Clinical Case Report Medicine ®

OPEN

Laparoscopic distal splenoadrenal shunt for the

treatment of portal hypertension in children with
congenital hepatic fibrosis
A case report
∗
Jin-Shan Zhang, MMeda, Wei Cheng, PhD, MBBS, FRCSb,c, Long Li, MD, PhDa,

Abstract
Background: The distal splenorenal shunt is an effective procedure for the treatment of portal hypertension in children. However,
there has been no report about laparoscopic distal splenorenal shunt in the treatment of portal hypertension in children.
Methods: From December 2015 to August 2016, 4 children with upper gastrointestinal bleeding underwent laparoscopic distal
splenoadrenal shunt. Portal hypertension and splenomegaly were demonstrated on the preoperative computed tomography (CT)
and sonography. The distal splenic vein was mobilized and anastomosed to the left adrenal vein laparoscopically. All patients were
followed-up postoperatively.
Results: The laparoscopic distal splenoadrenal shunt was successfully performed in all patients. The liver fibrosis was diagnosed by
postoperative liver pathology. The operative time ranged from 180 to 360 minutes. The blood loss was minimal. The length of hospital
stay was 6 to 13 days. The duration of following-up was 1 to 9 months (median: 3 months). The portal pressure and splenic size were
decreased postoperatively. The complete blood count normalized and the biochemistry tests were within normal range after surgery.
Postoperative ultrasound and CT confirmed shunt patency and satisfactory flow in the splenoadrenal shunt in all patients. No patient
developed recurrence of variceal bleeding.
Conclusions: The laparoscopic splenoadrenal shunt is a feasible treatment of portal hypertension in children.
Abbreviations: CT = computed tomography, EVL = endoscopic variceal ligation, OPSI = overwhelming postsplenectomy
infection, UGI = upper gastrointestinal imaging.
Keywords: children, laparoscopy, portal hypertension, Warren shunt

1. Introduction are only used to treat the hypersplenism caused by portal

hypertension, and laparoscopic esophagogastric devasculariza-
With the improvements of laparoscopic surgery, the laparoscopic
tion is used to control the variceal bleeding. Splenectomy can
techniques were used for the treatment of portal hypertension in
effectively relieve the hypersplenism, but it is associated with
children, such as laparoscopic splenectomy with esophagogastric
perioperative and postoperative complications.[4] The long-term
devascularization and laparoscopic splenic vessel ligation.[1–3]
result of laparoscopic splenic vessel ligation is uncertain. The
However, laparoscopic splenectomy and splenic vessel ligation
distal splenorenal shunt (Warren shunt) is an effective procedure
for the treatment of portal hypertension in children[5,6]; it
Editor: Johannes Mayr.
preserves the spleen, avoids the overwhelming postsplenectomy
Funding: This study has received funding from Capital Special Health
sepsis, reduces the splenic vein pressure and keeps the hepatopetal
Development Research (Code: 2016-4-2104), Natural Science Foundation of
Beijing (Code: 7164242), and Beijing Municipal Administration of Hospitals blood flow of portal vein. Long-term patency rates greater than
Incubating Program (Code: PX2016003). Special Research Grant for Non-profit 90% have been reported. However, there has been no report
Public Service (Code: 201402007). about laparoscopic distal splenorenal shunt in the treatment of
The authors have no conflicts of interest to disclose. portal hypertension in children. In this study, we reported our
a
Department of General Surgery, Capital Institute of Pediatrics, b Department of experience in laparoscopic distal splenoadrenal shunt for the
Pediatric Surgery, Beijing United Family Hospital, Beijing, P.R. China, treatment of portal hypertension.
c
Department of Pediatric, Monash Children’s, Monash University, Victoria,
Australia.
∗
Correspondence: Long Li, Department of Pediatric Surgery, Capital Institute of
2. Patients and methods
Pediatrics, No. 2 Yabaolu Rd., Beijing 100020, China Between December 2015 and August 2016, 4 children (age
(e-mail: [email protected]).
2.7–7.8 years, 3 boys and 1 girl) with hematemesis and melaena
Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc.
were admitted to our hospital. The abdominal sonography,
This is an open access article distributed under the Creative Commons
Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial computed tomography (CT), blood routine, and biochemistry
and non-commercial, as long as it is passed along unchanged and in whole, with were performed preoperatively. The abdominal ultrasound and
credit to the author. CT showed portal hypertension, liver fibrosis, and splenomegaly.
Medicine (2017) 96:3(e5843) The liver function was normal.
Received: 4 October 2016 / Received in final form: 2 December 2016 / Surgical indication included absence of previous surgical
Accepted: 15 December 2016 history; portal hypertension caused by liver cirrhosis and fibrosis,
http://dx.doi.org/10.1097/MD.0000000000005843 or extrahepatic portal hypertension which was unsuitable for

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Rex shunt; the diameter of adrenal vein was greater than 5 mm; discontinuously. Under laparoscope, the anastomotic stoma was
no contraindication of laparoscopic surgery. amplified, which helped to expose the vascular end and perform
the vascular anastomosis. After anastomosis, the vascular clamps
of splenic and renal vein were removed, and the vascular clamp of
2.1. Surgical procedure
splenic artery was removed after confirming that there was no
The patients were placed in supine position. After induction of anastomotic bleeding. The patency of the bypass vein was
general anesthesia, a transumbilical 2 to 3 cm superficial checked and the superior mesenteric vein pressure was measured.
longitudinal incision was made. The small intestine was All the children were followed up at postoperative 1, 3, 6, 12
exteriorized through the umbilical incision, and a catheter was months and every 6 months thereafter. During the follow-up,
inserted into a branch of superior mesenteric vein to measure the abdominal ultrasound, CT, upper gastrointestinal imaging
portal pressure and perform the mesenteric angiography. The (UGI), and laboratory tests (routine blood test, liver function,
selective mesenteric angiography was used to identify the coagulation function, and blood ammonia) were conducted at
morphology of portal venous system. A 13-mm port was placed each visit. The spleen size and patency of bypass vein were
in the umbilical incision and other three 5-mm ports were placed assessed with ultrasound and CT.
as shown in Fig. 1. The pancreas and splenic hilum were exposed
through dissecting the gastrocolic and splenogastric ligament and
suspension of posterior gastric wall. The splenic artery was 2.2. Ethical statement
dissected along the upper border of pancreas, and was clipped All procedures performed in studies involving human partic-
using a vascular clamp (Fig. 2). The splenic vein was dissected off ipants were in accordance with the ethical standards of the
the posterior and inferior borders of pancreas, and was ligated institutional research committee and with the 1964 Helsinki
using a hem-o-lok at the junction of splenic and inferior declaration and its later amendments or comparable ethical
mesenteric vein (Fig. 3A). The proximal end of splenic vein was standards. All infants’ guardians signed their informed consent
clipped using a vascular clamp (Fig. 3B). The left renal and before their inclusion in the study.
adrenal veins were exposed by dissecting the descending colon
which was retracted to the right by the assistant (Fig. 4A). The
adrenal vein was clipped at the confluence of adrenal and renal 3. Results
vein (Fig. 4B). The adrenal vein was ligated and divided 1 cm from
the renal vein, and the lumen of splenic and adrenal vein was The laparoscopic distal splenoadrenal shunt was successfully
irrigated by heparinized saline through a percutaneous tube to performed in all 4 patients. No conversion was required. The liver
avoid thrombosis (Fig. 5). The adrenal vein was anastomosed fibrosis was diagnosed by postoperative liver pathology. The
end-to-end with the distal end of the splenic vein (Fig. 6). The operative time was between 180 and 360 minutes (mean: 270
vascular anastomosis was performed using 7/0 Prolene suture minutes). The blood loss was minimal without necessity for blood
transfusion. The postoperative hospital stay was 6 to 13 days
(mean: 8.5 days). The anastomotic diameter was 0.5 to 1 cm
(mean: 0.73 cm). The duration of follow-up was 1 to 9 months
(mean: 3.8 months). The levels of red blood cell, platelet and
white blood cell returned to normal postoperatively. The liver
function was normal after the surgeries (the average of alanine
aminotransferase: preoperative: 22.3 U/L, postoperative: 28.5 U/
L). The portal pressure and size of spleen was reduced after
surgery (Table 1). There was no rebleeding. The patency of
bypass vein was shown by postoperative sonography and CT
(Fig. 7).

4. Discussion
Liver fibrosis is the common endpoint of liver disease, which is
not a rare disease in children. Currently, there is no effective
therapy for liver fibrosis. Liver fibrosis is one of the main causes of
intrahepatic portal hypertension in children.[7] Variceal hemor-
rhage caused by portal hypertension is an important complica-
tion of liver fibrosis in children. Management of variceal
hemorrhage secondary to portal hypertension includes medical
interventions, endoscopic variceal ligation (EVL) and sclerother-
apy, devascularization, and shunting procedures. About 15% of
patients suffered from recurrence of bleeding after medical
therapy. The varices disappeared in only 11.8% children
undergoing the sclerotherapy.[8] Rebleeding rate of 27.8% and
esophageal varies recurrence rate of 44.4% have been reported in
children undergoing EVL.[9] Splenectomy can effectively relieve
Figure 1. The position of the trocars. Trocars A and B were used by the the hypersplenism. However, children undergoing splenectomy
surgeon, trocar C was used for the camera, and trocar D was used by the
assistant.
are susceptible to overwhelming postsplenectomy infection
(OPSI) and portal venous thrombosis.[10] The incidence of

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Figure 2. The splenic artery was dissected (A), and the splenic artery was clipped using a clamp (B).

Figure 3. The distal end of splenic vein was ligated using a hem-o-lok (A); the proximal end of the splenic vein was clipped using a clamp (B).

Figure 4. The dissection of renal and adrenal vein (A), and the adrenal vein was clipped using a clamp (B).

Figure 5. The adrenal vein was cut off (A), and the lumen of splenic vein was irrigated by heparinized saline (B).

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Figure 6. The distal end of splenic vein was anastomosed with the adrenal vein (A: before surgery; B: after surgery).

Table 1
The pre- and postoperative parameters of the patients.
Splenic size (L  W), cm RBC, 1012/L PLT, 109/L HGB, g/L Portal pressure, cmH2O
Patients Age, Follow-up,
no. y mo Pre Post Pre Post Pre Post Pre Post Pre Post
I 7.8 9 10.3  4.4 9.3  3.4 2.9 4.75 156 138 68 105 27 24
II 5.8 3 13.1  2.9 12  2.8 2.9 4.0 154 164 88 116 34 26
III 2.7 1 13.7  4.4 12.3  4 3.16 4.5 124 132 80 112 29 22
IV 7 2 14  4.9 13  3.2 4.38 4.1 122 108 91 126 31 23
L = length, mo = month, post = postoperative, pre = preoperative, W = width, y = year.

portal vein thrombosis varied from 1.6% to 15% after laparoscopic distal splenoadrenal shunt was used to the
splenectomy.[11,12] In addition, Ikeda et al[13] observed a higher treatment of portal hypertension in children, it has the following
incidence of portal vein thrombosis after laparoscopy than after advantages: clear visual field, reduced tissue trauma, decreased
laparotomy, which might be related with the effects of pneumo- postoperative pain, better cosmetic results, and accelerated
peritoneum and the laparoscopic stapling technique for vessels. patient recovery. However, the operative time of laparoscopic
The shunting procedures include selective and nonselective shunt. surgery is longer than open surgery; this might be related with the
However, the nonselective shunt (such as mesocaval shunt and lack of experience and had a learning curve as other laparoscopic
portaocaval shunt) diverts a significant amount of portal venous procedures. In this study, the portal pressure and splenic size
blood from its normal liver metabolism, predisposing the was reduced after surgery, which suggested this procedure is a
development of hepatic encephalopathy. Fifty percent rebleeding feasible and effective treatment for portal hypertension. Howev-
rate and 53% mortality were reported in children with er, this study is a preliminary report about laparoscopic
intrahepatic portal hypertension undergoing nonselective splenoadrenal shunt. Further studies with a larger sample size
shunt.[14] Warren shunt is a selective shunt, which reduces the
splenic pressure and alleviates the hypersplenism through the
distal splenorenal bypass. The venous collaterals around the
stomach and lower esophagus are decompressed, which reduces
the risk of hemorrhage.[15] In addition, the Warren shunt
preserves the hepatopetal blood flow, which diminishes the risks
of postoperative encephalopathy and liver failure. Long-term
patency rates >90% have been reported.
Laparoscopic splenic vessel ligation and splenectomy
were used to treat hypersplenism secondary to portal
hypertension.[1–3] Laparoscopic splenectomy was first reported
in 1991. The advantages of the laparoscopic approach over open
surgery include a shorter hospital stay, decreased blood loss,
faster recovery, and better cosmesis.[16] However, a higher
incidence of portal vein thrombosis after laparoscopy than after
laparotomy has been reported.[13] Laparoscopic splenic vessels
ligation is a feasible treatment for hypersplenism, which has the
advantages of laparoscopic surgery.[2] However, this report has a
short-term follow-up and fewer cases, and the long-term outcome
need to be further studied. Splenectomy and splenic vessel
Figure 7. Contrast-enhanced computed tomography confirmed patency of
ligation might reduce the portal pressure, which were mainly used the bypass (6 months postoperative).
to treat the hypersplenism and splenomegaly. In this study,

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and longer follow-up duration are needed to improve the surgical hypertension in children. J Laparoendosc Adv Surg Tech A 2009;19:
545–50.
technique and verify our initial results.
[4] McCormick PA, Murphy KM. Splenomegaly, hypersplenism and
The successful operation was based on the operators’ extensive coagulation abnormalities in liver disease. Baillieres Best Pract Res Clin
experience for laparoscopic surgery and the technique of vascular Gastroenterol 2000;14:1009–31.
anastomosis. To date, the laparoscopic vascular anastomosis has [5] Maksoud JG, Miles S, Pinto VC. Distal splenorenal shunt in children.
been rarely reported in children. The challenges of laparoscopic J Pediatr Surg 1978;13:335–40.
[6] Botha JF, Campos BD, Grant WJ, et al. Portosystemic shunts in children:
splenoadrenal shunt include: Owing to the retroperitoneal a 15-years experience. J Am Coll Surg 2004;199:179–85.
location of splenic and renal vein, the exposure of the surgical [7] Grimaldi C, de Ville de Goyet J, Nobili V. Portal hypertension in
field is difficult. We have reported the suspension method and children. Clin Res Hepatol Gastroenterol 2012;36:260–1.
dissection of pancreas in our previous literature.[17,18] In this [8] Bandika VL, Goddard EA, De Lacey RD, et al. Endoscopic injection
sclerotherapy for bleeding varices in children with intrahepatic and
study, stomach- and pancreas-suspension methods were used to
extrahepatic portal venous obstruction: benefit of injection tract
expose the surgical field. The port C (the camera port) forms a embolization. S Afr Med J 2012;102:884–7.
triangle with the port A and B, which facilitates triangulation [9] Dos Santos JM, Ferreira AR, Fagundes ED, et al. Endoscopic and
(Fig. 1). In this study, the usage of the vascular clamps and right pharmacological secondary prophylaxis in children and adolescents with
angle clamp make it possible to do the laparoscopic vascular esophageal varices. J Pediatr Gastroenterol Nutr 2013;56:93–8.
[10] Buzelé R, Barbier L, Sauvanet A, et al. Medical complications following
anastomosis. In this study, the splenic vein was anastomosed with splenectomy. J Visc Surg 2016;153:277–86.
the adrenal vein, which facilitates the blockage of renal vein and [11] Vant Riet M, Burger JW, Van Muiswinkel JM, et al. Diagnosis and
avoids the dissection of renal vein. Previous studies have treatment of portal vein thrombosis following splenectomy. Br J Surg
suggested that the splenoadrenal shunt is an effective treatment 2008;87:1229–33.
[12] He S, He F. Predictive model of portal venous system thrombosis in
for children with portal hypertension.[19,20] The splenic artery
cirrhotic portal hypertensive patients after splenectomy. Int J Clin Exp
was clipped before dissection of the splenic vein, and the clamp of Med 2015;8:4236–42.
the splenic artery was removed after vascular anastomosis, which [13] Ikeda M, Sekimoto M, Takiguchi S, et al. High incidence of thrombosis
reduced the bleeding during the operation. of the portal venous system after laparoscopic splenectomy: a prospective
study with contrast-enhanced CT scan. Ann Surg 2005;241:208–16.
[14] Fonkalsrud EW. Surgical management of portal hypertension in
5. Conclusion childhood. Arch Surg 1980;115:1042–5.
[15] Hemann RE, Henderson JM, Vogt DP, et al. Fifty years of surgery for
In conclusion, our report suggests that laparoscopic distal portal hypertension at the Cleveland Clinic Foundation: lessons and
splenoadrenal shunt for the treatment of portal hypertension in prospects. Ann Surg 1995;221:459–66.
children is feasible and safe in experienced centers. [16] Mattioli G, Pini Prato A, Cheli M, et al. Italian multicentric survey on
laparoscopic spleen surgery in the pediatric population. Surg Endosc
2007;21:527–31.
References [17] Zhang JS, Li L, Diao M, et al. Single-incision laparoscopic excision of
[1] Yu H, Guo S, Wang L, et al. Laparoscopic splenectomy and pancreatic tumor in children. J Pediatr Surg 2015;50:882–5.
esophagogastric devascularization for liver cirrhosis and portal hyper- [18] Zhang JS, Li L, Cheng W. Single incision laparoscopic 90%
tension is a safe, effective, and minimally invasive operation. J pancreatectomy for the treatment of persistent hyperinsulinemic
Laparoendosc Adv Surg Tech A 2016;26:524–30. hypoglycemia of infancy. Pediatr Surg Int 2016;32:1003–7.
[2] Zhang JS, Li L, Li Q, et al. Laparoscopic splenic vessels ligation as a [19] Mazariegos GV, Reyes J. A technique for distal splenoadrenal shunting in
treatment of hypersplenism and thrombocytopenia in children. Surg pediatric portal hypertension. J Am Coll Surg 1998;187:634–6.
Endosc 2016;30:3916–21. [20] Gu S, Chang S, Chu J, et al. Spleno-adrenal shunt: a novel alternative for
[3] Li SL, Li YC, Xu WL, et al. Laparoscopic splenectomy and portosystemic decompression in children with portal vein cavernous
periesophagogastric devascularization with endoligature for portal transformation. J Pediatr Surg 2012;47:2189–93.