A STUDY OF THE ASSOCIATION BETWEEN PATHOLOGICAL CHARACTERISTICS OF SPLENIC VEIN AND SHUNT THROMBOSIS IN PATIENTS UNDERGOING PROXIMAL SPLENORENAL SHUNT FOR NON-CIRRHOTIC PORTAL HYPERTENSION
Shahana GUPTA*1, Biju Pottakkat2
1All India Institute of Medical Sciences Mangalagiri, Mangalagiri, Andhra Pradesh, India; 2Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Tamil Nadu, India
Background:Non-cirrhotic portal hypertension (NCPH) accounts for ~50% of portal hypertension in India.Proximal splenorenal shunt (PSRS) is a one-time procedure that changes the natural course of this disease beneficially.Shunt thrombosis is an important complication of PSRS(5.6-47%).The aim of this study was to assess the hitherto unexplored association of pathological characteristics of splenic vein(SV) with shunt thrombosis in patients with Extrahepatic portal vein obstruction (EHPVO) and Non-cirrhotic portal fibrosis (NCPF) undergoing PSRS.Methodology:A prospective observational study was conducted on 96 patients with NCPH(EHPVO:39 and NCPF:57)who underwent PSRS (2011-2017).All patients underwent preoperative Doppler-study of porto-splenomesenteric system, Upper GI endoscopy and CT portovenogram.Intraoperatively, portal pressure, SV and shunt diameter, extent of fall in portal pressure,lie of the shunt (mechanical properties) were assessed.Macroscopic appearance of the splenic vein wall(presence of calcification, thrombosis, thickening ;global or focal) was noted along with examination under surgical magnification loupe to look for intimal defects. Histopathological(HPE) features of SV(presence of medial hypertrophy, wall thickening, intimal fibrosis, adventitial attenuation,venous thrombosis,vein wall calcification) were studied in all patients undergoing shunt surgery.Shunt thrombosis rates at 3 years follow-up were considered.Results:Study group comprised of 96 patients (80% female) with NCPH,aged 12-55years.Of these,PSRS was performed in 80 patients.SV considered abnormal based on the presence of ≥2 pathological abnormalities on HPE.Intraoperatively 77% SV were found to be abnormal while on HPE 94% were abnormal. At 3 years follow-up, shunt thrombosis was noted in 20% of patients.On HPE of veins, SV in was abnormal in 94%. Medial hypertrophy and wall thickening of SV were present in all.Intimal fibrosis was noted in 50% with shunt thrombosis and 25% of patients without shunt thrombosis.On multivariate analysis, which considered only pathological characteristics, intimal fibrosis in the SV wall was found to be significantly associated with shunt thrombosis(p=0.023).In a separate multivariate analysis considering both the mechanical and pathological characteristics,only intimal fibrosis reached statistical significance(p=0.05).Conclusions:SV is pathological in nearly all patients of NCPH with or without shunt thrombosis,probably related to the presence of hyperdynamic circulation.Pathological SV, when detected intra-operatively, should not obviate the performance of shunt.Presence of intimal fibrosis on HPE should prompt a more rigorous follow-up for shunt thrombosis.
Back to 2023 Posters