• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.3
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• pp.264-270
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• 2023

Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. Methods: A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. Results: During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. Conclusions: Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.26 no.2
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• pp.204-209
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• 2022

The state of intense peripancreatic inflammation in chronic pancreatitis can give rise to various vascular complications such as venous thrombosis and arterial pseudoaneurysms. Due to its intimate location with the pancreas, spleno-mesenteric-portal axis suffers the greatest blunt of thrombotic complications. Treatment modalities for such cases of chronic portal vein thrombosis have always been controversial and challenging. Medical management with anticoagulants is both risky and unsatisfactory due to presence of varices, hypersplenism, and persistence of the inflammatory pathology. Although endovascular techniques have been tried in various case reports, there are definite anatomical challenges in cases of long segment porto-mesenteric thrombosis with massive ascites. Surgical shunts have been historically described for cirrhotic and non-cirrhotic portal hypertensive patients. However, its use in patients with refractory ascites due to chronic pancreatitis induced portal vein thrombosis has not been reported in the medical literature. Here, we present a case of an extensive portal vein thrombosis with massive refractory ascites in a patient with alcohol-induced chronic pancreatitis successfully treated with a surgical mesocaval shunt using an interposition small diameter graft.