrhosis were divided into group A (36 patients) and group B (35 patients). In group A, a anticoagulation tube was inserted via splenic vein branch during shunt and anticoagulation therapy was given after operation., Results: All the patients received color Doppler examination 3 months after operation. No thrombosis occurred in the group A and thrombosis occurred in 13 patients (37.14%) in the group B., Conclusion: Portal anticoagulation therapy is the effective in preventing portal thrombosis after porta-azygous devascularization for portal hypertension.

Objectives: The use of duplex studies for the portal tree has revolutionized the concepts of haemodynamic pathophysiology in the case of portal hypertensive bleeders. The identification of possible haemodynamic patterns in schistosomal bleeders, and the effects of devascularization procedure and distal lienorenal shunts on a selected haemodynamic pattern, are the aim of this work., Patients and Methods: Patients (219) with schistosomal hepatic fibrosis and history of bleeding oesophageal varices were studied. The patency, diameter, velocity and flow volume/min in the portal and splenic veins were followed by coloured Duplex. Two matched groups (30 patients each) with the most commonly found haemodynamic pattern (splenic vein flow exceeding portal vein flow) were operated upon. Devascularization procedure was done for the first group (A) and distal splenorenal shunt for the second group (B)., Results: Coloured duplex assessment of portal circulation in schistosomal patients identified four haemodynamic patterns. Pattern I (approximately 59%); splenic vein flow exceeds the portal vein flow. Pattern II (approximately 28%); portal vein flow exceeds splenic vein flow. In both patterns, the portal flow was hepatopedal. Patterns III and IV (8% and 5%, respectively) were associated with hepatofugal flow. Splenic vein flow exceeds portal vein flow in pattern III and the reverse in pattern IV. Distal lienorenal shunts done for patients with haemodynamic pattern I was followed by a rebleeding rate of 3.3% while devascularization done for patients with the same pattern was followed by a rebleeding rate of 26.6%. Mild encephalopathy was detected in 10% of patients with distal lienorenal shunts and responded to dietary regulations., Conclusions: DSRS proved to be ideal for schistosomal patients with hepatopedal flow and splenic vein flow exceeding portal vein flow; since in addition to eliminating the high splenic flow out of portal circulation, it decreased the pressure in the gastroesophageal region. Other patterns with their frequencies and the suggested surgical procedures were also presented.

Background/aims: Long-term results were compared for 3 types of distal splenorenal shunt for the treatment of esophageal varices., Methodology: Between July 1983 and December 1997, 45 patients with esophageal varices underwent distal splenorenal shunt. Group 1 underwent standard distal splenorenal shunt (n = 11). Group 2 underwent distal splenorenal shunt with splenopancreatic disconnection (n = 11). Group 3 underwent distal splenorenal shunt with splenopancreatic disconnection and gastric transection (n = 23)., Results: Additional treatment for recurrent varices was required in group 1, (n = 1, 9.1%), group 2 (n = 2, 18.2%), and group 3 (n = 1, 4.3%). All of the patients with recurrent varices developed a shunt stenosis within the 1st year after distal splenorenal shunt. The prevalence of hyperammonemia in group 1 was 40.0% at 1, 5, and 10 years. In group 2, the prevalence was 14.3% at 1 year, 31.4% at 5 years, and 54.3% at 10 years. In group 3, the prevalence was 0% at 1 year, and 9.1% at 5 and 10 years. The differences between group 3 and groups 1 and 2 were significant (P < 0.01). The cumulative survival rates at 1 year were 90.9%, 63.6%, and 95.7% for groups 1, 2, and 3, respectively. At 10 years, the cumulative survivals rates were 70.7%, 63.6%, and 69.4% for groups 1, 2, and 3, respectively. There were no significant differences in survival between the 3 groups., Conclusions: Distal splenorenal shunt with splenopancreatic disconnection and gastric transection may reduce the incidence of postoperative hyperammonemia.

Background: Patients with cirrhosis exhibit splanchnic, peripheral and pulmonary vasodilation, which are thought to play a role in increasing portal pressure, promoting sodium retention and determining arterial hypoxaemia. The present study investigated whether these abnormalities are influenced by portal hypertension or by portal systemic shunting., Methods: Sixty-one patients with cirrhosis who had haemodynamic measurements before and after end-to-side portacaval shunt (n = 30) or distal splenorenal shunt (n = 31) were evaluated., Results: End-to-side portacaval shunts were more effective than distal splenorenal shunts in decompressing the portal system (portocaval pressure gradient 3.2 +/- 2.5 vs splenocaval gradient 6.5 +/- 3.2 mmHg, P < 0.0001), because of a greater shunt blood flow (33 +/- 12 vs 21 +/- 12 mL/min per kg, P < 0.005). Azygos blood flow and hepatic blood flow decreased significantly after both surgical shunts. However, end-to-side portacaval shunts caused a greater decrease in peripheral resistance than distal splenorenal shunts (-23 +/- 18 vs -11+/- 27%, P < 0.05). Mean arterial pressure and pulmonary vascular resistance were significantly reduced after an end-to-side portacaval shunt (-7 +/- 10%, P < 0.001 and -14 +/- 33%, P < 0.004, respectively), but not after splenorenal shunt., Conclusions: These results show that end-to-side portacaval shunts, despite normalizing portal pressure, worsen the peripheral and pulmonary vasodilatation. The splenorenal shunt that maintained a higher portal pressure, caused less peripheral vasodilatation and did not enhance pulmonary vasodilatation. These findings suggest that portal systemic shunting is more important than increased portal pressure in determining peripheral vasodilatation in cirrhosis.

Background/aims: Though the distal splenorenal shunt has been applied for gastroesophageal varices caused by liver cirrhosis, many patients develop secondary hypersplenism due to the portal hypertension following liver cirrhosis. We examined whether this operation could be effective for alleviating secondary hypersplenism for a long post-operative period. The subjects were 42 cases with gastroesophageal varices following liver cirrhosis in which we had performed distal splenorenal shunts with splenopancreatic and gastric disconnection at our institution in the period from 1983 1994 and the post-operative survival periods had been over 3 years., Methodology: White blood cell counts, platelet counts and spleen volume were measured prior to operation, 1 month after operation and during the post-operative period of 3-5 years. Quality of life and clinical symptoms were evaluated during the post-operative period of 3-5 years., Results: White blood cell counts, platelet counts and spleen volume were improved respectively at 1 month and during the 3-5-year period after surgery, compared to those prior to operation. None of the clinical symptoms of hypersplenism were observed and the long-term performance status was satisfactory., Conclusions: We can conclude that the distal splenorenal shunt with splenopancreatic and gastric disconnection alleviated hypersplenism for post-operatively long periods.