The surgical treatment of gastrointestinal bleeding resulting from portomesenteric thrombosis can vary and is quite difficult to standardize. Technical challenges are mostly related to wide variations in the venous anatomy and hemodynamic patterns, which dictate the most suitable procedure for collateral decompression. In this setting, surgical shunts have played a major role in the management of patients with portal hypertension and bleeding gastrointestinal varices.[1-3] Another option for diffuse mesenteric thrombosis is organ transplantation. However, this is a major undertaking in which the recipient's portomesenteric venous system is completely replaced via multivisceral transplantation. Vianna et al. reported 25 patients with diffuse portomesenteric thrombosis who underwent multivisceral transplantation. They concluded that multivisceral transplantation can be considered when patients experience repeated life-threatening episodes of gastrointestinal bleeding after all other medical and surgical options have been exhausted. However, the indication of liver or multivisceral transplantation for patients without cirrhosis who have portomesenteric thrombosis remains controversial. We report a patient who had idiopathic, diffuse splenoportomesenteric thrombosis requiring splenectomy and gastric devascularization followed by emergent surgical mesosystemic shunts using saphenous and gonadal veins. This report suggests pursuing a unique surgical idea to spare patients from organ transplantation.
To The Editors:
The patient was a 43-year-old Caucasian female who presented with fullness and tenderness in the left upper quadrant. She was found to have marked splenomegaly with diffuse portal mesenteric vein thrombosis and preserved liver function; she was diagnosed with idiopathic splenoportomesenteric thrombosis and, subsequently, the development of massive congestive splenomegaly. This patient had multiple episodes of gastrointestinal bleeding. Endoscopy revealed esophageal varices extending to the proximal esophagus as well as large gastric varices. The patient required splenectomy combined with esophagogastric devascularization. An intraoperative assessment of the mesenteric and portal vasculature was planned because portal decompression was a possibility.
The liver was small and firm with very sharp edges suggestive of chronic atrophy (possibly due to portal hypoperfusion). There were extensive varices throughout the liver. No ascites was noted. An ultrasound examination of the bowel mesentery revealed a short (8- to 9-mm) segment of mesenteric vein collateral apart from the location of the superior mesenteric vein. This was quite tense on digital palpation. According to color Doppler ultrasound, the diminutive portal branches appeared to have no flow. The round ligament was taken down to its insertion into the left portal vein. The round ligament had a 2-mm collateral vein that could not be cannulated to evaluate intrahepatic portal channels. Splenectomy and esophagogastric devascularization were performed as planned.
Emergent Mesosystemic Shunting With Saphenous and Gonadal Veins
While the abdomen was being inspected before closure, the small bowel appeared dusky with significant congestion of venous channels, and restoration of some mesenteric outflow was critical for bowel salvage. A single mesenteric collateral was identified at the mesentery of the left colon; this had a maximal diameter of 6 mm and a length of 2 cm. A 6-cm segment of proximal saphenous vein was recovered from the left thigh. Under clamp control of the mesenteric vein, the collateral was bypassed to the left renal vein with the saphenous vein segment. Flow was restored with good thrill and modest regional improvement in the mesenteric congestion.
The outflow of the mesentery remained suboptimal, however, in view of the continued segmental venous congestion and bowel discoloration. The left gonadal vein (4-5 mm in diameter) was dissected and mobilized for approximately 8 cm. A large mesenteric vein, measuring 6 to 7 mm in diameter, was dissected along the mesenteric arcade. The left gonadal vein was positioned cephalad toward the bowel mesentery, and the vein was anastomosed to the mesenteric arcade vein. Because of the segmental nature of decompression and the high risk for thrombosis, we decided to construct an additional shunt. Another collateral was noted around the duodenum. The right gonadal vein was mobilized through the small bowel and colon mesentery and was anastomosed to the duodenal collateral. At this time, sufficient mesenteric drainage was achieved with decompression of mesenteric venous branches, and the bowel regained its normal color and turgor (Fig. 1).
Abdominal computed tomography was performed 7 and 14 days, 2 and 6 months, and 1 and 2 years after the procedure. The patency of the mesorenal and mesocaval shunts was ensured, and an enlargement was noted in the left mesocaval gonadal shunt (Fig. 2). The patient did not develop encephalopathy or gastrointestinal bleeding from varices. According to multiple subsequent upper endoscopy procedures, gastroesophageal varices remained successfully decompressed.
In this report, we describe a unique experience of emergent surgical shunting that required nonconventional techniques. In the context of diffuse thrombosis in the portal, splenic, and superior mesenteric veins, previously described conventional shunts were not feasible.[1, 2, 5, 6] The outflow of the mesentery had to be restored; otherwise, liver or multivisceral transplantation might have been necessary to prevent further complications secondary to diffuse thrombosis in the portomesenteric system. Our technique of triple surgical mesosystemic shunting, including a mesorenal shunt using the saphenous vein graft and mesocaval shunts using both sides of gonadal veins, was effective and successful in restoring intestinal venous outflow. Because of the long-term patency and excellent patient outcome, the salvage procedure was a success.
In the setting of thrombosis, a flexible and creative approach with an understanding of the mesenteric venous anatomy and collaterals is required to reconstruct the mesenteric outflow. This case report describes an additional surgical treatment option for the restoration of the mesenteric outflow. Notably, the left mesosystemic gonadal vein shunt gradually became enlarged and quite prominent, and this further ensured successful decompression of collaterals and intestinal outflow. Although possible complications after a mesosystemic shunt include encephalopathy, thrombosis, and rebleeding from varices, our patient did not develop any such complications after the surgical shunts.
Although liver or multivisceral transplantation is a feasible treatment option for patients with portal hypertension secondary to diffuse portomesenteric thrombosis, it is important to recognize that nonconventional surgical shunting can spare patients from organ transplantation. Innovative surgical approaches and techniques were essential to restoring the mesenteric venous outflow and accomplishing variceal decompression in this case.
Shunji Nagai, M.D., Ph.D.
Marwan S. Abouljoud, M.D., F.A.C.S.
Marwan Kazimi, M.D.
Atsushi Yoshida, M.D., F.A.C.S.
Division of Transplant and Hepatobiliary Surgery Henry Ford Transplant Institute Henry Ford Hospital Detroit, MI