Miranda Pablo Beltran, Artacho Gonzalo Suarez, Bellido Carmen Bernal, Marín Gómez Luis Miguel, Franco Carmen Cepeda, Álamo Martinez Jose María, Padillo Ruiz Francisco Javier, Gómez Bravo Miguel Ángel
HPB and Liver Transplant Unit, General and Digestive Surgery Department, University Hospital Virgen del Rocio, Seville, Spain.
HPB and Liver Transplant Unit, General and Digestive Surgery Department, University Hospital Virgen del Rocio, Seville, Spain.
Transplant Proc. 2020 Mar;52(2):566-568. doi: 10.1016/j.transproceed.2019.11.049. Epub 2020 Feb 10.
The presence of collateral circulation in liver cirrhosis patients with portal hypertension is quite frequent due to re-permeabilization of closed embryonic channels. In some cases, these shunts could measure over 1 cm wide, therefore, containing a significative blood flow. Its management during liver transplantation could be challenging due to possible complications resulting from either ligation of the shunts or from ignoring them. We present the case of a patient with recurrent hepatic encephalopathy (HE) and a large spontaneous portosystemic shunt (SPSS) who submitted to liver transplant and review the literature identifying options, complications, and outcomes with the aim of facilitating decision making.
A 68-year-old, Spanish man diagnosed with liver cirrhosis with portal hypertension and recurrent episodes of HE is proposed for LT. The patient's Child-Pugh score was A6-B7, and the Model for End-stage Liver Disease score was 12. Preoperatively, a computed tomography scan showed a large SPSS running to the inferior cava vein. During the surgery, a small-sized portal vein and a large shunt measuring almost 3 cm wide were identified. After reperfusion, portal vein flow was 1000 to 1100 mL/min. Owing to the previous HE and the risk of low portal flow, the shunt was closed increasing the portal flow to 1800 mL/min. The patient was discharged without any complications.
The presence of large SPSSs are frequent during LT. Decision making intraoperatively can be challenging due to possible complications derived from ligation of the SPSS or from ignoring it. Either preoperative assessment of a further HE risk or portal vein flow measurement after reperfusion are essential to achieve a correct resolution.
由于封闭的胚胎通道重新开放，肝硬化门静脉高压患者出现侧支循环十分常见。在某些情况下，这些分流通道直径可超过1厘米，因而有显著的血流量。在肝移植过程中，对其处理颇具挑战性，因为结扎分流通道或忽视它们都可能引发并发症。我们报告一例患有复发性肝性脑病（HE）和大型自发性门体分流（SPSS）的患者接受肝移植的病例，并回顾相关文献，明确处理方法、并发症及预后情况，以助于决策制定。
一名68岁的西班牙男性，诊断为肝硬化伴门静脉高压及复发性HE，拟行肝移植。患者Child-Pugh评分为A6 - B7，终末期肝病模型评分为12分。术前计算机断层扫描显示一条大型SPSS通向腔静脉。手术中，发现门静脉细小，而分流通道粗大，近3厘米宽。再灌注后，门静脉血流量为1000至1100毫升/分钟。鉴于既往有HE病史及门静脉低流量风险，遂结扎分流通道，使门静脉血流量增至1800毫升/分钟。患者无并发症出院。
肝移植期间大型SPSS很常见。术中决策颇具挑战性，因为结扎SPSS或忽视它都可能引发并发症。术前评估再发HE风险或再灌注后测量门静脉血流量对于做出正确决策至关重要。
