title: Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation?
abstract: OBJECTIVE
  Management of splenorenal shunt (SRS) during whole liver transplantation is still controversial. Splenectomy (SP) permits its radical removal, at the price of a specific related morbidity. Left renal vein ligation (LRVL) performs a downstream ligation with potential renal repercussions. This study aimed to compare these techniques regarding portal revascularization and postoperative outcomes.
  
  
  METHODS
  From 1994 to 2012, 22 SPs and 7 LRVLs were performed for large SRS (>1 cm) management.
  
  
  RESULTS
  There was no difference in operating times or transfusion rates. In both groups, efficient portal flow was initially obtained in all cases. After a median follow-up of 79 months, 2 patients in the SP group presented an altered portal flow owing to persistence of a not disconnected mesentericogonadic or splenorenal shunt. Postoperative morbidity, including infection and portal vein thrombosis, was not significantly different (32% vs 14%). SP allowed a faster correction of the thrombocytopenia. The LRVL group had a moderate and temporary impairment of renal function.
  
  
  CONCLUSIONS
  SP and LRVL represent 2 effective procedures to avoid vascular steal in the presence of SRS, but they require a patent portal vein. SP appears to be associated to specific but acceptable intraoperative morbidity, permits treatment of associated splenic artery aneurysm, and enables a faster correction of thrombocytopenia. However, the presence of a remote hilum SRS or another large portosystemic shunt represents a cause of failure of the procedure. LRVL is a safer and less demanding procedure that can suppress portal steal whatever the location of the SRS, but at the price of moderate renal morbidity.
authors: Digestive Surgery and Liver Transplant Department, Hôpital de la Croix-Rousse, Lyon, France. Electronic address: nicolas.golse@wanadoo.fr.
authors: N
authors: N
authors: Golse
authors: Digestive Surgery and Liver Transplant Department, Hôpital de la Croix-Rousse, Lyon, France.
authors: K
authors: K
authors: Mohkam
authors: Radiology Department, Hôpital de la Croix-Rousse, Lyon, France.
authors: A
authors: A
authors: Rode
authors: Digestive Surgery and Liver Transplant Department, Hôpital de la Croix-Rousse, Lyon, France.
authors: S
authors: S
authors: Mezoughi
authors: Digestive Surgery and Liver Transplant Department, Hôpital de la Croix-Rousse, Lyon, France.
authors: H
authors: H
authors: Demian
authors: Digestive Surgery and Liver Transplant Department, Hôpital de la Croix-Rousse, Lyon, France.
authors: C
authors: C
authors: Ducerf
authors: Digestive Surgery and Liver Transplant Department, Hôpital de la Croix-Rousse, Lyon, France.
authors: J-Y
authors: JY
authors: Mabrut
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000601:surgery*; D008026:Ligation; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000601:surgery*; D012082:Renal Veins / Q000601:surgery*; D013156:Splenectomy / Q000379:methods*; D014656:Vascular Surgical Procedures / Q000379:methods*