PROXIMAL SPLENORENAL SHUNT FOR PORTAL HYPERTENSION COMBINED WITH HYPERSPLENISM IN LIVER CIRRHOSIS Authors: I.Timaru, I.P.O...
<ul><li>CENTRAL SPLENORENAL SHUNT ( LINTON)   =   </li></ul><ul><li>non-selective porto-systemic shunt, achieving:   </li>...
CENTRAL SPLENORENAL SHUNTS: <ul><li>variceal bleeding prophylaxis. </li></ul><ul><li>ONLY INDICATED for  cirrhotic non-enc...
<ul><li>ELECTIVE CRITERIA FOR PATIENT SELECTION: </li></ul><ul><li>CHILD  A  patients </li></ul><ul><li>CHILD  B (with no ...
<ul><li>PATIENT EVALUATION FOR SURGERY </li></ul><ul><li>Clinical evaluation  </li></ul><ul><li>-  hepatic cyrrhosis + por...
<ul><li>DETAILS OF THE CENTRAL SPLENORENAL SHUNTING </li></ul><ul><li>SPLENECTOMY  -  usually difficult (fragile, perisple...
<ul><li>POSTOPERATIVE MONITORING </li></ul><ul><li>Peripheral blood cell count (! Platelets) </li></ul><ul><li>Hepatic and...
<ul><li>SPLENORENAL SHUNT   </li></ul><ul><li>–  CLINICAL OUTCOME CRITERIA  - </li></ul><ul><li>< 20% POSTOPERATIVE DEATHS...
CONCLUSIONS <ul><li>Central (proximal) splenorenal shunt  =  non-selective portal-systemic shunt, valuable for variceal bl...
 
OUR EXPERIENCE <ul><li>1990  -  2002:  17  central splenorenal shunt operations </li></ul><ul><li>17 patients: 14 male,  3...
POSTOPERATIVE OUTCOME <ul><li>Good splenorenal shunt blood flow (sonography measurement), and no shunt thrombosis recorded...
<ul><li>PATIENTS WITH LIVER CIRRHOSIS  </li></ul><ul><li>SHOULD BE ASSIMILATED  </li></ul><ul><li>IN A DATA-BASE NATIONAL ...
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  1. 1. PROXIMAL SPLENORENAL SHUNT FOR PORTAL HYPERTENSION COMBINED WITH HYPERSPLENISM IN LIVER CIRRHOSIS Authors: I.Timaru, I.P.Oprea, C.Musat, M.Tanase, A.Zaciu, N.Tudor, C.Dutu, R.Nica THE CENTRAL CLINICAL EMERGENCY MILITARY HOSPITAL The 2 nd Surgical Clinic
  2. 2. <ul><li>CENTRAL SPLENORENAL SHUNT ( LINTON) = </li></ul><ul><li>non-selective porto-systemic shunt, achieving: </li></ul><ul><li>A. POSITIVE EFFECTS </li></ul><ul><li>- removes the spleen; </li></ul><ul><li>- lowers portal blood pressure; </li></ul><ul><li>- diminishes gastric and esophageal varices and </li></ul><ul><li>lowers the risk of variceal bleeding; </li></ul><ul><li>- diminution / ascites prophylaxis. </li></ul><ul><li>B. NEGATIVE EFFECTS </li></ul><ul><li>- high risk of hepatic encephalopathy; </li></ul><ul><li>- lowers intrahepatic blood flow, thus, diminishes hepatic function; </li></ul><ul><li>- not convenient for further liver transplantation. </li></ul>
  3. 3. CENTRAL SPLENORENAL SHUNTS: <ul><li>variceal bleeding prophylaxis. </li></ul><ul><li>ONLY INDICATED for cirrhotic non-encephalopathic patients with portal hypertension + splenomegaly and hypersplenism </li></ul><ul><li>+ good liver function (= CHILD A patients) + </li></ul><ul><li>+ mild ascites (= CHILD B patients) </li></ul><ul><li>Alternative procedures: those including splenectomy and </li></ul><ul><li>azygo-portal disconnection. </li></ul>
  4. 4. <ul><li>ELECTIVE CRITERIA FOR PATIENT SELECTION: </li></ul><ul><li>CHILD A patients </li></ul><ul><li>CHILD B (with no hepatic encephalopathy, no jaundice, </li></ul><ul><li>controllable ascites, serum albumin > 3g/dl, PTT > 1.5, </li></ul><ul><li>BSP > 30%) </li></ul><ul><li>Portal hypertension of 3 rd – 4 th degree </li></ul><ul><li>Splenomegaly and hypersplenism (peripheral blood cytopenia, mainly thrombocytopenia) </li></ul><ul><li>Clinical and endoscopy features showing high risk of variceal bleeding </li></ul><ul><li>Age < 60 </li></ul><ul><li>Good nutritional status </li></ul><ul><li>Experienced surgical and anesthesiology team </li></ul><ul><li>The patients are not eligible for liver transplantation. </li></ul>
  5. 5. <ul><li>PATIENT EVALUATION FOR SURGERY </li></ul><ul><li>Clinical evaluation </li></ul><ul><li>- hepatic cyrrhosis + portal hypertension + variceal bleeding </li></ul><ul><li>- nutritional status </li></ul><ul><li>- neurologic assessment. </li></ul><ul><li>Biological evaluation </li></ul><ul><li>- hepatic function status </li></ul><ul><li>- biliary excretion (bilirubinemia, alcalin phosphatase) </li></ul><ul><li>- peripheral blood and bone marrow cell count </li></ul><ul><li>- renal function. </li></ul><ul><li>Esophago-gastric endoscopy (variceal status) </li></ul><ul><li>Doppler ultrasonography (portal, splenic, mesenteric, renal, caval flow and diametres) </li></ul><ul><li>Selective arteriography (truncus coeliacus, renal arteries), left renal venography </li></ul><ul><li>Radioisotopic portography (portal blood flow, porto-systemic shunts, hepatic shunts, splenic fraction shunt) </li></ul><ul><li>Excretory urography. </li></ul>
  6. 6. <ul><li>DETAILS OF THE CENTRAL SPLENORENAL SHUNTING </li></ul><ul><li>SPLENECTOMY - usually difficult (fragile, perisplenic vascular adhesions, collateral portal circulation, anatomic variations in the hilum) </li></ul><ul><li>SPLENIC VEIN DISSECTION </li></ul><ul><li>LEFT RENAL VEIN DISSECTION </li></ul><ul><li>SPLENORENAL ANASTOMOSIS (end-to-side, side-to-side, end-to-end) </li></ul><ul><li>ASSESSMENT: intraoperative Doppler sonography, diminution of portal circulation (omentum, phrenic vessels), measurement of portal blood pressure. </li></ul>
  7. 7. <ul><li>POSTOPERATIVE MONITORING </li></ul><ul><li>Peripheral blood cell count (! Platelets) </li></ul><ul><li>Hepatic and renal function </li></ul><ul><li>Ultrasonography </li></ul><ul><li>Esophageal and gastric endoscopy </li></ul><ul><li>POSTOPERATIVE MORBIDITY </li></ul><ul><li>Postoperative bleeding </li></ul><ul><li>Surgical wound / systemic sepsis </li></ul><ul><li>Shunt thrombosis </li></ul><ul><li>Splenic / portal thrombosis </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>Hepatic failure </li></ul><ul><li>Hepatic encephalopathy </li></ul><ul><li>Renal failure </li></ul>
  8. 8. <ul><li>SPLENORENAL SHUNT </li></ul><ul><li>– CLINICAL OUTCOME CRITERIA - </li></ul><ul><li>< 20% POSTOPERATIVE DEATHS </li></ul><ul><li>HEPATIC ENCEPHALOPATHY </li></ul><ul><li>RECURRENT VARICEAL BLEEDING (due to shunt thrombosis ~ 18%) </li></ul><ul><li>PATIENT SURVIVAL IMPROVEMENT </li></ul>
  9. 9. CONCLUSIONS <ul><li>Central (proximal) splenorenal shunt = non-selective portal-systemic shunt, valuable for variceal bleeding prophylaxis, in selected patients. </li></ul><ul><li>The surgical procedure must be well prepared; the eligible patients will be thoroughly investigated to match the proper criteria. </li></ul><ul><li>Postoperative complications are usually severe. </li></ul><ul><li>The postoperative clinical outcome is similar to azygo-portal disconnection and splenectomy, and inferior to selective shunts (calibrated portacaval /mesenterocaval shunts, Warren operation). </li></ul>
  10. 11. OUR EXPERIENCE <ul><li>1990 - 2002: 17 central splenorenal shunt operations </li></ul><ul><li>17 patients: 14 male, 3 female </li></ul><ul><li>Age: 36 – 54 (avg. 43) </li></ul><ul><li>Viral hepatic cirrhosis (B and C) - 14 patients </li></ul><ul><li>Alcoholic cirrhosis - 3 patients </li></ul><ul><li>Mild ascites - 7 patients </li></ul><ul><li>Esophageal varices - stage III - 10 patients </li></ul><ul><li>- stage IV - 7 patients </li></ul><ul><li>Child-Pugh score - A - 10 patients </li></ul><ul><li>- B - 7 patients </li></ul>
  11. 12. POSTOPERATIVE OUTCOME <ul><li>Good splenorenal shunt blood flow (sonography measurement), and no shunt thrombosis recorded. </li></ul><ul><li>Hepatic failure (coagulation disorders, jaundice, hepatocyte lysis) </li></ul><ul><li>- 5 patients </li></ul><ul><li>Hepatic encephalopathy - permanent - 3 patients </li></ul><ul><li>- temporary - 7 patients </li></ul><ul><li>Thrombocytosis (due to splenectomy) – started 3 rd – till 10 th day P.O. </li></ul><ul><li>required thrombosis prophylaxis: </li></ul><ul><li>- < 500.000 platelets/sqmm. – 14 patients (l.m.w. heparin fractions) </li></ul><ul><li>- > 500.000 platelets/sqmm. (up to 1.2 mil.) – 3 patients (heparin) </li></ul><ul><li>Variceal bleeding - free survival: min. 9 months (recurrent alcohol ingestion), max. 2 years . </li></ul><ul><li>Survival period (for 8 patients) - 2 yrs.8 mon. – 11 yrs. </li></ul>
  12. 13. <ul><li>PATIENTS WITH LIVER CIRRHOSIS </li></ul><ul><li>SHOULD BE ASSIMILATED </li></ul><ul><li>IN A DATA-BASE NATIONAL PROGRAM. </li></ul>
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