Jain Sundeep, Kalla Mukesh, Suleman Adil, Verma Alok
Department of Gastrointestinal & HPB Surgery, Fortis Hospital, A-57, Apartment 203, Pearl Grands, Shanti Path, Tilak Nagar, Jaipur, 302004, India.
Department of Gastroenterology & Hepatology, S. R. Kalla Hospital, Jaipur, India.
BMC Surg. 2017 Jun 2;17(1):65. doi: 10.1186/s12893-017-0262-6.
Presence of retro-aortic left renal vein poses special challenge in creating spleno-renal shunt potentially increasing the chance of shunt failure. The technical feasibility and successful outcome of splenectomy with proximal spleno-renal shunt (PSRS) with retro-aortic left renal vein is presented for the first time. The patient was treated for portal hypertension and hypersplenism due to idiopathic extra-hepatic portal vein obstruction.
A twenty year old male suffering from idiopathic extra-hepatic portal vein obstruction presented with bleeding esophageal varices, portal hypertensive gastropathy, asymptomatic portal biliopathy and symptomatic hypersplenism. As variceal bleeding did not respond to endoscopic and medical treatment, surgical portal decompression was planned. On preoperative contrast enhanced computed tomography retro-aortic left renal vein was detected. Splenectomy with proximal splenorenal shunt with retro-aortic left renal vein was successfully performed by using specific technical steps including adequate mobilisation of retro-aortic left renal vein and per-operative pressure studies. Perioperative course was uneventful and patient is doing well after 3 years of follow up.
PSRS is feasible, safe and effective procedure when done with retro-aortic left renal vein for the treatment of portal hypertension related to extra-hepatic portal vein obstruction provided that attention is given to key technical considerations including pressure studies necessary to ensure effective shunt. Present case provides the first evidence that retro-aortic left renal vein can withstand the extra volume of blood flow through the proximal shunt with effective portal decompression so as to treat all the components of extra-hepatic portal vein obstruction without causing renal venous hypertension.
主动脉后左肾静脉的存在给脾肾分流术带来了特殊挑战，可能增加分流失败的几率。首次报道了对伴有主动脉后左肾静脉的患者行脾切除加近端脾肾分流术（PSRS）的技术可行性及成功结果。该患者因特发性肝外门静脉阻塞导致门静脉高压和脾功能亢进。
一名20岁男性，患有特发性肝外门静脉阻塞，出现食管静脉曲张出血、门静脉高压性胃病、无症状门静脉胆管病和有症状的脾功能亢进。由于内镜和药物治疗对静脉曲张出血无效，计划行手术门静脉减压。术前增强CT检查发现主动脉后左肾静脉。通过采取包括充分游离主动脉后左肾静脉和术中压力研究等特定技术步骤，成功实施了脾切除加近端脾肾分流术并保留主动脉后左肾静脉。围手术期过程顺利，随访3年后患者情况良好。
对于与肝外门静脉阻塞相关的门静脉高压症，当对伴有主动脉后左肾静脉的患者进行PSRS时，如果注意关键技术要点，包括确保有效分流所需的压力研究，该手术是可行、安全且有效的。本病例首次证明，主动脉后左肾静脉能够承受近端分流增加的血流量，实现有效的门静脉减压，从而治疗肝外门静脉阻塞的所有症状，且不会导致肾静脉高压。
