Retroperitoneal Approach for Portasystemic Decompression Ronald J.

Stoney, MD; John Thomas Mehigan, MD; Cornelius Olcott IV, MD

\s=b\ A left retroperitoneal approach has been developed and used to perform a renal-splenic shunt for portal decompression in seven patients with massive variceal hemorrhage. In each patient, at least one intra-abdominal finding contraindicated a conventional transperitoneal portasystemic shunt. Retroperitoneal approach avoided possible complications and permitted successful portal decompression with cessation of bleeding in each instance. These results support the use of this technique when it is necessary to avoid the peritoneal cavity in a patient requiring

portasystemic decompression. (Arch Surg 110:1347-1350, 1975)

remains the definitive varices. When the anatomic relation¬ a using transperitoneal approach ships of major portal and systemic venous trunks permit the choice of a variety of anastomoses for portal decom¬ pression. However, no alternative approaches have been described when conditions exist that make the trans¬ peritoneal route hazardous or impossible. The purpose of this article is to describe a retroperitoneal approach for portal decompression and to report the results obtained with its use.

Portasystemic ofdecompression bleeding esophageal treatment

SUBJECTS AND METHODS Case Material Seven patients with massive variceal hemorrhage secondary to advanced liver disease were admitted to the University of Califor¬ nia Medical Center, San Francisco. Hemorrhage in two patients ceased spontaneously and an elective portal decompression oper¬ ation was performed. The remaining five patients with intractable variceal bleeding underwent emergency portal decompression. Since all patients had had previous abdominal surgery and ascites

Accepted

for publication June 27, 1975. From the Department of Surgery, University of California Medical Center, San Francisco. Read before the 23rd scientific meeting of the International Cardiovascular Society, Boston, June 19, 1975. Reprint requests to Department of Surgery, University of California Medical Center, San Francisco, CA 94143 (Dr Mehigan).

both that would make surgery for a traditional transperitoneal shunt hazardous, all operations were performed through the left retroperitoneal space. A renal-splenic shunt was constructed in each case. The Table shows the status of the liver disease accord¬ ing to Child's classification and the contraindications to a conven¬ tional transperitoneal portal decompression in these patients. or

Surgical Technique The patient is placed in the left lateral position with the left flank slightly elevated. The incision is made from the left rectus border to the posterior axillary line over the course of the 11th rib. The rib is resected to avoid the pleural cavity, and the muscles and fascia of the abdominal wall are divided. The retroperitoneal space is developed and the anterior surface of the left kidney ex¬ posed. Dissection is continued medially to free the left renal vein and surrounding structures between the renal hilus and the vena cava.

The splenic vein is identified by reflecting the pancreas superi¬ orly to expose the posterior pancreatic surface. The splenic vein is mobilized for a distance of 4 to 6 cm ending at the junction of the left colic and splenic veins (Fig 1). The splenic vein is thin-walled and adherent to the pancreas because of bridging tributary veins that drain the pancreas. Because of these factors, circumferential dissection is not performed when the diameter of the splenic vein is greater than 1.5 cm. A satisfactory anastomosis can be con¬ structed using partial occlusion of the splenic vein; this requires circumferential dissection of this vein with ligation of the pancre¬ atic tributary veins. Following mobilization of the splenic and renal veins, the inter¬ vening retroperitoneal tissue and lymphatics are resected to per¬ mit approximation of these veins for anastomosis. If an adequate length of the main renal vein is available for anastomosis without tension, the gonadal and adrenal tributaries are preserved for re¬ nal venous outflow. The renal vein is then divided just medially to the entry of these tributaries. Often, however, an adequate length of renal vein is achieved only by division of these tributaries, and division and ligation of the renal vein at the renal hilus. Renal venous outflow then occurs via capsular veins. The end of the left renal vein is beveled following its division, facilitating anastomosis to the inferior aspect of the splenic vein. The splenic vein is then occluded and a phlebotomy is made along its inferior surface by excising a small elipse of vein wall. The end-to-side anastomosis is completed using continuous suture

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Fig 2.—Renal vein oversewn in renal hilus. Anastomosis of par¬ tially occluded splenic vein to divided renal vein.

1.—Inset shows position of incision overlying 11th rib, which has been removed and retroperitoneal space developed to ex¬ pose left renal vein. Splenic vein lying on posterior aspect of pan¬ creas is in close juxtaposition with renal vein, the tributaries of which have been ligated to facilitate anastomosis.

Fig

technique (Fig 2). When the clamps are released, a thrill should be detected over the anastomotic site, indicating satisfactory flow. Prior to closure of the incision, postshunt portal pressure is mea¬ sured and compared with preshunt pressure.

Report of

a

Case

Ten years ago, the patient, a 64-year-old diabetic woman, un¬ derwent a hiatal hernia repair that was complicated by postopera¬ tive wound infection and dehiscence. Incisional hernioplasty was performed five years later, but failed because of the same compli¬ cations. Three years ago, hernioplasty with Marlex mesh was suc¬ cessful; however, there was postoperative hemorrhage of the up¬ per part of the gastrointestinal tract for the first time. Multiple episodes of bleeding from esophageal varices have been noted since that time. Recently, because of variceal bleeding, the patient underwent an attempted portacaval shunt via a right subcostal incision. Se¬ vere bleeding from dense adhesions was encountered, and the por¬ tal vein could not be identified. The operation was terminated and the patient was transferred to the University of California Medi¬ cal Center the following day. At the time of admission, the patient's condition was stable with normal vital signs and no evidence of hemorrhage. The abdo¬ men was distended; there was massive ascites with copious drain¬ age from the drain site. Esophagoscopy revealed massive varices; superior and mesenteric splenic arteriograms showed a patent portal system. Laboratory studies revealed the following values: bilirubin, 1.6 mg/100 ml; total protein, 5.2 mg/100 ml; albumin, 2.8 mg/100 ml; and liver enzymes, within normal limits. Cultures of the ascitic fluid yielded Enterobacteriaceae. The following day, massive hemorrhage of the upper part of the gastrointestinal tract occurred. Whole blood was administered and an emergency

shunt was performed. The portal vein pressure was lowered from 35 to 22 cm of water. Postopera¬ tively the ascitic drainage ceased and no further variceal bleeding occurred. Liver function remained stable. Intravenous pyelogram indicated decreased left renal function that returned to normal one month later. The patient was discharged on an unrestricted diet. She has had no evidence of encephalopathy, ascites, or fur¬ ther bleeding in the nine subsequent months.

retroperitoneal renal-splenic

RESULTS

Satisfactory portal decompression was achieved in all patients. The average portal pressure prior to shunting was 43 cm of water. Following shunting the pressure was 22 cm of water. All patients survived operation. Two pa¬ tients died later. No further variceal bleeding has oc¬ curred 1 to 24 months following operation. No patient has experienced hepatic dysfunction attributable to this oper¬ ation. Ascites was eliminated in three of five patients and reduced in the other two patients. Hepatic encephalopathy has not been observed despite the resumption of a regular diet. Postoperative renal scans were routinely performed and revealed temporarily impaired function of the left kidney in one patient. Long-term renal function remained normal in all patients. Patent shunts were found at autopsy in the two pa¬ tients who died (one of hepatitis and the other of myocar¬ dial infarction). Two of the five survivors have had followup angiographie demonstration of a patent shunt. COMMENT

The left retroperitoneal approach for portasystemic de¬ compression is an acceptable alternative to the conven¬ tional transperitoneal route. It provides access to the left renal vein and splenic vein and allows performance of sat¬ isfactory portal decompression when intra-abdominal con¬ ditions exist that render the traditional transperitoneal route hazardous.

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Retroperitoneal Renosplenic Shunt Patient/

Child's Classification

Contraindications to

Age (yr)/Sex

Date

1/36/F

6/73

Transperitoneal Approach Multiple previous laparotomies

2/57/F

2/74

Multiple previous laparotomies

3/64/F

9/74

Multiple previous laparotomies, infected ascites, Marlex mesh

4/72/F

11/74

Multiple previous laparotomies,

in abdominal wound

5/65/F

1/75

ascites Ascites

6/51/M

3/75

Multiple previous laparotomies,

7/52/F

5/75

ascites Previous laparotomy, ascites

Infected ascites, although rare, is a contraindication for the use of an intraperitoneal prosthetic shunt (mesocaval H graft) because of the risk of infecting the prosthesis. The presence of dense intra-abdominal adhesions from previous laparotomies is common in patients requiring portal decompression. These adhesions, containing mul¬ tiple hypertensive portal collaterals, are known to compli¬ cate the construction of a transperitoneal portasystemic shunt. Dissection is tedious and bleeding may be severe. Previous operations involving the biliary tract and upper part of the gastrointestinal tract, which are frequent in cirrhotic patients, obliterate tissue planes in the region of potential shunt sites and produce scarring in the portal triad that complicates mobilization of the portal system necessary to perform a shunt. Finally, massive aseites is frequently present in these patients. Acute loss of this large volume of protein-rich fluid occurs when the peri¬ toneal cavity is entered prior to performing any trans¬ peritoneal shunt. Rapid volume shifts with the transudation of colloid-rich fluid from the circulating volume into the peritoneal cavity is a complicating feature post¬ operatively. Increased use of plasma substitutes and saltpoor albumin is mandatory in such instances in order to create circulatory homeostasis. A continued loss of ascitic fluid through the abdominal wound can be expected fol¬ lowing operation, which further complicates circulatory dynamics and delays wound healing. We have been pleased with the postoperative course and the long-term results in this small series of patients. Since the peritoneal cavity is not entered, postoperative ileus has been minimal. Pulmonary complications have not oc¬ curred, no diaphragmatic dysfunctions have been noted and no intraoperative bleeding problems have occurred. Postoperatively there have been no significant intravascu¬ lar volume shifts and colloid infusion has not been re¬

quired. The

of the left retroperitoneum limits choice of portasystemic shunts and requires knowledge of the renal status of the patient. If the presence of the left kidney use

Results Died at 5 weeks from pulmonary emboli and pre¬ existing biliary cirrhosis Patent shunt by angiogram at 1 month, alive at 16 months without further bleeding Alive at 9 months without further bleeding Died at 8 weeks from myocardial infarction Patent shunt by angiogram at 5 months, no further bleeding Alive at 3 months without further bleeding Alive at 1 month without further bleeding

and left renal vein are not evident from previous portographic studies, an abdominal roentgenogram following the intravenous injection of 50 ml of diatrizoate meglumine (Renografin) will define the presence and location of the left kidney prior to an urgent operation.

The divided left renal vein has been used as a conduit to systemic venous system to the portal system since 1964. ' Subsequent authors have expanded the use of the divided left renal vein for anastomosis to various veins of the portal system.2 Normal renal venous drainage will occur if the adrenal and gonadal tributaries are pre¬ served. Warren and associates1 reported no permanent re¬ nal damage when these potential collateral sources were ligated during mobilization of the left renal vein. We have used the divided left renal vein for 25 consecu¬ tive portal decompressive procedures (seven retroperito¬ neal, 18 transperitoneal). In two thirds of the patients, an adequate length of main renal vein was obtained for a re¬ nal-splenic anastomosis only by ligating the adrenal and gonadal tributaries. No patient has sustained irreversible damage to the left kidney as a result. Anomalies of the left renal vein are not uncommon.' Construction of a successful renal-splenic shunt was pos¬ sible in the two patients in our series with such anomalies. One patient had a double renal vein and the other a ret¬ roaortic renal vein. The retroperitoneal approach may be contraindicated in the patient who has had previous dissection of the retro¬ peritoneal space (eg, left renal operation) or peripancreatic fibrosis following acute pancreatitis. In these instances, dissection and identification of the splenic and renal veins may be hazardous or impossible and an alternative site for a postasystemic shunt should be considered. connect the

References 1. Erlik D, Barzilai A, Shramek A: Aorto-renal shunt: A newtechnique of portosystemic anastomosis in portal hypertension. Ann Surg 159:72-78,

1964. 2. Baird

RJ, Tutassaura H, Miyagishima RT: Use of the left renal vein

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for portal decompression. Ann Surg 173:551-553, 1971. 3. Warren WD, Salam AA, Faraldo A, et al: End renal vein-to-splenic vein shunts for otal or selective portal decompression. Surgery 72:995\x=req-\ 1006, 1972. 4. Thomford NR: Abnormal left renal vein: No barrier to Warren shunt. Am J Surg 129:503-505, 1975.

Discussion William F. Blaisdell, MD, San Francisco: I would like to con¬ the Stoney-Mehigan-Olcott group for their description of an alternative approach to portal decompression. Certainly the patients with massive ascites and those with vascular adhesions due to previous surgery constitute a problem for the surgeon. This approach offers a means of avoiding some of these difficulties. The blood loss associated with dissection of adhesions and plasma loss associated with drainage of the ascitic fluid maycreate cardiovascular instability that may aggravate liver dam¬ age and jeopardize the patient's recovery. Dr Mehigan might put the ease with which the operation can be conducted in better perspective by answering the following ques¬ tions: (1) what is the duration of the operation when carried out by the retroperitoneal route as opposed to the transperitoneal route; (2) what is the duration of operation when compared to the stan¬ dard operation of end-to-side portacaval shunt; (3) what is the blood loss with this retroperitoneal approach as opposed to the standard intraperitoneal approach; (4) how practical would this approach be as a standard method of portal decompression; (5) you have stated that the presence of pancreatitis is a relative con¬ traindication of this approach: how does one define pancreatitis severe enough to contraindícate this operation; (6) finally, how is the ascites managed in these patients: is preliminary decompres¬ sion carried out and ascitic fluid removed by paracentesis prior to performing the operation? William S. Blakemore, MD, Toledo, Ohio: Several years ago Drs Nusbaum, Baum, and I introduced the use of surgical poste¬ rior pituitary injection (Pituitrin) intra-arterially during surgery for portal hypertension. We have continued its use and believe it decreases the loss of blood and the time required for the dis¬ section, even though the amount of time is difficult to evaluate quantitatively. I appreciate the dilemma Dr Stoney also has with comparing one technique of measuring intraoperative blood loss to another when dealing with a group of patients with complica¬ tions. The approach reported here increases the options available to the surgeon in these patients. Robert R. Hopkins, MD, Providence, RI: Approximately nine years ago, at a meeting of the Society for Vascular Surgery, Dr Simeone and I presented a consecutive series of 11 patients in which the divided left renal vein was used to decompress the por¬ tal vein for portal hypertension. The renal vein can be ligated and

gratulate

cavai end used for decompression of the portal vein with little or no impairment of renal function. When catheterizing the ureters in several of these patients, we encountered technical problems; however, we were able to mea¬ sure the creatinine clearance postoperatively in two patients. The values remained normal or near normal. In one patient, the intravenous pyelogram showed diminished function of the kidney with the divided vein at three weeks, but function was normal at six weeks. Postoperative pyelograms of the remaining patients were normal. It seems that the renal vein can be ligated almost with im¬ vena

punity.

Dr Stoney: The following are in answer to Dr Blaisdell's ques¬ tions. First, if one compares the retroperitoneal approach to a stan¬ dard transperitoneal approach for the "ideal" patient, I think a straightforward, uncomplicated, end-to-side portal cavai shunt could be done in two thirds of the time that would be required to do a retroperitoneal renal-splenic shunt. In the type of patient we selected for the retroperitoneal operation, it might take twothirds longer to do an end-to-side portal cavai shunt, using the

transperitoneal route. Secondly, blood loss has not been a problem with this approach. The average blood loss is 1 to 3 units. There has not been major operative bleeding even when we have had to mobilize a circum¬ ferential segment of splenic vein. In response to the question regarding contraindications, one at¬ tack of abdominal pain, presumably pancreatitis in the alcoholic patient, would not be a contraindication. We encountered one pa¬ tient who had, in fact, clear-cut evidence of recurrent pancreatitis with abscess formation. We made the mistake of attempting the retroperitoneal approach and were forced to abandon this route to use the transperitoneal approach, which was simpler in this pa¬ tient. Previous left renal surgery might be another contraindication. Regarding the management of preoperative ascites, Dr Blais¬ dell, we have not used paracentesis. Since we do not enter the peri¬ toneal cavity, we avoid the ascitic fluid entirely. Postoperatively, patients slowly resorb most or all of their ascites. The gradual fluid shifts that occur are easily tolerated, as compared to the acute fluid shifts that occur following loss of the ascitic fluid in a conventional transperitoneal operation. Dr Blakemore, we have not used intra-arterial or intravenous posterior pituitary injections either preoperatively or for the man¬ agement of operative bleeding. Dr Hopkins, we are indeed indebted to the work that you and Dr Simeone and others have reported regarding the safety of divi¬ sion of the left renal vein for access to the aorta or for a conduit for portal decompression.

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Retroperitoneal approach for portasystemic decompression.

A left retroperitoneal approach has been developed and used to perform a renal-splenic shunt for portal decompression in seven patients with massive v...
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