The meso-spleno-renal shunt procedures: a comprehensive approach to portasystemic decompression

Portal cavernoma cholangiopathy: Update and recommendations on diagnosis and management

Portal cavernoma cholangiopathy is defined as an obstruction of the biliary system due to distended veins surrounding bile ducts that mainly occur in patients with extrahepatic portal venous obstruction. The periductal venous plexuses encircling the ducts can cause morphological changes which may or may not become symptomatic. Currently, non-invasive techniques such as ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and dynamic contrast enhanced magnetic resonance images are being used to diagnose this disorder. Only a few patients who have symptoms of biliary obstruction require drainage which might be accomplished using endoscopic stenting, decompression of the portal venous system usually via a lienorenal shunt, a difficult direct hepaticojejunostomy, and rarely a liver transplant.

Therapeutic approaches for portal biliopathy: A systematic review

Portal biliopathy (PB) is defined as the presence of biliary abnormalities in patients with non-cirrhotic/non-neoplastic extrahepatic portal vein obstruction (EHPVO) and portal cavernoma (PC). The pathogenesis of PB is due to ab extrinseco compression of bile ducts by PC and/or to ischemic damage secondary to an altered biliary vascularization in EHPVO and PC. Although asymptomatic biliary abnormalities can be frequently seen by magnetic resonance cholangiopancreatography in patients with PC (77%-100%), only a part of these (5%-38%) are symptomatic. Clinical presentation includes jaundice, cholangitis, cholecystitis, abdominal pain, and cholelithiasis. In this subset of patients is required a specific treatment. Different therapeutic approaches aimed to diminish portal hypertension and treat biliary strictures are available. In order to decompress PC, surgical porto-systemic shunt or transjugular intrahepatic porto-systemic shunt can be performed, and treatment on the biliary stenosis includes endoscopic (Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy, balloon dilation, stone extraction, stent placement) and surgical (bilioenteric anastomosis, cholecystectomy) approaches. Definitive treatment of PB often requires multiple and combined interventions both on vascular and biliary system. Liver transplantation can be considered in patients with secondary biliary cirrhosis, recurrent cholangitis or unsuccessful control of portal hypertension.

Surgical management of portal cavernoma cholangiopathy

The majority of patients with portal cavernoma cholangiopathy (PCC) are asymptomatic, however some (5-38%) present with obstructive jaundice, cholangitis, or even biliary pain due to bile duct stones which form as a result of stasis. Most patients with extrahepatic portal venous obstruction (EHPVO) present with variceal bleeding and hypersplenism and these are the usual indications for surgery. Those who present with PCC may also need decompression of their portosystemic system to reverse the biliary obstruction. It is important to realize that though endoscopic drainage has been proposed as a non-surgical approach to the management of PCC it is successful in only certain specific situations like those with bile duct calculi, cholangitis, etc. A small proportion of such patients will continue to have biliary obstruction and these patients are thought to have a mechanical ischemic stricture. These patients will require a second stage procedure in the form of a bilioenteric bypass to reverse the symptoms related to PCC. In the absence of a shuntable vein splenectomy and devascularization may resolve the PCC in a subset of patients by decreasing the portal pressure.

Determination of liver volume in vivo in rats using MRI

Accurate estimation of the liver volume may be important for the diagnosis of several pathological processes in patients and for the study of new therapies in experimental oncology. Although sonography and computed tomography (CT) have been used for this purpose in patients, the lack of spatial resolution and tissue differentiation is a source of measurement errors which, at present, makes it impossible to accept sonography and CT widely for the determination of the liver volume. In the present study, the liver volumes of seven rats were measured by magnetic resonance imaging (MRI) and an automated image analysis system before and after the animals were killed. Volume computation was carried out by adding up the individual volumes in the sequential MR sections. Adequate MR images with high contrast between the liver and surrounding structures were obtained with spin echo pulse sequence and retarded phase encoding while no contrast material was used. The mean volumes of the livers measured by MR in vivo and in cadavers were 11.91 +/- 0.40 and 11.92 +/- 0.45 ml, respectively. When compared with the actual liver volumes measured in vitro after resection, the errors of determinations in vivo and in cadavers were as small as 3.1 and 2.1%, respectively. These data indicate that MR imaging is an accurate means to determine the liver volume in vivo and that it may be potentially useful to measure small intrahepatic lesions in patients.

Selective distal splenorenal shunts. Technique and results

Selective distal splenorenal shunt was successfully performed in 20 patients from October 1974 to August 1978. All of them had had gastrointestinal hemorrhage from gastroesophageal varices, diagnosed by barium swallow roentgenography or esophagogastroscopy. Only one patient underwent emergency surgery. Portal hypertension was due to hepatic schistosomiasis in 16 patients, and all underwent rectal biopsy and examination of stools to confirm the clinical diagnosis. A small group of patients had ascites, jaundice and hemorrhage. Hepatic encephalopathy has not been a problem, although the follow-up study is short.

Hepatic tissue perfusion studies during distal splenorenal shunt

Hepatic tissue perfusion was measured by the krypton-85 clearance technique during surgery in four patients with bleeding esophageal varices before and immediately after Warren distal splenorenal shunt. No significant reduction in perfusion was found in any patient, thus confirming the concept that this type of portasystemic shunt maintains portal flow to the liver.