Evolution of Innovative Surgical Techniques Using the Example of Selective Splenorenal Anastomosis Surgery

RELEVANCE Despite the obvious successes of transjugular intrahepatic portosystemic shunt and orthotopic liver transplantation in some high-tech centers of the Russian Federation, the relevance of substantiating the use of selective splenorenal anastomoses in the treatment plan for portal hypertension, when hundreds of patients return to emergency surgery departments every year after conservative treatment with new episodes of bleeding, liver failure and high mortality rates, is beyond doubt.

AIM OF THE STUDY To substantiate the viability of the selective splenorenal anastomosis operation by improving the technique of performing the intraoperative vascular maneuver exposure and venous reconstruction through the use of original modern innovative approaches.

MATERIAL AND METHODS A retrospective controlled clinical study included 56 patients with intrahepatic portal hypertension with relatively preserved liver function, in whose complex treatment program for secondary prevention of bleeding, various options for selective splenorenal bypass surgery were used. In 21 patients of comparison group A, who were treated between 2006 and 2017, selective splenorenal anastomoses were performed using the traditional technique. In 35 patients of the main group B, who were treated between 2018 and 2021, the surgical technique was improved through the use of two innovative surgical techniques: intraoperative vascular maneuver exposure and venous reconstruction during the formation of a splenorenal shunt.

RESULTS Original intraoperative vascular maneuver exposure at the first stage of surgery in patients with portal hypertension provides convenient volumetricspatial relationships in the surgical wound, creates comfortable conditions for performing the main surgical technique, vascular anastomosis. The duration of surgical interventions in patients of group A was 35% longer, and the average intraoperative blood loss was 58.6% higher than in patients of group B. The difference was statistically significant. The suggested intraoperative maneuver of vascular exposure has a minimal risk of developing specific complications associated with the approach to the vessels of the left retroperitoneal space.

Seven days after the operation, patients in both groups showed a decrease in the size of the portal and splenic veins and the volume of the spleen. The blood flow velocity indices in the portal vein decreased, while those in the splenic vein increased. Turbulent blood flow was observed in the lumen of the shunts. No thrombosis of vascular conduits was detected in the early postoperative period according to Doppler ultrasound data. The observed differences were statistically insignificant.

In group A, 7 patients (33.3%) died during the study period, and in group B, 3 patients (8.6%). The differences in mortality were statistically significant. The survival rate of patients in group A was significantly lower than that of patients in group B.

CONCLUSION Changing the technique of execution through the use of modern innovative surgical techniques intraoperative vascular maneuver exposure and venous reconstruction during the formation of the splenorenal shunt allowed to improve the treatment results of patients with portal hypertension, reduce the duration of surgical interventions from 305.5±44.3 to 198.6±21.1 min (p=0.00155), average intraoperative blood loss from 930.0±198.6 to 385.1±84.7 ml (p=0.00004), reduce the incidence of complications in the early postoperative period, including postoperative pancreatitis from 19.0% to 0, anastomotic thrombosis from 28.6% to 5.7%, and mortality from 33.3% to 8.6% (p<0.05), increase the 8-week survival rate, thereby confirming the viability of the selective shunt operation splenorenal anastomosis, conditioned by the reserve for evolution built into it by the authors .

When performed in a center with technical expertise, the procedure provides long-term survival and reliable hemostasis, potentially obviating the need for liver transplantation in a significant number of appropriately selected patients with portal hypertension and relatively preserved liver function.

1. Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967;166(3):437–455. PMID: 6068492 https://doi.org/10.1097/00000658-196709000-00011

2. Warren WD, Fomon JJ, Zeppa R. Further evaluation of selective decompression of varices by distal splenorenal shunt. Ann Surg. 1969;169(5):652–660. PMID: 5779126. https://doi.org/10.1097/00000658-196905000-00002

3. Henderson JM, Millikan WJ, Warren WD. The distal splenorenal shunt: An update. World J. Surg. 1984;8(5):722–732. PMID: 6390991 https://doi.org/10.1007/BF01655769

4. Henderson JM, Gilmore GT, Hooks MA, Galloway JR, Dodson TF, Hood MM, et al. Selective shunt in the management of variceal bleeding in the era of liver transplantation. Ann Surg. 1992;216(3):248–254; discussion 254–255. PMID: 1417174 https://doi.org/10.1097/00000658-199209000-0000

5. Wright AS, Rikkers LF. Current management of portal hypertension. J Gastrointest Surg. 2005;9(7):992–1005. PMID: 16137597 https://doi.org/10.1016/j.gassur.2004.09.028

6. Livingstone AS, Koniaris LG, Perez EA, Alvarez N, Levi JU, Hutson DG. 507 Warren-Zeppa distal splenorenal shunts: a 34-year experience. Ann Surg. 2006;243(6):884–892; discussion 892–894. PMID: 16772792 https://doi.org/10.1097/01.sla.0000219681.08312.87

7. Elwood DR, Pomposelli JJ, Pomfret EA, Lewis WD, Jenkins RL. Distal Splenorenal Shunt Preferred Treatment for Recurrent Variceal Hemorrhage in the Patient with Well-Compensated Cirrhosis. Arch Surg. 2006;141(4):385–388. PMID: 16618897 https://doi.org/10.1001/archsurg.141.4.385

8. Gerunda GE, Faccioli AM. The Distal Splenorenal Shunt. In: Rossi P. (eds.) Portal Hypertension: Diagnostic Imaging and Imaging-Guided Therapy. Springer-Verlag Berlin Heidelberg; 2000. pp. 183–189. https://doi.org/10.1007/978-3-642-57116-9_16

9. McCulloch P, Cook JA, Altman DG, Heneghan C, Diener MK. IDEAL framework for surgical innovation 1: the idea and development stages. BMJ. 2013;346:f3012 https://doi.org/10.1136/bmj.f3012

10. Hutchison K, Rogers W, Eyers A, Lotz M. Getting Clearer About Surgical Innovation: A New Definition and a New Tool to Support Responsible Practice. Ann Surg. 2015;262(6):949–954. PMID: 25719812 https://doi.org/10.1097/SLA.0000000000001174

11. Anisimov AYu. Ocherki khirurgii portal’noy gipertenzii. Kazan: Meditsina Publ.; 2023. (In Russ.)

12. Rebrova OYu. Statisticheskiy analiz meditsinskikh dannykh. Primenenie paketa prikladnykh programm STATISTICA. Moscow: MediaSfera Publ.; 2006. (In Russ.)

13. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Amer Statist Assoc. 1958;53(282):457–481. https://doi.org/10.2307/2281868. JSTOR 2281868

14. Riddell AG, Bloor K, Hobbs KEF, Jacquet N. Clinical Problems: Elective Splenorenal Anastomosis. Br Med J. 1972;1(5802):731–732. PMID: 4536911 https://doi.org/10.1136/bmj.1.5802.731

15. Zatevakhin II, Shipovskiy VN, Tsitsiashvili MSh, Monakhov DV. Portal’naya gipertenziya. Diagnostika i lechenie. Moscow: Buki Vedi Publ.; 2015. (In Russ.)

16. Mattox KL, Whisennand HH, Espada R, Beall ACJr. Management of acute combined injuries to the aorta and inferior vena cava. Am J Surg. 1975;130(6):720–724. PMID: 1200288 https://doi.org/10.1016/0002-9610(75)90428-6

17. Mattox KL. Abdominal venous injuries. Surgery. 1982;91(5):497–501. PMID:7071738

18. Anisimov AY, Andreev AI, Ibragimov RA, Аnisimov AA, Kalimullin IA. Clinical and Anatomical Substantiation of Access to the Splenic and Left Renal Veins in the Operation of Distal Splenorenal Anastomosis. Russian Sklifosovsky Journal of Emergency Medical Care. 2021;10(2):293–302. (In Russ.) https://doi.org/10.23934/2223-9022-2021-10-2-293-302

19. Barsoum M.S., Rizk-Allah M.A., El-Said Khedr M., Khattar N. Y. A new posterior exposure of the splenic vein for an H-graft splenorenal shunt. BJS Society. 1982;69(7):376–379. PMID: 7104604 https://doi.org/10.1002/bjs.1800690706

20. Batignani G, Vizzutti F, Rega L, Zuckermann M, Fratini G, Pinzani M, et al. Small diameter H-graft porta-caval shunt performed at different stages of liver disease. Hepatobiliary Pancreat. Dis. Int. 2004;3(4):516–521. PMID: 15567736

21. Voskanyan SE, Shabalin MV, Voevodin AL, Artemyev AI, Kolyshev IYu, Naydenov EV, et al. H-shaped Partial Splenorenal Shunting with the Use of a Reinforced Graft Made of Porous Polytetrafluoroethylene. Angiology and Vascular Surgery. 2020;26(1):108–112. (In Russ.) https://doi.org/10.33529/ANGIO2020116

22. Anisimov AYu, Anisimov AA, Andreev AI, Ibragimov RA, Garaev AT. First Clinical Experience of Venous Reconstruction with Autologous Vascular Prosthesis from the Sickle Ligament of the Liver with Partial Portosystemic Bypass Surgery. Russian Sklifosovsky Journal Emergency Medical Care. 2021;10(3):589–597. https://doi.org/10.23934/2223-90222021-10-3-589-597