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Objective:To compare the clinical efficacy of splenorenal shunt and traditional devascularization in the treatment of portal hypertension.Method:The clinical data of 109 patients with portal hypertension due to hepatitis B cirrhosis undergoing splenorenal shunt and traditional devascularization at Affiliated Hospital of Nantong University from Jan 2012 to Nov 2021 were retrospectively analyzed.Results:The operation time (208±43) min in shunt group was longer than that of (172±53) min in devascularization group ( t=-3.677, P<0.05). The intraoperative blood loss of (131±89) ml and postoperative hospital stay (21±6) d in shunt group were not significantly different from those of (164±109) ml and (21±8) d in devascularization group ( t=1.621, P>0.05; t=-0.403, P>0.05). There was no significant difference in the incidence of moderate to severe ascites, intraabdominal hemorrhage and hepatic encephalopathy between the two groups ( χ2=0.973, 0.830, 0.095, all P>0.05). The rebleeding rate in shunt group (5%) was lower than that in devascularization group (28%) ( χ2=5.280, P<0.05). The operation method was an independent predictor of rebleeding. The 1-, 2-, 3-, and 5-year cumulative survival rates in the shunt group were 95%, 94%, 91% and 88%, and in devascularization group were 95%, 88%, 85% and 73%. Rebleeding was an independent risk factor affecting the survival rate, and the risk of death in patients with postoperative rebleeding. Conclusion:Compared with devascularization, splenorenal shunt has obvious advantages in reducing postoperative rebleeding rate and prolonging survival time.
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Portal vein thrombosis (PVT) is a rare condition in the general population that develops serious complications if left untreated for long time. We present a case of a 29-year-old woman who developed PVT due to protein S deficiency versus neonatal funiculitis. Over time, the patient developed upper gastrointestinal bleeding due to esophageal varices and hypersplenism with splenic sequestration that caused minor bleeding episodes. Laparoscopic splenectomy and proximal splenorenal shunt with distal pancreatectomy due to aneurysmal dilatations of the splenic artery were successfully performed to avoid mayor progression of portal hypertension. Patient was discharged with indefinite anticoagulation and after surgery platelets raised up to 200x103/mm3. Laparoscopic splenectomy and proximal splenorenal shunt for portal hypertension due to portal vein thrombosis is an adequate surgery procedure which should be applied in these medical cases.
La trombosis de la vena porta (TVP) es una afección poco común en la población general que desarrolla complicaciones graves si no se trata durante mucho tiempo. Presentamos el caso de una mujer de 29 años que desarrolló TVP por deficiencia de proteína S versus funiculitis neonatal. Con el tiempo, la paciente desarrolló hemorragia digestiva alta por varices esofágicas e hiperesplenismo con secuestro esplénico que provocó episodios hemorrágicos menores. La esplenectomía laparoscópica y la derivación esplenorrenal proximal con pancreatectomía distal por dilataciones aneurismáticas de la arteria esplénica se realizaron con éxito para evitar una mayor progresión de la hipertensión portal. La paciente fue dada de alta con anticoagulación indefinida y tras la cirugía se elevaron las plaquetas hasta 200x103/mm3. La esplenectomía laparoscópica y la derivación esplenorrenal proximal para la hipertensión portal por trombosis de la vena porta es un procedimiento quirúrgico adecuado que debe aplicarse en estos casos médicos.
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BACKGROUND@#Hepatopulmonary syndrome (HPS) is not uncommon in the setting of liver disease, especially in liver cirrhosis patients. The prevalence of HPS in liver cirrhosis patients varies from 4% to 47%.[1-3] About the definition of HPS, it is a pulmonary vascular disorder with evidence of intrapulmonary arterial venous shunt.[4] Pulmonary dyspnea and polycythemia are common presentations of HPS. Dyspnea, cyanosis and clubbed fingers were present in most of all cases. Spider nevi is another common clinical feature of patients with HPS.
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EHPVO more commonly involves children from the lower socioeconomic strata in developing countries. Variceal bleeding is the most common presentation.. Management with endoscopic means provide temporary palliation. It is believed that surgery carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly in those who have limited access to medical facilities.Our aim was to evaluate the results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction. Methods: Between Aug 2017 & Jan 2019, we performed 20 elective proximal splenorenal shunts for EHPVO in the Department of Surgical Gastroenterology, SCB Medical College, Cuttack. Outcome was evaluated in term of rebleeding, encephalopathy, and pneumococcal infection. Results: Rebleeding occurred in 4 cases, pneumococcal infection & encephalopathy was detected in one patient & one patient died during follow up. Conclusion: A proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.
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Objective To evaluate the safety and efficacy of individualized treatment of splenorenal shunt during liver transplantation. Methods Clinical data of 2 recipients who underwent orthotopic liver transplantation and splenorenal shunt intraoperatively were retrospectively analyzed. According to the perfusion status after splenorenal shunt and donor liver reflow, the left renal vein ligation and splenorenal shunt vessel ligation were performed in two recipients during liver transplantation. The general postoperative conditions of the recipients were observed, including surgical related complications, peak portal blood flow velocity, liver and renal function indexs. The postoperative conditions of the recipients were monitored by abdominal ultrasound. Results No intraoperative or postoperative complications occurred in two recipients. The changes of peak portal blood flow velocity before and after splenorenal shunt in two recipients were 22.9-35.1 cm/s and 24.3-58.8 cm/s respectively. No delayed recovery of alanine aminotransferase (ALT) level was observed in two patients after operation. Case 1 experienced a transient increase in the serum creatinine (Scr), which was recovered to normal at postoperative 13 d. During the postoperative follow-up, ultrasound examination demonstrated that the direction and velocity of portal blood flow were normal and liver perfusion was excellent. Conclusions It is safe and effective to selectively ligate the left renal vein or splenorenal shunt vessels of the recipients with severe splenorenal shunt during liver transplantation.
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Objective To evaluate the effect of distal splenorenal shunts (DSRS) in treatment of portal hypertension.Methods A retrospective analysis was made on 16 patients undergoing DSRS between 2009 and 2015 in a single institution.Perioperative free portal pressure (FPP),blood routine,liver function were collected and analyzed.Postoperative complications,long-term anastomotic status and the rate of re-bleeding were observed.Results Before and after DSRS,FPP were (43 ± 9) cmH2O and (31 ± 6) cmH2 O,a decrease of 29.1％ (t =7.326,P ＜ 0.01).Postoperative serum total bilirubin and peripheral blood leukocyte increased significantly (t =-3.462,t =-2.822,P ＜ 0.05).There was no significant difference in the changes of platelet and albumin before and after surgery.7 patients (7/16,43.8％) had one or more complications including 5 cases (31.3％) of portal vein thrombosis,massive ascites in 4 cases (25.0％),1 case (6.3％) of pulmonary infection and 1 case (6.3％) of wound infection.There was no inhospital mortality and all the 16 cases were followed up with no shunt anastomotic stenosis as showed by enhanced CT scan,meanwhile postoperative re-bleeding occurred in 1 case (6.3％) and 1 case (6.3％) died from liver failure.Conclusions Distal splenorenal shunts provides an effective method for the treatment of portal hypertension.
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Objective To explore the risk factors of postoperative liver dysfunction in cirrhotic patients with Child-Pugh A liver function after splenorenal shunt and esophagogastric devascularization.Methods 128 Child-Pugh A cirrhotics undergoing splenorenal shunt and portal-azygous disconnection in our hospital from February,2014 to February,2016 were evaluated for risk factors of postoperative liver dysfunction.Results 22 cases (17.2％) developed postoperative liver dysfunction.By single factor analysis,age,history of upper gastrointestinal hemorrhage,ascites,serum prealbumin,serum albumin,mechanical ventilation time after surgery,postoperative serum albumin were associated with postoperative liver dysfunction.Non-conditional Logistic regression showed that age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction.Conclusion Patients' age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction after splenorenal shunt and portal-azygous disconnection.
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Objective To explore the risk factors of postoperative liver dysfunction in cirrhotic patients with Child-Pugh A liver function after splenorenal shunt and esophagogastric devascularization.Methods 128 Child-Pugh A cirrhotics undergoing splenorenal shunt and portal-azygous disconnection in our hospital from February,2014 to February,2016 were evaluated for risk factors of postoperative liver dysfunction.Results 22 cases (17.2％) developed postoperative liver dysfunction.By single factor analysis,age,history of upper gastrointestinal hemorrhage,ascites,serum prealbumin,serum albumin,mechanical ventilation time after surgery,postoperative serum albumin were associated with postoperative liver dysfunction.Non-conditional Logistic regression showed that age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction.Conclusion Patients' age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction after splenorenal shunt and portal-azygous disconnection.
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During living donor liver transplantation, a large spontaneous splenorenal shunt (SRS) should be addressed to obtain adequate portal inflow. Various procedures such as direct ligation of the SRS, splenectomy, left renal vein ligation (LRVL), and renoportal anastomosis can be applied to treat a large SRS according to the hemodynamics of the portal flow and anatomic conditions. Of these surgical procedures, LRVL is a simple and effective solution for treatment of a large SRS. However, to perform a LRVL, rigorous evaluation of the recipient's anatomic and hemodynamic variations is mandatory. In the present case, we ligated the left renal vein to treat a large SRS, which resulted in an unexpected thrombosis of the left renal vein and remaining portal vein stenosis in the SRS. Therefore, we revised our decisions regarding whether the LRVL was properly applied.
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Humans , Constriction, Pathologic , Hemodynamics , Ligation , Liver Transplantation , Liver , Living Donors , Portal Vein , Renal Veins , Splenectomy , Splenorenal Shunt, Surgical , ThrombosisABSTRACT
Objective To evaluate the impact of splenic vein-left adrenal vein shunting on prehepatic portal hypertension caused by cavernous transformation of portal vein in young patients.Methods From June 2004 to February 2012,9 patients with prehepatic portal hypertension due to cavernous transformation of portal vein received splenic vein-left adrenal venous shunting.The clinical data were reviewed.Results The procedure was uneventful in all the patients.There was no mortality,recurrent hemorrhage or hepatic encephalopathy on follow-up.The patients were discharged home on the 7th postoperative day.Conclusions In young patients with prehepatic portal hypertension secondary to cavernous transformation of portal vein,the left adrenal vein was often found to be large.Spleno-adrenal shunting,utilizing the left adrenal vein as a conduit,represents an excellent option in selected cases.
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End-stage liver disease is often accompanied by portal vein thrombosis (PVT) and large spontaneous splenorenal shunts (SRS). Recently, renoportal anastomosis (RP-A) of spontaneous splenorenal shunts in liver transplantation was reported as an effective method of portal vein reconstruction in cases of PVT with SRS. Here we report a successful case of RP-A in living donor liver transplantation (LDLT). A 46-year-old female with a large spontaneous splenorenal shunt and a portal vein thrombosis propagated to the superior mesenteric vein underwent living donor liver transplantation. At the operation, a side-to-end renoportal anastomosis was done using an interposing cadaveric iliac vein graft. Adequate portal venous blood flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. She has recovered well with normal graft function and renal function. Renoportal anastomosis for patients with large splenorenal shunts and expansive portal vein thrombosis to the superior mesenteric vein can be an effective and safe technique in patients PV thrombectomy.
Subject(s)
Female , Humans , Middle Aged , Cadaver , Iliac Vein , Liver , Liver Diseases , Liver Transplantation , Living Donors , Mesenteric Veins , Portal Vein , Splenorenal Shunt, Surgical , Thrombectomy , Thrombosis , TransplantsABSTRACT
Objective To evaluate the curative effect of selective decongestive devascularization shunt of gastrosplenic region(SDDS-GSR) for the treatment of portal hypertension. Methods From September 2000 to June 2008, 44 patients with portal hypertension had received SDDS-GSR in our hospital. Twenty-nine of them had been followed up for 12-85 months (mean=44months). Results Operative mortality was 0 %. Mesenteric area pressure(33.82±5.12 cm H_2O) was higher than splenic area pressure(24.57±4.63 cm H_2O)soon after the operation finished(P<0.01). No re-bleeding ca-ses were found, and the encephalopathy occurred in 2.27% of the patients in the early stage of post-operation. However, the rates of 3.45% for re-bleeding and 3.45% for encephalopathy were noticed in long-term follow-up. The 1-, 3- and 5-year survival were 100%, 95% and 95%, respectively. Dur-ing the long-term follow-up, the platelet counts markedly increased from (49.2±21.8 × 10~9/L) of preoperative value to (77.2±29.5×10~9/L) (P<0.01), while spleen size was significantly reduced.Conclusion SDDS-GSR is a reliable and reasonable surgical procedure for the management of portal hypertension.
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Objective To evaluate the effect of spleno-left adrenal vein shunt for the treatment of portal hypertensive upper GI bleeding caused by portal vein cavernous transformation in children.Methods Spleno-left adrenal vein shunt was performed in 8 children with portal hypertension due to cavernous transformation.The clinical data was reviewed.Results Portal vein pressure decreased significantly from (30±11)mm Hg to(22±7) mm Hg after shunt.There was no mortality perioperatively and during the follow-up.There were no recurrent hemorrhage nor hepatic encephalopathy occurring in the follow-up and all the children have normal intelligence and normal liver function though blood ammonia level increased significantly from(18±7)μmol/L to (60±17)μmol/L in 4 cases.In 7 cases in which preoperative whole blood cell count significantly decreased,the postoperative WBC,RBC,Hb and PLT was (7.64 ±4.46)×10~9/L,(4.54±0.97)×10~(12)/L,(133±5) g/L and (355.40±107.36)×10~9/L respectively (all P ＜0.05).In one case suffering from preoperative low PLT count the postop PLT reached 333×10~9/L,which was significantly higher than that preoperatively.Esophageal varices ameliorated in 6 cases.No stenosis of anastomotic stoma and thrombosis developed.Conclusion Spleno-left adrenal vein shunt is an effective procedure to treat portal vein cavernous transformation induced portal hypertension in children.
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Objective To evaluate the changes of splanchnic hemodynamics after selective decongestive devascularization shunt of gustrosplenic region (SDDS-GSR) in the treatment of patients with portal hypertension. Methods All these 41 portal hypertensive patients underwent a combination surgery including partially occlusion of the splenic artery, Warren distal splenorenal shunt and devascularization. Postoperative patients were followed-up by ultrasonography for changes of splanchnic hemodynamics. Results were compared with that of 21 healthy volunteers. Results The thickness of spleen 2 weeks and 1 year after surgery (47±8) mm, (46±8) nun decreased from preoperative (60±9) mm (P<0.01). The diameter of portal vein (1.13±0.19) cm and splenic artery (0.49±0.08) cm 2 weeks after surgery decreased (P<0.05) and that of hepatic artery (0.40±0.07) cm increased (P<0.05). Patients' preoperative portal vein blood flow volume (1716±1262) ml/min and splenic artery (1269±570) ml/min were larger than that of normal group (P<0.05), while that of hepatic artery (321±126) ml/min was significantly less than that of normal group (P<0.05). The portal blood flow (649±294) ml/min and that of splenic artery (446±254) ml/min 2 weeks after surgery decreased significantly (P<0.01). The hepatic artery blood flow (612±295) ml/min increased significantly (P<0.01). When reevaluated at 1 year the hepatic artery blood flow (401±152) ml/min was not significantly different compared with that before surgery and that in normal group (P>0.05). Conclusions There are significant alterations in hepatic and splenic hemodynamics in patients with portal hypertension, and that SDDS-GSR can partially reverse the chaos of the hepatic and splenic hemodynamics in cirrhotic portal hypertensive patients.
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OBJETIVO: Um dos maiores desafios no tratamento da hipertensão porta é o sangramento de varizes intestinais. O objetivo deste artigo é apresentar um novo tratamento para hemorragia entérica grave provocada por hipertensão porta cirrótica, utilizando a esplenectomia subtotal combinada com derivação esplenorrenal proximal. TÉCNICA: Uma paciente de 64 anos apresentou sangramento intenso proveniente de varizes em alça jejunal em Y de Roux, para derivação biliodigestiva, após lesão coledociana, complicada com cirrose hepática. O procedimento consistiu em esplenectomia subtotal, preservando o pólo superior do baço, suprido apenas pelos vasos esplenogástricos, e anastomose término-lateral da veia esplênica, em sua extremidade proximal, à veia renal esquerda. RESULTADOS: Esse procedimento foi seguro, sem sangramento maior, dificuldade técnica ou complicação. No acompanhamento de 30 meses, a paciente não teve novos episódios de sangramento, a cirrose não avançou e, atualmente, encontra-se bem, sob controle. CONCLUSÃO: A esplenectomia subtotal combinada com derivação esplenorrenal proximal é uma boa alternativa operatória para tratar hemorragia proveniente de varizes intestinais, decorrentes de hipertensão porta.
BACKGROUND: One of the greatest challenges of portal hypertension treatment is the approach of severe variceal intestinal bleeding. The purpose of this article is to present subtotal splenectomy and splenorenal shunt as a new treatment of severe bleeding from a Roux en Y jejunal loop varices secondary to portal hypertension. TECHNIQUE: A 64-year-old white woman presented severe episodes of bleeding from varices inside a Roux en Y jejunal loop as a complication of cirrhosis due to bile duct injury. The treatment included subtotal splenectomy with preservation of the upper splenic pole supplied only by the splenogastric vessels combined with an end-to-side central splenorenal shunt. RESULTS: This procedure was safely performed with minor bleeding and no major technical difficulties or complications. A 30-month-post-operative-follow-up has been uneventful. No rebleeding occurred during this period and she returned to her normal life. CONCLUSION: Subtotal splenectomy combined with central splenorenal shunt seems to be a good option for the treatment of severe intestinal bleedings due to portal hypertension.
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Hepatic myelopathy is a rare complication of chronic liver disease that is associated with extensive portosystemic shunts. The main clinical feature of hepatic myelopathy is progressive spastic paraparesis in the absence of sensory or sphincter impairment. Early and accurate diagnosis of hepatic myelopathy is important because patients with early stages of the disease can fully recover following liver transplantation. Motor-evoked potential studies may be suitable for the early diagnosis of hepatic myelopathy, even in patients with preclinical stages of the disease. Here we describe two patients who presented with spastic paraparesis associated with a spontaneous splenorenal shunt and without any previous episode of hepatic encephalopathy. One patient experienced improved neurologic symptoms after liver transplantation, whereas the other patient only received medical treatment, which did not prevent the progression of spastic paraparesis.
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Adult , Humans , Male , Middle Aged , Disease Progression , Evoked Potentials, Motor/physiology , Hepatitis B, Chronic/complications , Hepatitis C, Chronic/complications , Liver Cirrhosis/complications , Liver Transplantation , Magnetic Resonance Imaging , Paraparesis, Spastic/etiology , Renal Veins/diagnostic imaging , Spinal Cord Diseases/diagnosis , Splenic Vein/diagnostic imaging , Tomography, X-Ray Computed , Vascular Fistula/diagnostic imagingABSTRACT
Adequate portal perfusion is essential in liver transplantation. End-stage liver disease is often accompanied by a large spontaneous splenorenal shunt and poor portal flow. To secure an adequate portal perfusion of the graft, collaterals including splenorenal shunt should be interrupted during liver transplantation. However, this procedure is usually too demanding because of massive bleeding, as well as time-consuming. As in living-donor liver transplantation size-matched liver graft and vascular grafts are not always available, an alternative must be sought. We performed living-donor liver transplantation with renoportal anastomosis in a 52 year-old male with a large spontaneous splenorenal shunt. During surgery, left renal vein was divided at the caval junction and the distal stump was end-to-end anastomosed to the graft portal vein using 16 mm interposition polytetrafluoroethylene graft without ligation of collaterals. The initial postoperative course of this patient was uneventful. However, on postoperative day 6 and 12 perihepatic hematoma evacuation and portal vein graft thrombectomy were performed respectively. Since then, adequate portal blood flow and patency of the interposition polytetrafluoroethylene graft was maintained throughout the postoperative period. The patient was discharged with normal graft function 10 weeks after transplantation. Renoportal anastomosis using an interposition polytetrafluoroethylene graft in living-donor liver transplantation could be an acceptable alternative for patients with end-stage liver disease with a large spontaneous splenorenal shunt.
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Humans , Male , Hematoma , Hemorrhage , Ligation , Liver , Liver Diseases , Liver Transplantation , Perfusion , Polytetrafluoroethylene , Portal Vein , Postoperative Period , Renal Veins , Splenorenal Shunt, Surgical , Thrombectomy , TransplantsABSTRACT
RACIONAL: A hipertensão portal com sua principal complicação, a hemorragia digestiva alta varicosa, são importantes causas de morbimortalidade em cirróticos. A cirurgia de Teixeira-Warren é uma derivação portal seletiva, adotada em doentes Child-Pugh A e B para tratamento da hemorragia varicosa por hipertensão portal não responsiva à terapêutica clínico-endoscópica após o quadro agudo. O índice de congestão portal baseia-se em valores obtidos pela ultra-sonografia Doppler abdominal e encontra-se elevado em pacientes com hipertensão portal. OBJETIVO: Verificar se o índice de congestão portal e o grau de insuficiência hepática (Child-Pugh) são fatores preditivos de recidiva hemorrágica após a cirurgia de Teixeira-Warren. MÉTODO: Em estudo longitudinal retrospectivo analisaram-se 62 prontuários de cirróticos operados pela técnica de Teixeira-Warren na Santa Casa de São Paulo. Foram submetidos a avaliação quanto ao índice de congestão portal pré-operatório 36 doentes, e 58 quanto à classe Child-Pugh. Os doentes foram divididos em grupos - com recidiva e ausência de recidiva hemorrágica - sendo analisada a diferença estatística quanto aos valores do índice e Child-Pugh pré-operatórios, relacionando-os à recidiva hemorrágica pós-operatória. RESULTADOS: Dos doentes que apresentaram recidiva hemorrágica, 69 por cento eram Child B e possuíam índice de congestão portal médio de 0,09. Já entre aqueles que não ressangraram, 62 por cento eram Child A e o índice de congestão portal médio foi de 0,076. A diferença foi estatisticamente significante para a classe Child-Pugh, porém, o mesmo não ocorreu para o índice de congestão portal. CONCLUSÃO: O índice de congestão portal no pré-operatório não foi fator preditivo de recidiva hemorrágica em cirróticos submetidos a cirurgia de Teixeira-Warren. Doentes classificados como Child-Pugh B possuem maior chance de recidiva hemorrágica pós-derivação esplenorrenal distal em relação aos Child-Pugh A.
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 percent were Child B, with portal vein congestion index = 0.09. The group without rebleeding show us 62 percent 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.
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Female , Humans , Male , Middle Aged , Gastrointestinal Hemorrhage/surgery , Hypertension, Portal/surgery , Liver Cirrhosis/surgery , Liver Failure/complications , Splenorenal Shunt, Surgical/methods , Blood Flow Velocity , Follow-Up Studies , Gastrointestinal Hemorrhage/etiology , Hypertension, Portal/complications , Hypertension, Portal , Longitudinal Studies , Liver Cirrhosis/complications , Liver Cirrhosis/physiopathology , Liver Failure/physiopathology , Predictive Value of Tests , Recurrence , Retrospective Studies , Severity of Illness Index , Splenorenal Shunt, Surgical/adverse effects , Ultrasonography, DopplerABSTRACT
Chylous ascites is a rare condition caused by various diseases and conditions that interfere with the abdominal or retroperitoneal lymphatics, and uncommonly it can manifest as a post-operative complication after abdominal, retroperitoneal or mediastinal surgery. Chylous ascites can be diagnosed by a high triglyceride content in ascites. The authors experienced a 5-year-old girl with congenital hepatic fibrosis who presented with chylous ascites after a splenorenal shunt operation, who was successfully managed by fasting and total parenteral nutrition, followed by a lipid-free diet with medium chain triglyceride supplementation. Here, the authors report this case of post-operative chylous ascites after a splenorenal shunt (Warren shunt) operation with a review of the pertinent literature.
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Child , Child, Preschool , Female , Humans , Ascites , Chylous Ascites , Diet , Fasting , Fibrosis , Parenteral Nutrition, Total , Splenorenal Shunt, Surgical , TriglyceridesABSTRACT
PURPOSE: Splenorenal bypass is a major surgical procedure that's used for the management of renal artery stenosis. Herein, we evaluate the feasibility and efficacy of performing laparoscopic splenorenal bypass in a chronic canine model. MATERIALS AND METHODS: A total of 12 animals were used for this study. The initial 6 acute animals were used to develop the technique. The remaining 6 surviving animals, which form the basis for this report, were used for a chronic study with up to 2 months follow-up. The renal artery and the distal splenic artery was dissected, its proximal end clamped and its distal end cut and spatulated. An end-to-end anastomosis of the splenic artery and renal artery was performed using only laparoscopic freehand suturing and knot-tying techniques. Upon revascularization, a laparoscopic doppler ultrasound probe was used to document blood flow in the renal artery. Three animals were each followed for 1 month and 2 months, respectively. RESULTS: The total operative time was 297+/-36 min. The mean number of suture bites per anastomosis was 14.3. The only intraoperative complication was hemorrhage from the anastomotic site. Intraoperative Doppler ultrasound documented good blood flow in all 6 animals upon releasing the clamp. At the time of euthanasia, intravenous pyelography (IVP) showed early visualization of the left kidney with prompt drainage in 5 of the 6 surviving animals. In one animal that had two left renal arteries, a distal thrombosis was found despite the patent anastomotic site. CONCLUSIONS: Laparoscopic splenorenal bypass can be performed in a reproducible fashion with using only intracorporeal techniques. We believe that with experience, complex urologic vascular procedures can be laparoscopically performed in the future.