Volume 32, Issue 4 , Pages 445-446, October 2006
A Technical Tip for Creation of a Drapanas Mesocaval Shunt
Article Outline
Keywords: Drapanas, End-to-side anastomosis, Superior mesenteric vein
Introduction
The goal of a portal shunt is portal decompression. Meso-caval shunts are advised for patients with portal vein thrombosis or when the possibility of future liver transplantation favours avoidance of a right upper quadrant shunt.1 Meso-caval shunt technique consists of division of the inferior vena cava (Clatworthy) and anastomosis side to end with the superior mesenteric vein. An alternative simplified technical approach to meso-caval shunt is the interposition shunt of Drapanas, in which a graft between the inferior vena cava and the superior mesenteric vein at the level of its first branches is accomplished.1, 2, 3
We present a case of portal hypertension, in which a new technique for end-to-side vascular anastomosis with a Drapanas mesocaval shunt was used.
Case-Operative Technique
A 58 years old man with liver cirrhosis, portal hypertension, ascites, hypersplenism and recurrent episodes of variceal bleeding underwent a surgical operation for portal decompression. At laparotomy with midline incision, after an extensive intra-abdominal dissection dorsally through the root of the great mesentery and to the right of the aorta, the inferior vena cava was identified. Then the transverse colon was retracted upwards, the small intestine to the right, and through a T-shaped incision of the peritoneum at the base of the transverse mesocolon, near the ligament of Treitz, the bed of superior mesenteric vein was recognised. During exposure, the vein was found to have an inflammatory appearance with adhesions to the local tissues. The dissection and the sufficient exposure of the superior mesenteric vein was impossible. Therefore, a 10-mm ringed tubular PTFE graft was sutured end-to-side in the anterior surface of the vein, with 5-0 prolene continuous suture, without opening the vein or using isolation clamps. Next, we opened longitudinally (1.5
cm) the graft near the anastomosis and a Fogarty catheter No 5 was inserted, penetrating the vein wall (see Fig. 1). After inflating the balloon, the catheter was withdrawn carefully in order to avoid dehiscence of the circular suture between the graft and the vein. Using a Pots or other fine scissor, the tear of the friable venous wall was widened and cut via the opening of the graft, whilst local control of haemorrhage was achieved by finger pressure on the course of superior mesenteric vein. The graft aperture was closed and an end-to-side anastomosis of the graft to the anter-medial surface of the inferior vena cava with 5-0 vascular suture was performed.
Fig. 1.
Graft implanted to superior mesenteric vein: in the schematic representation the steps of this new alternative procedure are shown.
The patient had an uneventful post-operative course with relief of ascites and hypersplenism. No post-operative encephalopathy was observed. The patient was prescribed ticlopidine for continuous long-term treatment and was followed-up for a period of 4 years without clinical evidence of graft thrombosis and recurrence of symptoms. The patient refused all follow-up imaging.
Conclusion
The described technique permits creation of an anastomosis between an insufficiently prepared and poorly exposed superior mesenteric vein with the graft. In addition no isolation clamps are needed. From a practical point of view this method merits serious consideration as an alternative operative technique under difficult circumstances, such as peritoneal or retroperitoneal inflammation. The principal advantage of the present technique remains the small blood loss, particularly relevant since these patients have a significant uncorrectable coagulopathy, with prolonged prothrombin time unresponsive to vitamin K, due to liver dysfunction and the thrombocytopenia resulting from hypersplenism. Moreover the limited exposure and preparation of the inferior vena cava, avoids bleeding from retroperitoneal venous collaterals.
References
- . Operative Therapy for Portal Hypertension. In: Rutherrford Robert B editors. Vascular Surgery. 5th ed. Philadelphia, Pensylvania: W.B Saunders Company; 2000;p. 1578–1592
- . Interposition mesocaval shunt for treatment of portal hypertension. Ann Surg. 1972 Oct;176(4):435–448
- . Hemodynamics of the interposition mesocaval shunt. Ann Surg. 1975 May;181(5):523–533
PII: S1078-5884(06)00110-9
doi:10.1016/j.ejvs.2006.02.008
© 2006 Elsevier Ltd. All rights reserved.
Volume 32, Issue 4 , Pages 445-446, October 2006
