Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation

Abstract

Earn MOC for this article: www.wileyhealthlearning.com/aasld.aspx Spontaneous portosystemic shunts (SPSS) are commonly observed in patients undergoing living donor liver transplantation (LDLT); however, their impact on the outcome after transplantation is unclear. We aimed to assess the type, size, and the effects of SPSS on outcomes after LDLT. A total of 339 LDLT recipients in a single institution were included. The type and diameter of the SPSS (splenorenal shunt [SRS], oesogastric shunt, and umbilical shunt) were retrospectively analyzed. A large shunt was defined as having a diameter ≤7 mm. No portal flow modulation was attempted over time. Portal complications were defined as stenosis, thrombosis, or hepatofugal flow requiring any treatment after transplantation. There were 202 (59.0%) patients who exhibited at least 1 large SPSS. Neither the size nor type of SPSS was associated with mortality, morbidity, or liver function recovery. However, the incidence of portal complications was significantly higher in patients with a large SRS (8.6% versus 2.9%; P = 0.04). Multivariate analysis of portal complications revealed 2 independent predictors: pre-LT portal vein thrombosis (PVT) and SRS size. The observed risk among recipients with pre-LT PVT was 8.3% when the SRS was ≤7 mm, but increased to 38.5% when the SRS was >15 mm. The present study suggests that large SPSS do not negatively affect the outcomes after LDLT. However, a large SRS is associated with a higher risk of portal complications, particularly in recipients with pre-LT PVT, for whom intraoperative intervention for SRS should be considered. Otherwise, a conservative approach to SPSS during LDLT seems reasonable.

The role of spontaneous portal-systemic shunts in liver transplantation: case report and literature review

“…Allard et al found that SPSS do not negatively affect the outcome after LDLT and suggested "do-nothing" approach in living donor LT. Furthermore, dissection of the spleen or ligation of the shunts could induce additional adverse events (18). Although Gomez Gavara et al found the incidences of post-LT HE and PVT were lower in the ligated SPSS group than those in nonligated SPSS group, they still supported the "do-nothing" idea in case of small size graft (split-liver living donor graft or small whole liver graft with low graft-to-body weight ratio) (19).…”

“…Although Gomez Gavara et al found the incidences of post-LT HE and PVT were lower in the ligated SPSS group than those in nonligated SPSS group, they still supported the "do-nothing" idea in case of small size graft (split-liver living donor graft or small whole liver graft with low graft-to-body weight ratio) (19). Only when portal flow is deemed insufficient either on the basis of visual examination or doppler ultrasonography (portal flow velocity <20 cm/s or portal flow <1 L/minute), the SPSS should be sought, isolated, and ligated after a positive clamping test (18). In case of spontaneous SRS, we could clamp the LRV on the left border of the IVC to test the effect of SRS on portal flow, in other case, the SPSS can be controlled directly.…”

Small‐for‐size graft, small‐for‐size syndrome and inflow modulation in living donor liver transplantation

“…91 However, there is debate as to whether to obstruct or not to obstruct such spontaneous portosystemic shunts after graft reperfusion. [92][93][94][95][96] In whole liver transplantation or pediatric LDLT, transplanted grafts could accommodate huge portal inflow and therefore shunts should be obstructed to prevent portal steal syndrome causing ischemic injuries to the grafts. In adult-to-adult LDLT, however, total obstruction of such shunts might cause excessive portal inflow and portal hypertension causing graft injuries, and preservation of them in turn might lead to portal steal phenomena and graft ischemia.…”

“…98,99 The Tokyo group recently reported that they perform neither obstruction of large portosystemic shunts nor splenectomy, under the use of large LDLT grafts >40% for GV/SLV, although the incidence of portal vein thrombosis after LDLT was high. 92 Kyushu group ligate large shunts to maintain adequate portal flow and to prevent the steal phenomenon as long as the portal pressure does not exceed 20 mm Hg after test clamping 94,100 (Figure 2). The important point in leaving large portosystemic shunts open is that only shunts connected to vena cava could be left open for possible interventional obstruction approach in case of post-transplant portal steal syndrome after LDLT.…”

Impact of spontaneous splenorenal shunt on liver volume and long‐term survival of liver cirrhosis

“…Spontaneous portosystemic shunts (SPSS), which refer to the development of collateral vessels for diverting blood from splanchnic circulation to inferior vena cava, 1 are a common complication of portal hypertension in liver cirrhosis with a prevalence of 43–60% 2,3 . It is a main precipitating factor for hepatic encephalopathy (HE) and negatively affects the outcomes of patients with liver cirrhosis 4,5 . Except for gastroesophageal varices, which are the most widely studied type of SPSS, spontaneous splenorenal shunt (SSRS) is one of the most common types of SPSS, 6 which is defined as abnormal collateral vessels from splenic vein to renal vein 7 .…”