Association between spontaneous portosystemic shunt and hepatorenal syndrome in liver cirrhosis / 临床肝胆病杂志

ObjectiveTo investigate the association between spontaneous portosystemic shunt （SPSS） and hepatorenal syndrome （HRS） in patients with liver cirrhosis. MethodsA retrospective analysis was performed for 93 patients with SPSS from Dezhou Hospital， Qilu Hospital of Shandong University， from January 2015 to January 2022， and the patients were followed up for 12 months with the onset of HRS as the observation endpoint. According to the presence or absence of HRS， the 93 patients with SPSS were divided into HRS group with 38 patients （40.86%） and non-HRS group with 55 patients （59.14%）， and the two groups were compared in terms of clinical data， laboratory data， complication， and shunt diameter. Based on the maximum shunt vein diameter of 1.5 cm， the 93 patients with SPSS were divided into high shunt group with 52 patients （55.91%） and low shunt group with 41 patients （44.09%）， and with the onset of HRS as the observation endpoint， the two groups were compared in terms of the incidence rate of HRS and survival time curve. The independent-samples t test was used for comparison of normally distributed continuous data with homogeneity of variance between two groups， and the chi-square test was used for comparison of categorical data between two groups. The receiver operating characteristic （ROC） curve was used to predict cut-off values， the Kaplan-Meier curve was used for comparison of survival time， and the Log-rank test was used to compare the differences in survival curves. The multivariate Cox regression analysis was used to investigate risk factors. ResultsCompared with the non-HRS group， the HRS group had significant increases in Child-Pugh score， Child-Pugh class， MELD score， serum creatinine， blood urea nitrogen， alanine aminotransferase， aspartate aminotransferase， maximum shunt vein diameter， the incidence rates of hepatic encephalopathy and spontaneous bacterial peritonitis， and the degree of ascites， as well as significant reductions in main portal vein diameter， serum sodium and albumin （all P<0.05）. Compared with the low shunt group， the high shunt group had a significant increase in the incidence rate of HRS （51.92% vs 26.83%， χ²=5.974， P=0.015） and a significant reduction in the time to the onset of HRS （Log-rank P=0.033）. A maximum shunt vein diameter of >1.5 cm （hazard ratio ［HR］=1.123， 95% confidence interval ［CI］： 1.041‍ ‍—‍ ‍1.211， P=0.003）， an increase in MELD score （HR=1.205， 95%CI： 1.076‍ ‍—‍ ‍1.437， P=0.039）， a reduction in serum albumin （HR=0.890， 95%CI： 0.814‍ ‍—‍ ‍0.974， P=0.011）， an increase in the degree of ascites （HR=2.099， 95%CI： 1.066‍ ‍—‍ ‍4.130， P=0.032）， and spontaneous bacterial peritonitis （HR=2.259， 95%CI： 1.020‍ ‍—‍ ‍5.003， P=0.045） were independent risk factors for the onset of HRS in SPSS patients. ConclusionThere is an association between SPSS and HRS， and shunt diameter >1.5 cm was an independent risk factor for HRS in SPSS patients， which should be taken seriously and require early intervention in clinical practice.

The Risk Factors for Bleeding of Fundal Varices in Patients with Liver Cirrhosis

BACKGROUND/AIMS: The relationship between portal hemodynamics and fundal varices has not been well documented. The purpose of this study was to understand the pathophysiology of fundal varices and to investigate bleeding risk factors related to the presence of spontaneous portosystemic shunts, and to examine the hepatic venous pressure gradient (HVPG) between fundal varices and other varices. METHODS: In total, 85 patients with cirrhosis who underwent HVPG and gastroscopic examination between July 2009 and March 2011 were included in this study. The interrelationship between HVPG and the types of varices or the presence of spontaneous portosystemic shunts was studied. RESULTS: There was no significant difference in the HVPG between fundal varices (n=12) and esophageal varices and gastroesophageal varices type 1 (GOV1) groups (n=73) (17.1+/-7.7 mm Hg vs 19.7+/-5.3 mm Hg). Additionally, there was no significant difference in the HVPG between varices with spontaneous portosystemic shunts (n=28) and varices without these shunts (n=57) (18.3+/-5.8 mm Hg vs 17.0+/-8.1 mm Hg). Spontaneous portosystemic shunts increased in fundal varices compared with esophageal varices and GOV1 (8/12 patients [66.7%] vs 20/73 patients [27.4%]; p=0.016). CONCLUSIONS: Fundal varices had a high prevalence of spontaneous portosystemic shunts compared with other varices. However, the portal pressure in fundal varices was not different from the pressure in esophageal varices and GOV1.

A Meta analysis for 4250 portal hypertension cases undergoing surgery in Chinese literature / 中华普通外科杂志

ObjectiveTo systematically evaluate the therapeutic effect of gastroesophageal devascularization( GD),portasystemic shunt( PSS),devascularization plus portasystemic shunt ( GD + PSS) for the treatment of 4250 cirrhotic portal hypertension cases reported in Chinese literature. MethodsThe literatures about the effect of gastroesophageal devascularization,portasystemic shunt,devascularization plus portasystemic shunt on portal hypertension were collected from Wanfang databases, China National Knowledge Infrastructure(CNKI) from 1980 to 2011.RevMan 4.2 and SPSS 13.0 were used for data analysis. ResultsIn this study 17 reports were enrolled into the meta-analysis.The results of the mta-analysis showed that long term survival rate in the group of GD plus PSS was higher than that in group of GD [OR=1.73,95％CI (1.23,2.44),P ＜0.01].That in group of PSS was similar with the group of GD [ OR =0.87,95 ％ CI (0.63,1.20),P =0.40 ].That of group GD plus PSS was similar with the group of PSS [ OR =1.73,95％ CI (0.95,3.13),P =0.07 ].For recurrent variceal bleeding rate,that in group of PSS was lower than that in the group of GD[ OR =0.46,95％ CI (0.35,0.61 ),P ＜0.01 ].That in the group of GD plus PSS was lower than that in the group of GD [ OR =0.25,95％ CI (0.18,0.35),P ＜ 0.01 ].The group of GD plus PSS was similar to that of group of PSS [ OR =0.72,95％ CI ( 0.40,1.29 ),P =0.27 ].Encephalopathy rate was higher in the group of PSS than the group of GD [ OR =3.57,95％ CI (2.43,5.23 ),P ＜0.01 ].That in group of GD plus PSS was lower than that in the group of PSS[ OR =0.37,95％ CI (0.20,0.69),P ＜0.01 ],while that in GD plus PSS was similar to the group of GD[ OR =1.58,95％ CI (1.02,2.43),P =0.04 ].ConclusionsThe only significant factor influencing the long term result in Chinese patients with portal hypertension is preoperative liver function.The three types of operation have different benefits and disadvantages.

Adult cavernous transformation of the portal vein / 中华普通外科杂志

Objective To set up a standard for surgical classification of cavernous transformation of the portal vein (CTPV) and their management strategy according to the classification.Methods The clinical data of 63 CTPV cases were analyzed retrospectively,the classification and the corresponding treatment strategy were evaluated.Results According to the imaging examination,surgical treatment and long-term follow-up,CTPV was classified into four types:Type Ⅰ:cavernous transformation involving main trunk of the portal vein and intrahepatic branches.Portasystemic shunt (mesocaval and splenocaval shunt)(or plus port-azygous devascularization) were used for this type;Type Ⅱ:cavernous transformation in the main trunk and proximal SV or SMV.Portasystemic shunt (mesocaval and splenocaval shunt) or plus portazygous devascularization were applied;Type Ⅲ:cavernous transformation involving the whole portal system.Portopulmonary shunt (splenopneumopexy) or inferior mesenteric-caval shunt plus port-azygous devascularization were suggested;Type Ⅳ:any types aforementioned accompanied by biliary and /or pancreatic abnormalities.The treatment should focus on main symptoms and two-stage operation.Conclusions Doppler ultrasound and multi-slice spiral CT (MSCT) three dimensional (3D) reconstruction are the mainstay for the diagnosis of CTPV;Correct diagnosis,classification as well as individualized management are of great importance in the treatment of adult CTPV.

"Síndrome pequeño para su tamaño", (small-for-size), como complicación de un trasplante hepático con donante vivo adulto relacionado / Small-for-size syndrome: report of one case

Although the use of cadaveric split or living donor liver transplantation is a valid option for liver transplants, they have several complications, being the "small-for-size syndrome" one of the most frequent. This entity is mainly due to the incapacity that the graft has to meet the blood drainage demands. We report a 61 year-old patient with sub-acute liver failure, transplanted with a partial liver graft that developed hyperbilirubinemia, ascites and liver function deterioration. A meso-caval shunt was performed, after which the ascites resolved, serum bilirubin normalized and the synthetic function of the liver improved. After one month, a follow-up CT seen showed the absence of blood flow in the shunt, possible due to the reduction of the hyper-perfusion of the liver. The clinical and biochemical condition of the patient continued improving despite the lack of flow through the shunt.

Intraoperative Iigation of recipient's portasystemic shunt in liver transplantation / 中华普通外科杂志

Objective To investigate the clinical significance of ligating the portasystemic shunt confirmed by preoperative CT evaluation during orthotopic liver transplantation. Methods From January 2007 to August 2008, 35 patients in Tianjin First Central Hospital underwent preoperative three-dimensional CT scan, among them 23 patients had spontaneous major portasystemic shunts, the other 12 patients did not have portasystemic shunts. 16 out of the 23 cases with significant shunts underwent shunt ligation based on portal blood flow volume measured by intraoperative portal vein flowmetry. The shunt of the other 7 patients were left untreated. Results The portal blood flow in the 12 patients without portasystemic shunt as judged by preoperative CT scanning were (1101±70) ml/min. The shunts in 7 patients with portal blood flow greater than 1000 ml/min were not ligated, that of the 16 patients with portal blood flow volume lower than 1000 mL/min were ligated. The portal blood flow volume in those 16 patients before and after ligating the shunt were (657±112) m//min and (1136±161) ml/min, respectively (P<0.05). Postoperatively 2 patients suffered from portal vein thrombosis, among them 1 patient suffered from intermittent disturbance of consciousness, 2 patients died within 3 months, with one dying of respiratory failure from pulmonary aspergillus infection one dying of hepatic failure in 2 months after operation because of graft dysfunction.The other 19 patients with normal blood flow and well-functioning graft were alive. Conclusion The ligation of portasystemic shunt is mandatory in patients when pretransplant CT evaluation showing a major porto-systemic shunts and portal blood flow volume was less than 1000 ml/min.