Residual Pulmonary Hypertension more than 20 Years after Repair of Shunt Lesions.

Background and Objectives: After successful surgical repair of a congenital shunt lesion, pulmonary hypertension (PH) often disappears. However, PH can persist long-term after the closure. This study aimed to assess the prevalence of PH long-term after surgical repair of congenital heart disease (CHD), and to evaluate the outcomes and preoperative factors related to residual PH. Materials and Methods: In this retrospective cohort study, we reviewed patients who underwent right heart catheterisation in Vilnius University Hospital Santaros Klinikos during the period of 1985-2007. Among 4118 right heart catheterisations performed, 160 patients underwent congenital systemic-to-pulmonary shunt repair at a young age (<18 years) and had pre-operative PH. Half of the patients were foreigners whose follow-up data were unavailable. Eventually, 88 patients with available follow-up data were included in this study. Results: The median age at diagnosis of CHD with PH was 0.8 (0.6-3.0) and 1.1 (0.6-3.9) years at surgery (50% females). Residual PH was assessed 9.5 years after surgery and observed in 30.7% (n = 27) of the patients. It was associated with having more than one shunt (44.4% (n = 12), p = 0.016) and higher median pulmonary vascular resistance (3.4 (2.5-6.5) vs. 2.2 (1.0-3.7), p = 0.035) at baseline. After a median follow-up of 21 (15-24) years, 9.1% of the patients were deceased. Kaplan-Meier survival analysis revealed significantly higher mortality in the residual PH group (p = 0.035). Conclusions: Residual PH affects a significant proportion of patients after surgical repair of a shunt lesion and is associated with worse long-term outcome.

Synchronous hybrid procedure combining interventional radiology and endoscopy for esophagogastric varices with large gastro-renal shunt.

Successful treatment of esophagogastric varices (EGV) with giant portal-systemic shunt is challenging. To explore the feasibility and safety of a novel hybrid procedure involving interventional radiology and endoscopy in the same sitting.Three cases clinically diagnosed to have decompensated cirrhosis and EGV with giant gastrorenal shunt (GRS) on contrast-enhanced computed tomography (CT) were included. The hybrid procedures included: indirect portography, hepatic vein pressure gradient (HVPG) measurement, HVPG-based partial splenic embolization (PSE), retrospective GRS balloon occlusion, endoscopic histoacryl injection (EHI), balloon catheter radiography and withdrawal. All the procedures were done in the same operation room. Main outcomes measurements included operation time, complications, and re-bleeding events.Hybrid interventions were performed successfully in 3 cases with a mean operation time of 63.3 minutes without any major intra- and post-operation complications. No rebleeding occurred at 6-month follow-up.Synchronous hybrid intervention combining radiology and endoscopy is feasible and safe for patients with EGV and giant GRS, preliminary study with limited cases deserves further exploration.

Survey of surgical specialists' content preferences in radiology reports for extrahepatic portosystemic shunts.

The aim of this prospective, survey study was to assess the opinions of specialist surgeons as to the preferred content, nomenclature, and classification of extrahepatic portosystemic shunts for inclusion in radiology reports. A link to an online survey was sent by email to members of the European College of Veterinary Surgeons and the Association of Veterinary Soft Tissue Surgeons, and was made available on the American College of Veterinary Surgeons web forum and Facebook page. There were 93 respondents (survey sent to over 2500 email addresses and made available in two online locations). Most respondents agreed that they both review the images themselves (87/92, 95%) and read the radiology report (82/92, 89%) prior to surgery. Most respondents believed that the radiology report should contain a detailed anatomic description of the insertion (83/92, 90%), origin (54/91, 59%), and course (70/92, 76%) of the shunt, as well as a measure of the diameter of the shunting vessel at its insertion (54/92, 59%). Most respondents (70/90, 78%) disagreed that a brief description of shunt type, such as portocaval or portophrenic, was sufficient. Respondents were undecided regarding the use of an alphanumeric classification system (36/92, 39% agree; 32/92, 35% disagree). There was agreement that details of the presence or absence of urolithiasis (91/93, 98%), renomegaly (54/93, 58%), and peritoneal fluid (72/92, 78%) should be included in the report. The results of this study will help to guide reporting radiologists in providing descriptions of extrahepatic portosystemic shunts that include information most preferred by the recipient surgeons.

Is Portal Venous Pressure Modulation Still Indicated for All Recipients in Living Donor Liver Transplantation?

There is a consensus that portal venous pressure (PVP) modulation prevents portal hypertension (PHT) and consequent complications after adult-to-adult living donor liver transplantation (ALDLT). However, PVP-modulation strategies need to be updated based on the most recent findings. We examined our 10-year experience of PVP modulation and reevaluated whether it was necessary for all recipients or for selected recipients in ALDLT. In this retrospective study, 319 patients who underwent ALDLT from 2007 to 2016 were divided into 3 groups according to the necessity and results of PVP modulation: not indicated (n = 189), indicated and succeeded (n = 92), and indicated but failed (n = 38). Graft survival and associations with various clinical factors were investigated. PVP modulation was performed mainly by splenectomy to lower final PVP to ≤15 mm Hg. Successful PVP modulation improved prognosis to be equivalent to that of patients who did not need modulation, whereas failed modulation was associated with increased incidence of small-for-size syndrome (SFSS; P = 0.003) and early graft loss (EGL; P = 0.006). Among patients with failed modulation, donor age ≥ 45 years (hazard ratio [HR], 3.67; P = 0.02) and ABO incompatibility (HR, 3.90; P = 0.01) were independent risk factors for graft loss. Survival analysis showed that PVP > 15 mm Hg was related to poor prognosis in grafts from either ABO-incompatible or older donor age ≥ 45 years (P < 0.001), but it did not negatively affect grafts from ABO-compatible/identical and young donor age < 45 years (P = 0.27). In conclusion, intentional PVP modulation is not necessarily required in all recipients. Although grafts from both ABO-compatible/identical and young donors can tolerate PHT, lowering PVP to ≤15 mm Hg is a key to preventing SFSS and consequent EGL with grafts from either ABO-incompatible or older donors.

Management of ascites in patients with cirrhosis. What to do when diuretics fail.

Resistant or refractory ascites is unusual in cirrhotic patients who comply with dietary sodium restriction and optimal diuretic therapy. Patients unresponsive to medical therapy often have end-stage liver disease and renal insufficiency, although reversible complicating factors must be excluded. For patients with truly refractory ascites, liver transplantation is the only option that improves chances of survival. When this is not feasible, therapeutic paracentesis is the procedure of choice for intractable ascites. Several surgical shunts have been used, but none have been found to be safer and more effective than large-volume paracentesis.

Emergency portosystemic shunt in patients with variceal bleeding.

Thirty-five patients for whom emergency sclerotherapy or conservative treatment, or both, failed to arrest variceal bleeding, or who had early rebleeding and required emergency portosystemic shunts (EPSS) were studied. EPSS permanently controlled the variceal bleeding in all but one patient. In this patient, the shunt was patent as demonstrated by angiography. Esophageal varices disappeared in 18 patients and were reduced in 14. Three patients died before the endoscopic examination could be performed. The causes of death were hepatic failure in two and bleeding ulcerations of the gastric fundus in the other patient. One patient was classified in Child's category B and two in Child's category C. Thirty-two patients submitted to EPSS and were discharged alive. Twelve of these patients subsequently died, at an average of 11.2 months after undergoing the shunt procedure. Four of 12 patients died of hepatic failure; two patients died of hepatomas; two, other neoplasia; three, hemorrhaging duodenal ulcers, and one patient, renal failure. Analysis of actuarial survival rates showed that the five year survival rate was 43 per cent. The long term survival rates were fewer for patients with Child's category C than for those with combined Child's categories A and B (five year survival rates were 21 versus 55 per cent; p less than 0.05). During the follow-up period, none of the patients had variceal bleeding. Chronic encephalopathy developed in six, which was mild in three, moderate in one instance and severe in two. It developed soon after EPSS, with onset in the first month after discharge in three. Thus, when conservative treatment fails to arrest variceal bleeding, EPSS should be performed to guarantee definitive control of hemorrhage and prolong the survival period.

Splenoportography--a reappraisal.

Seventy-five percutaneous splenoportographies and splenic pulp pressure measurements were performed in 70 patients. This procedure was done routinely during the preoperative investigation of patients with bleeding esophageal varices. Splenoportagraphy was also performed for evaluation of patients with portal hypertension of an obscure etiology, and for follow-up study after portosystemic shunt procedures, where the spleen had been preserved. There were no complications related to the procedure. Splenoportography is a simple and safe diagnostic tool. The information obtained is important for planning an operation to relieve portal hypertension. It may also help in the postoperative evaluation of the patency of certain types of shunt procedures.