title: Surgical disconnection of patent paraumbilical vein in refractory hepatic encephalopathy.
abstract: BACKGROUND
  Refractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE.
  
  
  METHODS
  Four patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE.
  
  
  METHODS
  Partial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery.
  
  
  RESULTS
  The mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 +/- 56.4 mug/dL, mean +/- SD) than after surgery (41.8 +/- 20.2 mug/dL; p=0.0299). No patient had symptoms of HE.
  
  
  CONCLUSIONS
  Ligation of the patent PUV is an effective treatment for patients with refractory HE.
authors.affiliation: Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo, Japan.
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Ishikawa
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Yoshida
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Mamada
authors.forename: Nobuhiko
authors.initials: N
authors.lastname: Taniai
authors.forename: Koichi
authors.initials: K
authors.lastname: Bando
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Mizuguchi
authors.forename: Daisuke
authors.initials: D
authors.lastname: Kakinuma
authors.forename: Tomohiro
authors.initials: T
authors.lastname: Kanda
authors.forename: Koho
authors.initials: K
authors.lastname: Akimaru
authors.forename: Takashi
authors.initials: T
authors.lastname: Tajiri
mesh_terms: D000328:Adult; D000368:Aged; D004621:Embolization, Therapeutic; D005260:Female; D005500:Follow-Up Studies; D006501:Hepatic Encephalopathy / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008026:Ligation; D008297:Male; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D013154:Spleen; D016896:Treatment Outcome; D014471:Umbilical Veins / Q000601:surgery*; D014654:Vascular Patency