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Liver Transplantation with Renoportal Anastomosis After Distal Splenorenal Shunt

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Liver Transplantation with Renoportal Anastomosis After Distal Splenorenal Shunt ORIGINAL ARTICLE Liver Transplantation With Renoportal Anastomosis After Distal Splenorenal Shunt Tomoaki Kato, MD; David M. Levi, MD; Wirviston DeFaria, MD; Seigo Nishida, MD; Andreas G. Tzakis, MD Background: The distal splenorenal shunt (DSRS) is de- Interventions: The donor portal vein was anasto- signed to maintain hepatopetal portal vein flow while de- mosed end-to-end to the left renal vein during liver trans- compressing gastroesophageal varices. However, over time, plantation. as the underlying liver disease progresses, the DSRS loses its selectivity. The most common method of addressing Main Outcome Measures: Perioperatve morbidity, por- this issue during orthotopic liver transplantation is shunt tal vein flow by Doppler study, patient survival, and graft ligation with or without splenectomy. Dismantling the survival. shunt increases the complexity of the transplantation, and splenectomy may increase the risk of infection. Results: In all patients, the graft liver reperfused promptly via flow through the left renal vein with adequate de- Hypothesis: Anastomosis of the donor portal vein to compression of the bowel. Normal portal venous flow was the left renal vein without dismantling the shunt is an demonstrated by intraoperative and postoperative Dop- effective method of portal vein reconstruction for pa- pler ultrasound studies. At the mean follow-up of 16 tients with a patent DSRS. months, 4 patients were alive with well-functioning grafts. Design: Retrospective analysis. Conclusions: This novel technique has the advantage of decreasing the complexity of the procedure, without Setting: University-based teaching hospital, Miami, Fla. requiring splenectomy, while securing adequate portal perfusion. Additionally, it can be applied without modi- Patients: Five liver transplant recipients with patent fications in patients with portal vein thrombosis. DSRS who received an orthotopic liver transplant be- tween September 1996 and August 1999. Arch Surg. 2000;135:1401-1404 LTHOUGH endoscopic pancreatic and retroperitoneal collaterals therapy and the transjugu- develop. At the time of OLT, portal vein lar intrahepatic portosys- flow may have reversed or portal vein temic shunt have super- thrombosis may have developed. There- seded the role of surgery in fore, most of the previously described sur- Athe management of portal hypertension, sur- gical techniques for OLT in patients with gical shunt procedures are still a desirable patent DSRSs interrupt the shunt be- option for selected patients.1,2 Compared cause flow to the portal vein may be de- with other nonselective surgical shunt pro- creased if the shunt is left intact.6-8 The dis- cedures, the distal splenorenal shunt (DSRS) mantling procedure is typically performed is widely used because it offers a low inci- by directly ligating the shunt during the dence of hepatic encephalopathy and he- splenectomy, and it can markedly in- patic decompensation.3-5 Despite success- crease the complexity of OLT. Further- ful portal decompression by DSRS, some more, a splenectomy may increase the risk patients may require subsequent ortho- of infection after OLT. topic liver transplantation (OLT) when their We hypothesized that anastomosis of liver disease progresses to hepatic failure. the donor portal vein to the left renal vein From the Division of The DSRS is designed to maintain without dismantling the shunt is an effec- Transplantation, University hepatopetal portal vein flow while decom- tive method of portal vein reconstruction of Miami School of Medicine, pressing the gastroesophageal varices. With for patients with patent DSRSs who are un- Miami, Fla. time, the shunt can lose selectivity as peri- dergoing OLT. (REPRINTED) ARCH SURG/ VOL 135, DEC 2000 WWW.ARCHSURG.COM 1401 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 METHODS Data were retrospectively collected on 5 patients with prior DSRS who underwent OLT with the left renal vein to the donor portal vein anastomosis between September 1996 and August 1999 at our institution. Data included patient age and sex, causes of cirrho- sis, history of DSRS, donor ages, postoperative course, and findings at follow-up. After the hilar dissection (during which the he- patic artery, portal vein, and bile duct are ligated and divided), the infrahepatic vena cava is dissected. Ve- novenous bypass is not necessary because a central- ized DSRS can sufficiently decompress the portal sys- tem into the vena cava. If the bowel becomes congested after the portal vein has been clamped, the surgeon should avoid this method because the con- gestion suggests either insufficient flow through the DSRS or inadequate communication between the por- tomesenteric system and the DSRS. The anterior surface of the infrahepatic vena cava is surgically explored and dissected to expose the ori- gin of the left renal vein. The duodenum may be mo- bilized with the Kocher maneuver. The surgeon should minimize this dissection to avoid bleeding from Portal vein anastomosis. The donor portal vein is anastomosed to the left the collateral vessels behind the pancreas. After the renal vein with an interpositional iliac vein graft. The mesenteric flow drains left renal vein is exposed and encircled, the retrohe- into the donor portal vein through the patent distal splenorenal shunt. patic dissection is performed. The short hepatic veins are ligated and divided, and the liver is removed us- ing the piggyback technique.9 Table 1. Patient Summary* The left renal vein is then clamped and divided very near the vena cava. To facilitate portal vein anas- Portal Flow Portal Vein by tomosis during the warm ischemia time, a donor iliac Patient No./ DSRS by Doppler Intraoperative vein graft is anastomosed to the distal renal vein as an Age,y/Sex Diagnosis to OLT Before OLT Observation interpositional graft. When the left renal vein is clamped, 1/44/F HCV 5 y HPF, extremely Phlebosclerotic, the bowel becomes congested, suggesting that this is small very small the primary route for mesenteric venous return. After 2/54/F Cryptogenic 14 mo PVT PVT the suprahepatic caval anastomosis is performed us- 3/51/M HCV 11 mo HFF HFF ing the piggyback technique, the donor portal vein is 4/50/M HCV 7 y HFF PVT anastomosed to the interpositional graft (Figure). 5/66/F PSC 5 y HFF HFF We performed simultaneous arterial and portal reperfusion in the first patient to secure blood flow *DSRS indicates distal splenorenal shunt; OLT, orthotopic liver to the liver in the event that portal vein flow was in- transplantation; HCV, hepatitus virus C infection; HPF, hepatopetal flow; PVT, adequate. With the experience gained from the first portal vein thrombosis; HFF, hepatofugal flow; PSC, primary sclerosing patient, we performed the arterial reconstruction af- cholangitis. ter reperfusion in the remaining 4 patients. ency of the DSRS was confirmed by pretransplant Dop- pler ultrasound study. All 5 patients received ABO-identical, size- matched liver grafts. The average donor age was 44.4 years RESULTS (range, 16-67 years). Cold ischemia time ranged from 4 hours 45 minutes to 11 hours 38 minutes, and warm is- Between September 1996 and August 1999, left renal vein chemia time ranged from 26 minutes to 67 minutes. to portal vein anastomosis was performed in 5 patients Doppler ultrasound evaluation before OLT showed (2 men and 3 women) with patent distal splenorenal reversed portal vein flow (hepatofugal flow) (n=3), por- shunts. The mean patient age was 53 years (range, 44-66 tal vein thrombosis (n=1), and an extremely small por- years). The causes of hepatic cirrhosis were hepatic C vi- tal vein with normal direction of flow (n=1). Angiogra- rus infection (n=3), primary sclerosing cholangitis (n=1), phy was performed in 3 patients, demonstrating patent and cryptogenic cirrhosis (n=1). Each patient had 1 to DSRSs with excellent flow. Portal vein thrombosis was 6 episodes of variceal bleeding before the DSRS proce- discovered during the procedure of 1 patient whose pre- dure. All DSRSs had been performed uneventfully; none transplantation angiogram had shown patent but hepa- of the patients experienced recurrent bleeding. The in- tofugal portal flow (Table 1). terval between DSRS and OLT ranged from 11 months The graft livers reperfused promptly in all patients. to 7 years (median, 3.8 years). In each patient, the pat- Intraoperative and postoperative Doppler ultrasounds (REPRINTED) ARCH SURG/ VOL 135, DEC 2000 WWW.ARCHSURG.COM 1402 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Table 2. Intraoperative and Postoperative Summary Blood Length of Time to Patient No. OR Time* Transfusion, U Complications Hospital Stay, d Status Follow-up 1 8 h 5 min 8 None 9 Alive 41 mo 2 12 h 35 min 15 Hepatic artery thrombosis, bile leak 92 Dead 92 d 3 11 h 26 min 10 None 9 Alive 16 mo 4 10 h 33 min 10 Wound infection, recurrent hepatitis C 13 Alive 8 mo 5 10 h 58 min 6 Wound dehiscence 32 Alive 6 mo *OR indicates operating room. demonstrated normal velocity (40-100 cm/s) in the por- mation of collateral vessels decreases the portal perfu- tal veins of all patients. Mean operative time was 10 hours sion pressure, and hepatopetal flow in the portomesenteric 43 minutes. Mean blood transfusion amount was 9.8 units. system will subsequently be lost through centralization Of the 5 patients, 3 had uneventful hospital courses with of the shunt.11 the length of stay ranging from 9 to 13 days after OLT. One of the initial concerns in performing OLT in One patient developed wound dehiscence resulting in a patients with patent DSRSs was identifying a method for prolonged hospital stay, and another died of multiple com- securing the portal venous flow; if left intact, the patent plications (Table 2). One patient developed renal in- shunt could decrease portal flow. Esquivel et al6 re- sufficiency during the early postoperative period, mani- ported the first successful series of liver transplantation fested by a transient increase in creatinine concentration.
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