Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation?

Golse, Nicolas; Mohkam, Kayvan; Rode, Agnès; Mezoughi, Salim; Demian, H.; Ducerf, C.; Mabrut, Jean Yves

doi:10.1016/j.transproceed.2015.06.019

Cited by 29 publications

(24 citation statements)

References 49 publications

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“…Large SPSS was defined as the presence of SPSS > 1 cm in diameter (splenorenal, left gastric, or mesenterico-iliac) on pretransplant imaging, ie, computed tomography (CT) scan and/or magnetic resonance imaging. (5,13) PVT, whenever present, was graded according to Yerdel's classification. (14) Patients with partial PVT and SPSS were evaluated with Doppler ultrasonography (DUS) whether portal flow was hepatofugal (ie, reversed) or hepatopetal.…”

Section: Study Population and Designmentioning

confidence: 99%

“…The majority of authors describe successful short‐term outcomes after ligation of SPSSs . However, longterm outcomes are rarely reported.…”

mentioning

confidence: 99%

“…The majority of authors describe successful shortterm outcomes after ligation of SPSSs. (4)(5)(6)(7)(8)(9) However, longterm outcomes are rarely reported. In addition, access to, and ligation of SPSS may be technically challenging and associated with massive bleeding in the setting of severe portal hypertension in a patient with cirrhosis (10) and could sometimes also lead to inferior vena cava (IVC) thrombosis.…”

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confidence: 99%

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Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

et al. 2018

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The management of large spontaneous portosystemic shunt (SPSS) during liver transplantation (LT) is a matter of debate. The aim of this study is to compare the short-term and longterm outcomes of SPSS ligation versus nonligation during LT, when both options are available. From 2011 to 2017, 66 patients with SPSS underwent LT: 56 without and 10 with portal vein thrombosis (PVT), all of whom underwent successful thrombectomy and could have portoportal reconstruction. The SPSS were either splenorenal (n = 40; 60.6%), left gastric (n = 16; 24.2%), or mesenterico-iliac (n = 10; 15.1%). Following portoportal anastomosis, the SPSS was ligated in 36 (54.4%) patients and left in place in 30 (45.5%) patients, based on the effect of the SPSS clamping/unclamping test on portal vein flow during the anhepatic phase. Intraoperatively, satisfactory portal flow was obtained in both groups. Primary nonfunction (PNF) and primary dysfunction (PDF) rates did not differ significantly between the 2 groups. Nonligation of SPSS was significantly associated with a higher rate of postoperative encephalopathy (P < 0.001) and major postoperative morbidity (P = 0.02). PVT occurred in 0 and 3 patients in the ligated and nonligated shunt group, respectively (P = 0.08). A composite end point, which included the relevant complications in the setting of SPSS in LT (ie, PNF and PDF, PVT, and encephalopathy) was present in 16 (44.4%) and 22 (73.3%) patients of the ligated and nonligated shunt group, respectively (P = 0.02). Patient (P = 0.05) and graft (P = 0.02) survival rates were better in the ligated shunt group. In conclusion, the present study supports routine ligation of large SPSS during LT whenever feasible. Liver Transplantation 24 505-515 2018 AASLD.

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Section: Study Population and Designmentioning

confidence: 99%

“…The majority of authors describe successful short‐term outcomes after ligation of SPSSs . However, longterm outcomes are rarely reported.…”

mentioning

confidence: 99%

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confidence: 99%

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Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

et al. 2018

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“…PV thrombectomy is not enough to overcome this situation because of poor portal flow. There are several methods to increase portal flow in cases of large SRSs, including left renal vein (RV) ligation, splenectomy, and renoportal anastomosis . However, direct ligation of a large SRS is not widely used in clinical situations because it can be technically difficult and even dangerous …”

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confidence: 99%

Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation

et al. 2017

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Patients with large spontaneous splenorenal shunts (SRSs) prove challenging during liver transplantation (LT), regardless of organizing portal vein (PV) thrombosis. Here, we detail the clinical outcomes of 26 patients who underwent direct ligation of large SRSs during LT. Direct ligation of large SRS was applied in poor portal flow during LT. We performed temporary test clamping of the SRS before direct ligation and applied PV pressure monitoring in patients who showed signs of portal hypertension, such as bowel edema. We retrospectively reviewed and evaluated their clinical outcomes. Among 843 patients who underwent LT between 2010 and 2015, 26 (3.1%) underwent direct ligation of SRS without any intraoperative event. Mean preoperative Model for End-Stage Liver Disease score was 16.7 ± 9.0. The main PV diameter on preoperative computed tomography was 8.3 ± 3.4 mm (range, 3.0-14.0 mm). SRS was easily identified at just below the distal pancreas and beside the inferior mesenteric vein in all patients. Accompanying PV thrombectomy was done in 42.3% of patients. Among 26 patients, massive and prolonged ascites was evident in 15.4% (n = 4) postoperatively. They were all living donor LT recipients with a small PV diameter (4.0-6.7 mm). Except for 1 patient who underwent splenic artery embolization, ascites was tolerable and well controlled by conservative management. There was a 7.7% rate of major complications related to direct ligation, including reoperation due to combined ligation of SRS along with a left renal vein at the confluence. Except for 1 hospital mortality due to sepsis, 25 patients (96.2%) are alive with no evidence of further PV complications. In conclusion, direct ligation of large SRS during LT is a safe and feasible method to overcome the effects of a large SRS. Liver Transplantation 23 899-906 2017 AASLD.

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“…(2) Second, we consider that PVF measurement is even more fundamental in cases of SRS because disconnecting SRS implies LRV ligation, a complex maneuver that could cause kidney injury. (3) Hence, for patients with SRS, we recommend shunt ligation only when LRV clamping test results in at least a 15%-20% increase of PVF. Prospective studies are warranted to refine PSS management strategy during LT with the contribution of intraoperative PVF measurement.…”

Section: To the Editormentioning

confidence: 99%

Ligating coronary vein varices: An effective treatment of “coronary vein steal” to increase portal flow in liver transplantation

Mohkam

Aurelus²,

Ducerf³

et al. 2016

Liver Transpl

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Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation?

Cited by 29 publications

References 49 publications

Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients

Tips and pitfalls in direct ligation of large spontaneous splenorenal shunt during liver transplantation

Ligating coronary vein varices: An effective treatment of “coronary vein steal” to increase portal flow in liver transplantation

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