Effect of a prior portasystemic shunt on subsequent liver transplantation

The role of portosystemic shunting in the management of portal hypertension

In this chapter, we have tried to indicate the role of the portosystemic shunt in the treatment of portal hypertension. The conclusions are evident: in the last 10 years it has lost its role as leader in the treatment of portal hypertension. However, some firm statements can be made. The selective shunt is an operation that provides both good variceal decompression and satisfactory maintenance of liver function. Its results in great part depend on the skill of the surgeon. Only a patient with good liver function (Child's classes A and B) is a candidate for shunt surgery, with, very occasionally, a patient with severe disease (class C). In an emergency, the operation is used only after failure of sclerotherapy, but it must be used at the right time before the patient's condition has deteriorated. In the prevention of variceal rebleeding, the selective shunt or sclerotherapy can be routine measures. The choice between the two treatments depends on the patient's willingness and the ability of the institution to perform both procedures successfully. If sclerotherapy is chosen, the institution must be able to rapidly rescue a sclerotherapy failure by shunt surgery. Liver transplantation is probably the treatment of the future, but it is at present impossible to suggest that the procedure is feasible for all patients with variceal bleeding and severe liver disease.

Selective shunt in the management of variceal bleeding in the era of liver transplantation

This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach.

The role of spontaneous portosystemic shunts in the course of orthotopic liver transplantation

Spontaneous portosystemic shunts are commonly found in cirrhotic patients. Not yet established is their role after orthotopic liver transplantation (OLTx), especially when an increase in portal pressure develops, as during early acute rejection. In this study, 34 cirrhotic patients in a series of 70 OLTx are considered. Each patient had preoperative angiographic assessment, and, in 21 (62%), large spontaneous portosystemic shunts were evident. In 12 cases the shunts were not affected by the surgical procedure and were present during the postoperative period; in 9 the hepatectomy itself involved interruption of the shunts. The patient population was divided into two groups: patients with postoperative shunts (n = 12) and those without (n = 22). The two groups were similar in age, sex, Child's stage, transplantation variables, and number and grade of rejection episodes. However, mean transaminases (AST) values in the first 2 weeks were significantly higher levels in shunt versus nonshunt patients (421 +/- 335 vs 183 +/- 126; P less than 0.025), and this was even more evident when rejection occurred (626 +/- 375 vs 195 +/- 129; P less than 0.001). Furthermore, during an acute rejection reaction, three cases showed a true "steal phenomenon" through the large reopened shunts with ischemic damage to the grafts. The data indicate a possible detrimental effect of the spontaneous shunts on graft perfusion and suggest the prophylactic surgical interruption of the residual shunts during the transplantation.

Liver transplantation: the challenges of the 1990s

An enormous increase in liver transplantation has been observed over the last decade since it now represents a suitable therapeutic option for patients with end-stage liver disease. The overall one-year survival rate is about 75% for adults and 85% for children, when fulminant hepatic failure and malignancies are excluded. Such improvements in both survival and quality of life are due to many concurrent factors: better timing and selection; development of the UW solution for liver preservation; improvement in operative management including surgical technique, veno-venous bypass and cell-saver; progress in intensive care management of immunosuppressed patients. Nevertheless, the increasing demand for livers is now confronting the transplant teams with organ shortage, for which the introduction of graft reduction, hepatic biparition and living-related donation will contribute to alleviate the scarcity of donors. As a consequence of the increasing number of long-term survivors, greater efforts are now being directed towards the long-term outcome after liver transplantation: disease recurrence, the need for permanent immunosuppression and the quality of rehabilitation will become the challenges of the 1990s before reaching the next step towards multiple organ transplantation.

Liver transplantation in patients with portal vein thrombosis and central portacaval shunts

The authors have analyzed the impact of pre-existing portal vein pathology on the outcome of orthotopic liver transplantation. The incidence was high in patients suffering from chronic active hepatitis, hypercoagulable states, trauma or previous dissection of the porta hepatis, and splenectomy. The existence of portal vein thrombosis (23 patients) or surgical central portosystemic shunt (10 patients) was documented by preoperative Doppler sonogram or angiography (26/33), or operative findings of occluded vein (7/33). Successful thrombectomy and dismantling of portacaval shunts were achieved in most cases (24/33). Only nine patients required the placement of an interposition vein graft to the superior mesenteric vein. The intraoperative course was characterized by increased blood loss and coagulopathy, significantly higher than in patients with a patent portal vein. When compared with all liver transplants, the immediate postoperative complication rate was higher for primary nonfunction (33% versus 8%), re-exploration for intraperitoneal bleeding and hematomas, and morbid infections. Rethrombosis rate of thrombectomized veins or vein graft was low (2/33). The mortality rate was 35% in the presence of portal vein thrombosis (PVT) and 30% for portacaval shuct (PCS), both significantly higher than the 12% for other orthotopic liver transplant (OLT) patients. These results are expected to improve with better patient selection, surgical experience, and anticipation of the complex postoperative course. The authors conclude that PVT or the presence of PCS are not contraindications to orthotopic liver transplantation.

The endoscopic and surgical management of portal hypertension in children: analysis of 123 cases

Since 1973, 178 children with portal hypertension (PH) have been seen at Instituto da Criança of the University of São Paulo Medical School. Fifty-five of these children were excluded from this analysis for various reasons, including no treatment required, death before treatment, or incomplete data. From the remaining 123 children with esophageal varices, only 96 (76.1%) of them had at least one episode of upper gastrointestinal hemorrhage. Eighty-eight children were submitted to injection sclerotherapy; 26 treated prophylactically, and 62 for treatment of previous bleeding. Eleven (42.3%) children from the prophylactic group bled from esophageal varices during the treatment. They were all successfully managed thereafter. Satisfactory results were achieved in 53 (85.4%) children in the therapeutic group. Twenty-eight (45.1%) children had at least one episode of bleeding after beginning of sclerotherapy, 19 of whom eventually had successful control of the variceal bleeding. From 1973 to 1984, distal splenorenal shunt (DSS) was the procedure of choice for the treatment of bleeding esophageal varices. Forty-two children have undergone DSS during this period. Only one child was shunted prophylactically. Since 1985, injection sclerotherapy has been the first choice for the treatment and only seven children with sclerotherapy failure have since been treated by DSS. Characteristically these children had very similar splenoportographic pattern with huge esophageal and gastric varices and deviation of portal vein blood flow toward the left gastric vein.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver transplantation with atrioatrial anastomosis for Budd-Chiari syndrome

We report the case of a young woman with Budd-Chiari syndrome in whom mesentericoval shunt was first performed, followed by transcaval liver resection and hepatoatrial anatomosis 3 years later. Liver transplantation became necessary 5 years later because of deterioarating liver function with portal hypertension and bleeding. Successful transplantation was performed with atrioatrial anastomosis with help of cardiopulmonary bypass, simplifying considerably the technical procedure and reducing dramatically blood loss.

Current management of the Budd-Chiari syndrome

Twenty-six patients with the Budd-Chiari syndrome were treated surgically at the Johns Hopkins Hospital. Twenty-one of the patients were female and five were male, with a median age at diagnosis of 37 years. Nine patients had polycythemia vera, 6 were receiving estrogen therapy, 5 had a previous hepatitis A or B infection, and 4 had cirrhosis. There was one case each of hepatic malignancy, paroxysmal nocturnal hemoglobinuria, and idiopathic thrombocytopenic purpura. In five cases no etiologic factors or associated disorders were identified. Ascites was the most common presenting feature in this group of patients. Hepatic function at the time of diagnosis, as measured by standard serum chemistries, was only minimally abnormal. The diagnosis of the Budd-Chiari syndrome was confirmed in all 26 patients by hepatic vein catheterization. Inferior vena cavography was also performed and revealed caval occlusion in 4 patients, significant caval obstruction in 13 patients, and a normal vena cava in 9 patients. Interpretation of the vena cavogram was helpful in selecting the appropriate surgical procedure for each patient. Twenty-three of the twenty-six patients underwent percutaneous liver biopsy before operation, with no morbidity or mortality. Four patients had well-established cirrhosis noted on biopsy. Thirty mesenteric-systemic venous shunts were performed on the 26 patients. In 11 patients a mesocaval shunt was performed and in one instance conversion to a mesoatrial shunt was required as a second procedure. In 15 patients a mesoatrial shunt was performed as the initial procedure. Graft thrombosis occurring in 2 of these 15 patients prompted one revision in 1 patient and 2 revisions in the second patient. After mesenteric-systemic venous shunt, eight of the patients (31%) died before discharge from the hospital. The remaining 18 patients in this series were discharged from the hospital alive and well with patent shunts. Patients were followed for a median of 43 months (range, 9 months to 13 years). Five late deaths occurred between 5 and 84 months after the operation. Three- and five-year actuarial survival rates were 65% and 59%, respectively.

Diagnosis and management of the Budd-Chiari syndrome

Occlusion or obstruction of hepatic venous outflow results in the Budd-Chiari syndrome. The disorder should be suspected in any patient who suddenly develops massive ascites, and the diagnosis can be confirmed quickly and accurately by hepatic venography. In the absence of surgical intervention, survival is rare. Inferior venacavography and percutaneous liver biopsy can be performed safely in these patients, and both procedures provide useful information for the selection of appropriate surgical therapy. Most cases of the Budd-Chiari syndrome are amenable to mesocaval or mesoatrial shunting. Those patients with documented cirrhosis or fulminant hepatic failure are best managed by orthotopic liver transplantation.

Liver transplantation in patients with previous portasystemic shunt

Over a 9-year period, 58 patients who had previous portasystemic shunt procedures underwent orthotopic liver transplantation (OLTx) under a cyclosporine-steroid immunosuppressive regimen. The types of shunt used were distal splenorenal (18 patients), mesocaval (17 patients), end-to-side portacaval (11 patients), side-to-side portacaval (5 patients) and proximal splenorenal (7 patients). The mean interval between shunt and transplantation was 6 years. There was no statistical difference in survival between patients with previous shunts and the entire population of patients with primary liver transplantation performed during the same period of time. Age, sex, shunt patency, status of portal vein, and use of vein or artery graft did not affect survival. Child's classification had a significant influence on graft survival, even though no difference was subsequently observed in patient survival. A progressively improved intraoperative strategy and the use of veno-venous bypass and University of Wisconsin preservation solution had a significant impact on blood loss, length of operation, length of stay in intensive care unit, and ultimately, on survival. Distal splenorenal and mesocaval shunts with no or minimal hilum dissection are safer shunts if subsequent transplantation is planned; in fact, their 9-year survival was 87%, whereas all other shunts were associated with a survival no better than 52% (p less than 0.006).

Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era

We review herein our experience in the management of bleeding esophageal varices in cirrhotic patients and consider our findings in light of the dramatic changes in the treatment of cirrhosis resulting from the more widespread use of orthotopic liver transplantation (OLT). It does not seem realistic, at present, to propose OLT as the only effective treatment of variceal bleeding for a variety of reasons, and there remains a large group of patients who are noncompliant or unsuitable for liver transplantation. We propose that initial bleeding be controlled by endoscopic sclerotherapy, thereby allowing careful evaluation to be made electively. Grade A patients appear to be managed best by a reduced-size portacaval shunt (RPS) with prospects of good survival and few complications. Grade B patients can be managed by either sclerotherapy, RPS, or OLT, depending upon individual circumstances. Grade C patients are best managed by liver transplantation, again with excellent survival. In those grade C patients not deemed suitable for OLT (especially alcoholic patients), long-term endoscopic sclerotherapy is the best option. Changes in patient status may sometimes require revision of the treatment decision.

The interposition mesocaval shunt

The interposition mesocaval C-shunt is an excellent alternative for the management of bleeding esophageal varices. The comparable operative mortality, long-term survival, and minimal operative time and blood loss make it the emergency shunt of choice. The C-shunt modification has improved long-term patency and ease of operation. The interposition mesocaval shunt also is increasing in importance as the best portosystemic shunt in those patients who may eventually require liver transplantation.

Emergency surgical treatment of variceal hemorrhage

Emergency surgery should be considered one of the treatment options for the patient with acute variceal bleeding in whom the usual nonsurgical modes of therapy fail, and who is deemed fit to tolerate a major operation. A total shunt (portacaval or mesocaval) is recommended for most of these patients, although a distal splenorenal shunt might be considered for some very good risk, nonalcoholic patients who have only moderate bleeding. Devascularization procedures have a limited role in the emergency situation, but they may be useful in patients who are nonshuntable because of splanchnic venous thrombosis. The Sugiura type of operation is appropriate for the nonalcoholic patient, and esophageal transection is appropriate for the alcoholic patient with cirrhosis. Patients with end-stage nonalcoholic liver disease should also be considered for liver transplantation.

Liver transplantation for variceal hemorrhage

At the present time, liver transplantation must be considered among the treatment options for patients with variceal hemorrhage. For a significant percentage of variceal bleeders throughout the world, however, transplantation is not a viable option either because the patient is not an appropriate transplant candidate or because of the etiology of the patient's portal hypertension. Sclerotherapy and portosystemic shunts remain the mainstay of therapy for these patients. The survival rates with liver transplantation are superior to those reported for other therapies for variceal hemorrhage in patients who have moderate or severe liver disease in addition to variceal hemorrhage. Child's C patients whose variceal hemorrhage is controlled medically should be evaluated for transplantation and receive chronic sclerotherapy while they wait on the transplant list. If the variceal hemorrhage cannot be controlled medically in a transplant candidate, then the patient should undergo an emergency shunt procedure. The shunt of choice is a large-bore H-graft mesocaval or mesorenal shunt. This shunt effectively controls the acute hemorrhage, is relatively simple to perform, does not adversely impact on the subsequent liver transplant, and can simply be ligated after the transplant is completed. Patients who experience variceal hemorrhage as the only manifestation of their liver disease should be treated initially with endoscopic sclerotherapy. For that small group of patients who are either not candidates for sclerotherapy or who rebleed despite sclerotherapy, the choice of shunt or transplantation is presently a difficult one, because both therapies provide excellent results in this group of patients. The choice of therapy should be made on an individual basis and only after consultation with both transplant and shunt surgeons. If a shunt is chosen, we prefer the DSRS because it maintains hepatic portal perfusion in many patients and does not require dissection of the porta hepatis. The management of patients with a prior portosystemic shunt at the time of transplantation depends on the type of shunt and the duration of time between the shunt and the transplant. Shunts not involving the hepatic hilum have little adverse impact on the performance of the transplant. There are insufficient data to assess accurately the effect of a prior portacaval shunt on the transplant. However, our clinical experience and that of other transplant groups indicate that the transplantation of these patients is technically more difficult than that of patients with shunts not involving the hilum. With the availability of other shunting procedures that do not involve extensive dissection of the hepatic hilum, there is little role for either end-to-side or side-to-side portacaval shunts in patients who are potential liver transplant candidates.(ABSTRACT TRUNCATED AT 400 WORDS)