Combination of modified Sugiura technique and proximal splenorenal shunt for the management of portal vein thrombosis in noncirrhotic portal hypertension

Figures & data

Figure 1 Abdominal Doppler ultrasonography with ascites, dilatation of portal vein, and low portal vein peak velocity.

Figure 2 Contrast-enhanced abdominal CT scan with dilatation of portal vein with thrombus and dilatation of splenic vein.

Figure 3 Esophagogastroduodenoscopy, esophageal varices grade 3 with the positive red color sign (left), esophagogastric junction (middle), and cardia stomach varices (right).

Figure 4 Step by step the operation. Left subcostal incision (A); splenectomy (B); transection and end-to-end anastomosis of the lower esophagus (C); devascularization of the upper 2/3 of the major gastric curvature (D); pyloroplasty (E); proximal splenorenal shunt (F).

Figure 5 Esophagogastroduodenoscopy 2 months after surgery, esophageal varices grade 2 with the negative red color sign (left), cardia stomach edema (middle), and gastric snakeskin (right).

Table 1 Classification of noncirrhotic portal hypertension^1,5

Pre-hepatic

Extrahepatic portal vein obstruction (portal vein thrombosis) Splenic vein thrombosis Splanchnic arteriovenous fistula Splenomegaly due to any cause

Hepatic

Pre-sinusoidal Noncirrhotic portal fibrosis Idiopathic portal hypertension Schistosomiasis Sarcoidosis Primary or secondary biliary cirrhosis (pre-cirrhotic stage) Sclerosing cholangitis Congenital hepatic fibrosis Peliosis hepatis Hepatic arterioportal fistula Early myeloproliferative diseases and myelofibrosis Vinyl chloride, arsenic, or azathioprine hepatotoxicity Partial nodular transformation Sinusoidal Alcoholic hepatitis Hypervitaminosis A and methotrexate hepatoxicity Incomplete septal fibrosis Nodular regenerative hyperplasia Post-sinusoidal Veno-occlusive disease Hepatic vein thrombosis (Budd-Chiari syndrome)

Post-hepatic

Inferior vena cava web Constrictive pericarditis and restrictive cardiomyopathy Tricuspid regurgitation Severe right-sided heart failure

Table 2 Type of shunt techniques.^6,12

Portosystemic shunts
Nonselective
Portocaval	End-to-side or side-to-side anastomosis of the portal vein and inferior vena cava
Mesocaval	Side-to-side or with an interposition graft of superior mesenteric vein and inferior vena cava
Mesoatrial	Requires interposition polytetrafluoroethylene (PTFE) graft of superior mesenteric vein and right atrium
Proximal splenorenal	End-to-side anastomosis of the proximal splenic vein to left renal vein, involves splenectomy
Selective
Warren’s distal splenorenal	End-to-side anastomosis of the distal splenic vein and left renal vein, includes ligation of the left gastric vein and pancreatic veins
Inokuchi’s left gastric venous caval	End to side anastomosis of the left gastric vein and inferior vena cava, may require an autologous graft
Splenocaval	End-to-side anastomosis of the distal splenic vein and inferior vena cava, may need an interposition PTFE graft
Partial
Sarfeh’s portocaval	Uses 8 mm interposition PTFE graft
Portoportal shunt
Rex shunt	Superior mesenteric vein and left portal system at the Rex recess

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