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Use of Spleno-Gonado-Caval Shunt for Portal Hypertension - Report of a Case

Hemonta Kumar Dutta¹, Shree Harsh²
¹Department of Pediatric Surgery
²Department of Surgery
Assam Medical College and Hospital, Dibrugarh, Assam, India

 

 

Correspondence

Hemonta Kumar Dutta, M.S., Mch.
Assistant Professor of Pediatric Surgery
Assam Medical College and Hospital, Dibrugarh, Assam-786002, India
Tel: + 91-373-2301524, +91-373-2300132
Fax: +91-373-2300080
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Extrahepatic portal vein obstruction (EHPVO) is a common cause of portal hypertension in children. Portal decompression by shunt surgery provides definitive, one time management of these patients. We are presenting one patient with EHPVO where the conventional shunt procedures were not possible because of thrombosis of the major veins of the portal systems. A spleno-gonado-caval shunt was performed with excellent results. This procedure has not been reported earlier.

Key words: portal hypertension, portacaval shunt, spleno-gonado-caval shunt

  

 

Introduction 

Since the introduction of the portacaval shunt in 1945 by Whipple for the treatment of bleeding portal hypertension, surgery for this condition has evolved widely. In India extrahepatic portal vein obstruction (EHPVO) is the commonest cause of bleeding oesophageal varices in children [1,2], and it affects 13-40% of patients with portal hypertension [3,4]. We report a case of EHPVO with bleeding varices that was treated with Spleno-gonado-caval shunt, as conventional shunt surgery was not possible because of extensive thrombosis of the major portal veins. This procedure has not described in the available literature. 

Case Report

Ms.J.B.,17 years, female was admitted with history of 6 episodes of haematemesis and melaena requiring blood transfusion on each occasion during the last 4 years . She was known to have Hepatitis E disease. Examination revealed marked pallor, icterus, liver was palpable 2 cm below costal margin, spleen enlarged down to the right iliac fossa, firm and non tender. There was no ascites. Investigations revealed anemia with Hb 5.4 gm % , Platelet 32,000/mm3 ,Serum Bilurubin 3.2mg % ( 1.8% direct), SGOT 44 I.U., SGPT 36 I.U. , Serum alkaline phosphatase 234 I.U., Serum protein 6.8gm% (alb. 4.2 gm% and glob. 2.6gm%) . Abdominal ultrasonography revealed mild hepatomegaly, huge splenomegaly, thrombosis of portal, splenic and superior mesenteric veins and no ascites. Few dilated retroperitoneal veins were noted. 4 columns of Gr. IV varices could be seen on esophagoscopy. A diagnosis of extrahepatic portal venous obstruction was made. 2 units of whole blood and 3 units of Platelet was transfused preoperatively which raised the Hb to 7.2mg% and Platelet count to 54,000/mm3 .

Considering that the patient bled several times in the past, requiring several blood transfusions and she hailed from a remote place where medical facility was not adequate, we planned for Sugiura’s devascularisation procedure, as the major veins in the portal system were thrombosed. However, on exploration we found a dilated lower polar vein ( fig.1) in the splenic hilum (about 1 cm diameter), and several dilated, tortuous veins in the retroperitoneum. The left ovarian vein was dilated (about 8 mm). Hence we decided for a makeshift shunt using the left ovarian vein as an interposition graft between the lower polar vein of the spleen and the inferior vena cava ( fig. 2). Vascular anastomosis was performed with 6-0 prolene . The patency of the graft was immediately evident by dilatation of the inferior vena cava ( fig.3). Doppler scan on 15th post opperative. day showed good flow noted across the shunt. Followup at one month showed, Hb of 8.4 gm% and Platelet 72,000/mm3. She came for follow up at 1 year 10 months following surgery, she was married for 3 months, her spleen size decreased , Doppler scan showed a patent shunt and there were no varices on esophagoscopy.

Spleno-Gonado-Caval Shunt 1

Fig. 1. Dilated Splenic hilar vein

Spleno-Gonado-Caval Shunt 2

Fig. 2. Left ovarian vein

Spleno-Gonado-Caval Shunt 3

Fig. 3. Good flow noted

 

Discussion

Recent advances in endoscopic therapy and concerns regarding postsurgical complications have dramatically decreased the role of surgery in the management of extrahepatic portal hypertension (EHPH) in children [5,6] . Endoscopic variceal sclerotherapy or band ligation, however, does not eliminate portal hypertension, and these therapies have their own unique complications [7]. Additionally, multiple endoscopic procedures are usually necessary to obliterate varices, with patients remaining at risk for recurrent hemorrhage in the interval [8-10]. In contrast, porto-systemic shunt (PSS) procedures directly decompress the portal venous system, reducing the risk of hemorrhage as well as other manifestations of portal hypertension, such as hypersplenism. Earlier reports regarding the endoscopic or surgical management of portal hypertension during childhood have emphasized control of recurrent hemorrhage as the major benefit of porto-systemic shunt [10-13]. Porto-systemic shunts, although effective in preventing bleeding either from the esophageal or from other ectopic sites, are not feasible in at least 10-20% of patients with EHPVO because of the extent of the thrombotic process. The use of “makeshift” shunts using large collaterals does not help much because of early shunt blockage. Vessel size is also a limiting factor in children, as veins less than 1 cm in diameter most likely would develop thrombosis[14]. 

Earlier use of gonadal vein has been reported in mesogonadal shunts in 4 patients [15]. We are reporting this spleno- gonado-caval shunt for the first time. This procedure was necessitated because the patient had huge splenomegaly with evidence of hypersplenism and the conventional shunt procedures were not possible due to thrombosis of the major veins in the portal system. The patient had few dilated and tortuous retroperitoneal veins. The left ovarian vein was found to be dilated, so a decision was taken during the surgery to use this vein for the shunt. The shunt was successfully done and the early results of the surgery have been satisfying. 

 

 

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