Unconventional Shunts in Extrahepatic Portal Venous Obstruction-A Retrospective Review

Abstract

Background: Proximal splenorenal shunt (PSRS) is one of the most commonly performed portosystemic shunt (PSS) in extrahepatic portal venous obstruction (EHPVO) for portal decompression. Sometimes various anatomical and surgical factors related to the splenic vein and/or left renal vein may make the construction of a PSRS difficult or impossible. Unconventional shunts are required to tide over such conditions.

Methods: From January 2008 to December 2018, 189 patients with EHPVO underwent PSS, of which, the 10 patients who underwent unconventional shunts form the study group of this paper.

Results: The ten unconventional shunts included 8 proximal splenoadrenal shunts, one collateral-renal shunt, and one inferior mesenteric vein to inferior vena cava (IMV-Caval) shunt. The mean percentage drop in omental pressure was 34.2% post-shunt with a mean anastomotic diameter of 13.7 ± 3.1 mm. Three patients experienced some form of postoperative complication. With a mean follow-up period of 32.3 months (maximum of 111 months) all patients had patent shunts on follow-up Doppler. None of the patients had variceal bleed, or features of biliopathy and hepatic encephalopathy in follow-up.

Conclusion: Unconventional shunts can be used safely and effectively with good postoperative outcomes in EHPVO.

Keywords: BDI, Bile duct injury; EHPVO; EHPVO, Extrahepatic portal venous obstruction; EVL, endoscopic variceal ligation; IMV, Inferior mesenteric vein; LRV, Left renal vein; PHG, Portal hypertensive gastropathy; PHT, Portal hypertension; PSRS, Proximal splenorenal shunt; PSS, portosystemic shunt; SMV, Superior mesenteric vein; SV, Splenic vein; UGI, Upper gastrointestinal; make-shift shunts; unconventional shunts.

Figure 1

Splenoadrenal shunt. (A) Looped left adrenal vein on top, looped left gonadal vein below. (B) Completed splenoadrenal shunt (short splenic vein anastomosed with left adrenal vein with straight course without kink)

Figure 2

IMV-Caval shunt. (A) Dissected IMV, looped in red sling and IVC, inset-MRPV showing, IMV and SV with absence of left kidney. (B) Completed IMV side to side Caval shunt.

Figure 3

Schematic representation of various unconventional/makeshift shunts. (A) Proximal splenoadrenal shunt. (B) Collatero-renal shunt. (C) IMV-Caval shunt.