PubMed ID: 17555599Background. Currently, portal hypertension is still big problem for the patients with serious liver diseases. Variceal bleeding is one of the most important complications of portal hypertension. In case of failure of endoscopic and combined medical treatments, surgical decompressive shunts are required. We emphasized an alternative splenorenal shunt procedure using adrenal vein as a conduit. Case presentation. A 26-year-old male suffered from recurrent variceal bleeding was considered for surgical therapy. Although we planned to perform a distal splenorenal shunt procedure, it was observed to be difficult. Therefore left adrenal vein was used as a conduit between left renal vein and splenic vein after splenic artery was ligated. He did well and was discharged from the hospital on the postoperative day 6. In the follow up period for nine months, endoscopic and ultrasonographic examinations were normal. Conclusion. We concluded that, in case of failure to perform distal splenorenal shunt due to technical problems, alternative porto-systemic shunt procedure using the adrenal vein as a vascular conduit can be safely employed. © 2007 Aydin et al; licensee BioMed Central Ltd

AK Pujahari

AS Wright

E Jovine

GE Moreno

J Rosch

K Inokuchi

L Leger

LF Rikkers

M Wolff

MA Hassab

MJ Orloff

Murat Kilic

Pinar Yazici

Unal Aydin

VM Kulkarni

WD Warren

BMC Surgery

English

PubMed

Springer - Publisher Connector

Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for spleno – renal shunt

Aydin U.

Yazici P.

Kilic M.

Ege University Institutional Repository

Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for spleno - Renal shunt

Abstract Background Currently, portal hypertension is still big problem for the patients with serious liver diseases. Variceal bleeding is one of the most important complications of portal hypertension. In case of failure of endoscopic and combined medical treatments, surgical decompressive shunts are required. We emphasized an alternative splenorenal shunt procedure using adrenal vein as a conduit. Case presentation A 26-year-old male suffered from recurrent variceal bleeding was considered for surgical therapy. Although we planned to perform a distal splenorenal shunt procedure, it was observed to be difficult. Therefore left adrenal vein was used as a conduit between left renal vein and splenic vein after splenic artery was ligated. He did well and was discharged from the hospital on the postoperative day 6. In the follow up period for nine months, endoscopic and ultrasonographic examinations were normal. Conclusion We concluded that, in case of failure to perform distal splenorenal shunt due to technical problems, alternative porto-systemic shunt procedure using the adrenal vein as a vascular conduit can be safely employed.</p

Yazici Pinar

Aydin Unal

Kilic Murat

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BioMed CentralBMC Surgery
ssOpen AcceCase report
Porto-systemic shunt using adrenal vein as a conduit; an alternative 
procedure for spleno – renal shunt
Unal Aydin, Pinar Yazici* and Murat Kilic
Address: Ege University School of Medicine, Department of Surgery, Izmir, Turkey
Email: Unal Aydin - drunalaydin@yahoo.com; Pinar Yazici* - drpinaryazici@gmail.com; Murat Kilic - murat.kilic@ege.edu.tr
* Corresponding author    
Abstract
Background: Currently, portal hypertension is still big problem for the patients with serious liver
diseases. Variceal bleeding is one of the most important complications of portal hypertension. In
case of failure of endoscopic and combined medical treatments, surgical decompressive shunts are
required. We emphasized an alternative splenorenal shunt procedure using adrenal vein as a
conduit.
Case presentation: A 26-year-old male suffered from recurrent variceal bleeding was considered
for surgical therapy. Although we planned to perform a distal splenorenal shunt procedure, it was
observed to be difficult. Therefore left adrenal vein was used as a conduit between left renal vein
and splenic vein after splenic artery was ligated. He did well and was discharged from the hospital
on the postoperative day 6. In the follow up period for nine months, endoscopic and
ultrasonographic examinations were normal.
Conclusion: We concluded that, in case of failure to perform distal splenorenal shunt due to
technical problems, alternative porto-systemic shunt procedure using the adrenal vein as a vascular
conduit can be safely employed.
Background
In spite of new therapeutic modalities such as pharmaco-
logic, endoscopic (sclerotherapy or band ligation), and
transjugular intrahepatic portosystemic shunt (TIPSS),
surgical decompressive shunts still have an important
place in the treatment of portal hypertension (PHT). One
of the serious complications of PHT is variceal bleeding
which can lead to death. Nevertheless, the success rate of
the endoscopic and combined medical treatments is
about 50%. A few surgical procedures such as Sugiura pro-
cedure for esophageal varices and Hassab-Paquet (A com-
plete gastroesophageal devascularization with
splenectomy) procedure for gastric varices have also been
performed for PHT [1,2]. In case of failure of those proce-
dures, surgical methods should be considered. Distal
spleno-renal shunt (DSRS) and/or portocaval shunt are
still regarded as the most popular surgical procedures in
these patients [3]. Type of the surgical shunt should be
chosen in the light of prognosis, anatomic variations and
surgical experience.
The technique of DSRS was first described by Warren in
1967. DSRS is originally end to side anastomosis between
splenic and left renal veins [4]. End to side anastomosis
may be unfavorable due to scar tissues or inappropriate
diameter between the two veins. A few cases had been
used adrenal vein for DSRS in the English literature in
Pubmed search [5-9]. In this case report, we emphasized a
Published: 7 June 2007
BMC Surgery 2007, 7:7 doi:10.1186/1471-2482-7-7
Received: 5 November 2006
Accepted: 7 June 2007
This article is available from: http://www.biomedcentral.com/1471-2482/7/7
© 2007 Aydin et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
BMC Surgery 2007, 7:7 http://www.biomedcentral.com/1471-2482/7/7successful alternative procedure for portosystemic shunt
procedures.
Case presentation
The patient was 26-year-old man with medical history of
recurrent upper gastrointestinal (GI) bleeding. There was
no alcohol abuse in patient history. Endoscopic band liga-
tion was performed for the first bleeding episode before
this admission. On physical examination, findings related
to chronic liver disease were not observed except
splenomegaly. Pulse rate of 120 with a blood pressure of
110/80 mm Hg was found. The patient was also examined
by endoscopically and inactive gastric varices and esopha-
geal variceal re-bleeding were diagnosed. Liver function
tests were normal and the other laboratory data were as
follows; hematocrit level: 30%, erythrocyte count: 3400 ×
103/mm3, white blood cell count (WBC): 1500/mm3 and
platelet count: 31000/mm3. Prothrombin time (PT) and
International normalization Ratio (INR) was mildly ele-
vated (18.4 sec. and 1.49, respectively). The patient had a
duplex ultrasound (DUS) examination of the abdomen
that revealed the findings of PHT, splenomegaly, normal
liver and no ascites. The diameter of portal vein was 20
mm with hepatopedal flow and left gastric vein (coronary
vein) was 10 mm with hepatofugal flow. The patient also
underwent Magnetic Resonance Portography (MRP) for
further evaluation of portal venous anatomy. This
revealed that; the diameter of splenic vein (SV) was 30
mm, left renal was 10 mm and there were retroperitoneal
spontaneous shunts. Liver biopsy was also performed and
pathological examination revealed nonspecific morpho-
logical changes  in small portal tracts, portal vein branches
were inconspicuous. Extrahepatic non-cirrhotic PHT was
diagnosed and DSRS was planned  to prevent esophageal
variceal re-bleeding.
Surgical technique
Laparotomy was performed through a left subcostal inci-
sion. No ascites was observed in the peritoneal cavity and
the liver appeared normal. Nevertheless, the enlarged
spleen was identified during the operation. Firstly, divi-
sion of the gastrocolic ligament was performed and
extended distally to obtain adequate view of the lower
border of the pancreas. The splenic vein, left renal vein
(LRV) and left adrenal vein were then visualized. Because
it was quite difficult to achieve complete separation of SV
from the pancreas due to surrounding dense, fibrotic tis-
sue, end-to-side splenorenal anastomosis was not
observed as an appropriate surgical technique. However,
an excessive enlargement (4.5 cm diameter) and angula-
tion of SV were noted. Since the portal pressure (PP) was
measured 34 mm Hg, splenic artery was ligated in order to
prevent likelihood massive bleeding during hard and
risky dissection (figure 1). After then, PP was measured 26
mmHg. Adrenal vein stump measuring 1.2 cm in diame-
ter was thought to be an alternative conduit between the
SV and LRV (figure 2). Side-to-end spleno-adrenal vein
anastomosis was performed in a running fashion with 6/
0 polypropylene (figure 3, 4). Left gastric vein was also
dissected and ligated. After shunt procedure was per-
formed, PP was measured 16 mm Hg.
Postoperative course was unremarkable. Ammonia level
after the shunt procedure was normal. The patient was dis-
charged from hospital on the postoperative day 6 and fol-
lowed up for nine months period by ambulatory. He had
no complaint and had normal daily activities. DUS for
shunt patency and upper GI endoscopic examinations for
esophageal varices which may need to be treated were
both normal.
Discussion
DSRS as a selective porto-systemic shunt procedure is
more effective and has less complication rate than both
endoscopic therapy and TIPSS for the treatment and pre-
vention of esophageal variceal bleeding due to both cir-
rhotic and non-cirrhotic PH [3,10]. It does not alter the
liver function in extrahepatic portal hypertension (EHPH)
[11]. EHPH is defined as extrahepatic hypertension of the
portal venous system in the absence of liver cirrhosis.
Although the endoscopic therapy, liver transplantation,
and TIPSS have resulted in improved results for patients
treated surgically for variceal bleeding, portosystemic
shunts remain important and effective options for
selected patients with bleeding secondary to portal hyper-
Enlarged splenic vein and ligation of splenic artery due to dif-ficult dissection.Figur  1
Enlarged splenic vein and ligation of splenic artery due to dif-
ficult dissection.Page 2 of 4
(page number not for citation purposes)
BMC Surgery 2007, 7:7 http://www.biomedcentral.com/1471-2482/7/7tension. Whether TIPSS is as efficacious as surgical shunts
is rather unproven. Its main drawback is still a high rate of
restenosis or occlusion requiring frequent reinterventions
[12].
Recurrent variceal bleeding which is one of the most
important complications of PHT isn't uncommon even
after medical and endoscopic management in EHPH [10].
Since repeated investigation of both endoscopic sclero-
therapy and band ligation are often required, the patients
recommended endoscopic treatment should be in a close
contact with medical center. Nevertheless, the patients liv-
ing in rural area as our case have a disharmony for this
kind of therapy as cited in the literature [13]. Thus, surgi-
cal shunt therapy, particularly DSRS, is a popular pallia-
tive method to decompress PHT. It is an effective shunt
procedure and does not usually need repeated interven-
tion.
The main principle in shunt surgery is to create a tension-
free and wide anostomosis with sufficient caliber, and
thrombus-free veins to prevent obstruction of the shunt.
Inappropriate anatomy (excessive fibrotic tissue, inade-
quate diameter of splenic vein e.g.) may cause decreased
shunt patency that we suggest alternative shunt procedure
avoiding hard maneuvers. Due to these anatomical chal-
lenges, prosthetic materials may be used or coronario-
caval shunt or inferior mesenteric-left renal vein shunt can
be employed in selected cases [3]. As we performed on
Completed portosystemic shunt using adrenal vein (AV) as a conduit between plenic vein (SV) a d left renal vein (LRV)Figure 4
Completed portosystemic shunt using adrenal vein (AV) as a 
conduit between splenic vein (SV) and left renal vein (LRV). 
(AS = anostomosis site)
Splenic vein is isolated and separated from pancreas and sur-rounding tissueFigure 2
Splenic vein is isolated and separated from pancreas and sur-
rounding tissue (P: Pancreas, SV: Splenic vein, AV: Adrenal 
vein, RV: Renal vein.).
Anastomosis between SV and enlarged adrenal vein stumpy.Figure 3
Anastomosis between SV and enlarged adrenal vein stumpy.Page 3 of 4
(page number not for citation purposes)
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this case, ligation of splenic artery leads to reduce diame-
ter of the enlarged splenic vein. Thus, dissection of the
vascular structures and managing of the end – to- side
anostomosis can be performed much easier.
Adrenal vein as a conduit is another option to create a
selective splenorenal shunt. DSRS via the adrenal vein has
been used as an alternative technique in a few cases [5-9].
Because of the excessive fibrotic tissue surrounding SV and
inadequate diameter between the SV and left RV to make
a safe anastomosis, we preferred adrenal vein as a conduit
to perform porto-systemic shunt. Because, Doppler exam-
ination of the shunt patency including flow pattern was
optimal even after nine months later, any other diagnostic
method for control was not needed. In case of suspected
flow pattern with DUS, angiography may be useful to fig-
ure out the problem.
As in this case, in case of failure of DSRS because of tech-
nical problems, end-to side porto-systemic shunt proce-
dure should be considered as an alternative method. For
this procedure, prosthetic grafts, cadaveric vascular con-
duits, and autologous vascular graft as in this patient can
be used. Since prosthetic grafts have a high risk for throm-
bosis causing occlusion and supplement the cadaveric
vascular graft is difficult, adrenal vein as an autologous
vascular graft should be kept in mind.
Conclusion
In conclusion, in case of failure to perform routine surgi-
cal shunt procedure to decompress PHT, adrenal vein may
be safely used as vascular conduit to create porto-systemic
shunt procedure, particularly end-to-side splenorenal
shunt in selected cases.
Competing interests
There is no commercial association that might pose a con-
flict of interest in connection with this submitted commu-
nication which entitled "Porto-systemic shunt using
adrenal vein as a conduit; An alternative procedure for
spleno – renal shunt"
There are no sources of funding of the work.
Authors' contributions
UA conceived of the study, and participated in its design
and coordination, and managed the operation.
PY has made substantial contributions to acquisition of
data and involved in drafting the manuscript.
MK participated in its design and gave the final approval
of the version to be published.
All authors read and approved the final manuscript.
Acknowledgements
Written consent was obtained from the patient for publication of this 
paper. We are very thankful to Ekrem Kaya for drawing the technical pic-
tures.
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Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for spleno – renal shunt

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