From the Guidelines
Splenorenal shunts are primarily indicated for the management of portal hypertension and its complications, particularly variceal bleeding that has failed endoscopic and pharmacological therapy, with distal splenorenal shunts being preferred due to their selective decompression of gastroesophageal varices while maintaining portal perfusion to the liver, as shown in a prospective trial by Henderson et al 1. The main indications for splenorenal shunts include:
- Recurrent or refractory variceal hemorrhage
- Symptomatic hypersplenism
- Refractory ascites
- Hepatic hydrothorax in patients with preserved liver function (Child-Pugh class A or B) These shunts work by redirecting blood flow from the splenic vein to the left renal vein, reducing portal pressure while preserving hepatopetal flow. With the advancement of transjugular intrahepatic portosystemic shunts (TIPS), surgical shunts are now typically reserved for TIPS failure or contraindications, or in resource-limited settings where TIPS is unavailable, as noted in the 2009 update of the American Association for the Study of Liver Diseases (AASLD) Practice Guideline 1. Patients should have adequate renal function and anatomical suitability for the procedure, and management of bleeding gastric varices is best done through a collaborative, multidisciplinary approach including hepatologists, interventional radiologists, and interventional endoscopists, as recommended by the AGA clinical practice update on management of bleeding gastric varices 1. In cases where TIPS is utilized for management of gastric variceal bleeding, endovascular sclerosis and/or direct embolization of gastric varices should also be performed when feasible, and when a gastrorenal shunt is present, local expertise is available, and when severe comorbid complications of portal hypertension are absent, balloon-occluded retrograde transvenous obliteration (BRTO) is the optimal endovascular therapy for management of gastric variceal bleeding 1.
From the Research
Indications for Splenorenal Shunt
The indications for splenorenal shunt can be summarized as follows:
- Refractory variceal bleeding due to portal hypertension 2, 3, 4, 5
- Portal hypertension caused by hepatosplenic schistosomiasis 2
- Extrahepatic portal vein thrombosis (PVT) 4
- Sinistral portal hypertension associated with splenic vein ligation during pancreaticoduodenectomy with venous resection 6
- Failure of conservative management for portal hypertension 2
Patient Selection
Patient selection for splenorenal shunt is crucial, and the following factors should be considered:
- Child-Pugh class A and B cirrhosis 5
- Presence of contraindications for TIPS (transjugular intrahepatic portosystemic shunt) 2
- Technical feasibility of the shunt procedure 2
- Presence of complications of portal hypertension, such as variceal bleeding, ascites, and splenomegaly 4
Outcomes
The outcomes of splenorenal shunt can be summarized as follows: