Introduction
Splenorenal shunt surgery, also known as the “Warren shunt or splenorenal bypass surgery”, is a surgical intervention employed in the management of complications arising from portal hypertension (elevated pressure in the portal venous system), a systemic condition usually associated with cirrhosis of the liver. The normal function of the portal vein is to carry blood to the liver from the digestive organs such as the spleen, pancreas, and gallbladder. Any blockage in the flow of blood from the digestive system to the liver can result in increased blood pressure in the portal vein, resulting in portal hypertension. This article further discusses the indications, surgical technique, clinical outcomes, and potential complications associated with splenorenal shunt surgery.
What Is Splenorenal Shunt Surgery?
Splenorenal shunt surgery is a procedure performed by the surgeon, usually to reduce the pressure within the portal vein, which gets elevated due to chronic liver diseases such as cirrhosis of the liver. Splenorenal shunt surgery represents a surgical strategy aimed at reducing portal pressure by diverting blood flow away from the portal vein system. This surgical procedure can manage the associated symptoms but cannot cure portal hypertension completely.
What Are the Indications of Splenorenal Shunt Surgery?
The following are the indications of Splenorenal shunt surgery:
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In patients with portal hypertension (increased portal venous pressure) with failure of conservative treatment, medical management, and endoscopic interventions to control variceal bleeding.
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Recurrent variceal hemorrhage (rebleeding after initial recovery).
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Refractory ascites (severe compilation of ascites surgery).
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Systemic portal hypertension (increased blood pressure in portal venous system) despite pharmacological management.
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Blood in vomiting.
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Enlarged spleen.
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Kidney failure.
What Is the Procedure for Splenorenal Shunt Surgery?
The splenorenal shunt surgery is done in the following steps:
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Preoperative Assessment: Patients must undergo thorough preoperative evaluation, including radiographic imaging studies, blood tests, and assessment of liver function, to determine candidacy for surgery.
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Administration of Anesthesia: General anesthesia is usually given before starting the procedure.
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Surgical Incision: An incision (surgical cut) is placed by the surgeon in the midline of the abdomen for access to the abdominal cavity. Careful dissection (separation of muscles and vital vessels layer by layer) is performed to expose the spleen, splenic vein, left renal vein, and surrounding structures. In some cases, intraoperative (during the operation) ultrasound may be utilized to understand the vascular (arteries and veins) anatomy and facilitate the surgical approach.
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Surgical Procedure: Various surgical techniques for creating a splenorenal shunt, including proximal splenorenal, distal splenorenal, and side-to-side portosystemic shunts, are available. The choice of technique depends on factors such as the location of collateral vessels, surgeon preference, and patient anatomy. Currently, minimally invasive surgical techniques, such as laparoscopic (a thin tube attached with a tiny camera) and robotic-assisted techniques, have gained popularity due to their potential benefits, including reduced surgical trauma, shorter hospital stays, and faster recovery. The surgical technique involves creating a vascular connection (stunt creation) between the splenic vein (large blood vessels present posterior to the stomach, which drains into the spleen) and the left renal vein (kidney veins), bypassing the liver, and the graft is placed. The main aim of this surgical procedure is to remove the attached veins from the spleen and connect it to the left kidney.
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Hemostasis and Closure: Adequate hemostasis (control of surgical bleeding) is ensured, and the surgical site is thoroughly irrigated with saline solution to minimize the risk of postoperative (after-surgery) bleeding and infections. The abdominal incision is closed in layers using silk stitches, and a sterile dressing is applied to the wound.
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Pharmacological Therapy: After the surgery, the patient is kept on painkillers (intravenous medications). Intravenous (through the veins) fluids are given to restore the fluid and electrolyte loss.
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Follow-up and Recovery: A patient is advised to rest for one week after the surgery for recovery. A drain and catheter are changed regularly. The continuous monitoring of vitals is usually done. A needful diet plan is recommended by the nutritionist post-surgical procedure. Post-operative radiographic imaging tests are done to check the stunt's appropriate functioning.
What Are the Risks and Complications Associated With Splenorenal Shunt Surgery?
A few risks and complications associated with splenorenal shunt surgery are:
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Ascites (accumulation of the fluid in the stomach).
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Risk of post-surgical bleeding.
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Shunt thrombosis (blockage of the stunt due to blood clot formation).
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Hepatic encephalopathy (liver damage resulting in loss of brain function).
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Kidney dysfunction.
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Post-surgical infections (infection risk after the surgery).
Clinical Outcomes:
Splenorenal shunt surgery has been shown to effectively reduce portal pressure and alleviate symptoms of portal hypertension in appropriately selected patients. The outcomes of splenorenal shunt surgery vary depending on various factors, including the underlying cause of portal hypertension, the severity of liver disease, and the patient's overall health condition. Studies have reported improvements in variceal bleeding rates, ascites (fluid accumulation in the liver) control, and overall survival following shunt surgery. However, the procedure carries inherent risks, including postoperative complications such as shunt thrombosis (formation of blood clot), hepatic encephalopathy, and renal dysfunction. Long-term follow-up is necessary to monitor for shunt patency and assess for recurrence of portal hypertension-related complications.
Future Advancements:
Advancements in surgical techniques, including the use of vascular grafts (venous or arterial pedicle graft) and interventional radiology-guided approaches, have expanded the options available for splenorenal shunt surgery. Additionally, alternative therapies such as transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation may be considered in a few cases. These alternative approaches offer potential advantages in specific patient populations, emphasizing the importance of individualized treatment strategies.
Conclusion
Splenorenal shunt surgery remains an important therapeutic option for patients with portal hypertension refractory to medical management. By reducing portal pressure and mitigating the risk of variceal bleeding and other complications, this surgical intervention can significantly improve patient outcomes. However, careful patient selection, meticulous surgical technique, and comprehensive postoperative care are essential to optimize the safety and efficacy of splenorenal shunt surgery. With ongoing research and refinement of surgical approaches, splenorenal shunt surgery continues to evolve, offering hope for patients with portal hypertension and refractory variceal bleeding.
