Splenorenal Shunt

Splenorenal shunt

A splenorenal shunt is an operation which aims to redirect blood in the high-pressure portal venous system into the systemic circulation, usually through the left renal vein. It is mostly employed in the treatment of portal hypertension and its consequences e.g. frequent variceal bleeding.

Indications

• Repeated bleeding of the esophagus or gastric varices which cannot be managed by medical or endoscopic treatment.
• Cirrhotic or extrahepatic portal vein portal hypertension.
• Indicated in rare situations in the prevention of refractory ascites or hepatic encephalopathy.

Types

Distal splenorenal shunt (DSRS) -alternatively known as Warren shunt.

• Linking splenic vein to left renal vein maintains portal flow to the liver.
• Favored in cirrhotic patients as it decreases the occurrence of hepatic encephalopathy as opposed to total shunts.

Non-selective shunts

• Diverses all portal blood (e.g., portocaval shunt) -increased risk of hepatic encephalopathy.

Splenorenal shunt surgery

The surgery procedure of the splenorenal shunt is performed in the following steps:

Preoperative Preparation

Assessment

• Liver Function Test 
• Imaging: Doppler US, CT/MRI for assessment of the portal, splenic, and renal veins.
• Endoscopy to investigate varices.

Medical Optimization

• Proper anemia and coagulations.
• Prophylactic antibiotics.
• Vaccination in case of the intention to splenectomy in order to prevent encapsulated organisms.

Surgical Steps

Anaesthesia and Positioning

• General anaesthesia.
• Supine position of patient with left flank raised a little.

Incision and Exposure

• Left subcostal (Chevron) or midline incision.
• Withdraw the abdominal contents, and identify the splenic vein, and the left renal vein.

Mobilization

• Move the spleen gently (Splenectomy can be done in certain instances although in most cases DSRS does not affect the spleen).
• Section of the splenic vein of the spleen at the hilum.
• Define and cut left renal vein.

Vein Preparation

• Splenic vein control and left renal vein control using vascular clamps.
• Make sure that there is adequate anastomotic tension on veins.
• Heparin could be given systemically to minimize the risk of thrombosis.

Shunt Creation

• End-to-end anastomosis: splenic vein and left renal vein. 
• Be sure to add small vascular sutures. 
• Make sure to open up with a wide-caliber anastomosis in order to permit sufficient blood circulation.

Check Patency

• Release clamps gradually.
• Assure of good blood flow through the shunt (palpation, Doppler or finding).
• Control any bleeding.

Hemostasis and Closure

• Achieve a complete hemostasis.
• Close incision in layers.
• Place drain if necessary.

Postoperative Care

• First 24 to 48 hours ICU observation.

Monitor for:

• Bleeding
• Thrombosis of the shunt 
• Hepatic encephalopathy 
• Progressive movements and refeeding.
• The follow-up on liver disease and shunt functioning throughout life.

Splenorenal shunt complications

The following is a list of complications of splenorenal shunt surgery, which is definitive:

Early Complications 

• Bleeding
• Shunt Thrombosis
• Infection
• Pancreatic Injury
• Renal Complications

Late Complications

• Hepatic Encephalopathy
• Stenosis or Occlusion of the Shunt (venous) 
• Portal Vein Thrombosis
• Persistent or Recurrent Variceal Bleeding

Long-Term Complications

• Hypersplenism
• Post-splenectomy Sepsis
• Progression of Liver Disease

Splenorenal shunt recovery

Here is a good summary of the post-op following splenorenal shunt surgery:

Post-operation (First 24-72 h) 

• High-dependency or ICU monitoring.

Continuous monitoring of:

• Blood pressure and heart rate.
• Urine output
• Signs of bleeding
• IV analgesics management of pain.
• Indicated antibiotics and thromboprophylaxis.
• Doppler to ensure the presence of shunt.

Hospital Stay

• Duration: 5-10 days

Stepwise advancement: 

• Day 1-2: IV fluids, nil by mouth -liquids.
• Day 3–4: Soft diet
• Early ambulation was promoted.
• Elimination of drain when output decreases.

Initial Recovery (First 2 to 4 Weeks)

• Mild cramping and tiredness are normal. 

Wound care:

• Keep incision clean and dry
• Removal of suture/staples following 7-10 days.

Avoid:

• Heavy lifting
• Strenuous activity

Regular monitoring of:

• Liver function tests
• Blood counts (platelets can increase in case hypersplenism is cured)

Post-1-Month Recovery

• Most of the patients can return to normal life in 4-6 weeks.

Usual follow-up is:

• Doppler ultrasound to assess shunt patency.
• Surveillance of esophageal/gastric varices 
• Lifetime control of underlying liver disease.

Food and Lifestyle Recovery

• Low-salt diet in case of ascites.
• Sufficient intake of protein; unless the encephalopathy sets in.
• Strict alcohol avoidance
• Stay well hydrated

Best hospital for splenorenal shunt India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

One useful selection portosystemic shunt in the treatment of portal hypertension, especially in the patient with recurrent varices bleeding and intact liver, is the splenorenal shunt (especially, the distal splenorenal shunt) which is known as Warren shunt. It has good long-term management of bleeding and has a lower chance of causing hepatic encephalopathy than non-selective shunts by decompressing the varices without stopping portal blood flow to the liver. Effective outcomes require that patients be selected correctly, the surgical procedure done in a meticulous manner and that postoperative follow up be done with care. Though there are complications like shunt thrombosis, bleeding and late stenosis, most patients have reported a great relief of their symptoms and better quality of life with the long-term follow-up and management of the underlying liver disease.

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FAQ

What is the benefit of a distal splenorenal shunt?

• The warren shunt (distal splenorenal shunt) is selective, decompressing the varices but allowing a hepatic blood flow to liver, resulting a lower risk of hepatic encephalopathy.

How long is the operation? 

• This process normally lasts between 3 and 5 hours, which are based on anatomy, adhesions and surgeon experience.

Does variceal bleeding recur following splenorenal shunt?

• Yes, but it is uncommon. The recurrence normally results out of the thrombosis or stenosis of the shunt hence the necessity of performing regular follow-up.

Do you need lifelong medication after surgery?

• Not always. Based on the symptoms and the liver levels, some patients might require taking beta-blockers, anticoagulants or lactulose.

Will the Liver disease be cured through this surgery?

• No. The splenorenal shunt cures portal hypertension complications, but not the liver disease. A continuous liver management is necessary.

Is splenorenal shunt still being utilized in times of TIPS?

• Yes. It is still utilized in some patients that are chosen, particularly the young people that have good liver functions and long life time.