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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 212-214

Left adrenalectomy and proximal splenorenal shunt


Department of Surgery/Anaesthesiology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka

Date of Submission09-Aug-2020
Date of Decision14-Aug-2020
Date of Acceptance14-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Kuda B Galketiya
Department of Surgery/Anaesthesiology, Faculty of Medicine, University of Peradeniya, Peradeniya
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_27_20

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  Abstract 


Portal hypertension is managed using pharmacological, endoscopic and interventional radiology. Shunt surgery is used in selected patients with good long-term prognosis. We present a patient who underwent a left adrenalectomy and splenorenal shunt.

Keywords: Adrenalectomy, portal hypertension, splenorenal shunt, variceal bleeding


How to cite this article:
Dasanayake B, P Kanchana W G, Darmapala A D, Jayasinghaarachchi T, Pinto V, Galketiya KB. Left adrenalectomy and proximal splenorenal shunt. Kerala Surg J 2020;26:212-4

How to cite this URL:
Dasanayake B, P Kanchana W G, Darmapala A D, Jayasinghaarachchi T, Pinto V, Galketiya KB. Left adrenalectomy and proximal splenorenal shunt. Kerala Surg J [serial online] 2020 [cited 2020 Nov 30];26:212-4. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/212/300235




  Introduction Top


Portal hypertension is managed using pharmacological, endoscopic and interventional radiological methods. Shunt surgery provides better long-term solutions to portal hypertension, which need to be used in well-selected patients. In cirrhotic patients, shut surgery is recommended in child A and B patients when trans-jugular intrahepatic porto-systemic shunt (TIPSS) is not feasible.[1] Several studies have shown better long-term prognosis in non-cirrhotic portal hypertensive patients when compared to cirrhotic patients.[2] We present a patient who was diagnosed with non-cirrhotic portal hypertension and a left side adrenal incidentaloma, who underwent a splenorenal shunt and left adrenalectomy.


  Case Report Top


A 53-year-old female was evaluated for upper gastrointestinal bleeding. Endoscopy showed Grade II lower oesophageal varices, which were banded. The patient did not have any family history or any risk factors for liver disease, nor she had any stigmata of liver disease. Her liver functions were normal. Contrast-enhanced computed tomography of the abdomen showed no features of Chronic liver cell disease. Portal vein varices were seen with mild splenomegaly. A left side adrenal mass with suspicious features was also noted [Figure 1] and [Figure 2].
Figure 1,2: Contrast-enhanced computed tomography abdomen showing the left adrenal mass

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Figure 2: Exposure of left adrenal tumour

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Portal venous duplex did not show any evidence for portal vein thrombosis and there was no reversal of the flow. The liver biopsy did not show any features of chronic liver cell disease, liver fibrosis or active hepatitis. As the cause of portal hypertension was not evident with the investigations, the diagnosis of idiopathic non-cirrhotic portal hypertension was made. The adrenal tumour was non-functioning. Following multidisciplinary discussion, left adrenalectomy and the proximal splenorenal shunt was planned. Surgery was performed in the supine position using a left side subcostal incision. Splenectomy was done. Left side adrenalectomy was completed. The adrenal vein was then followed to expose the left renal vein [Figure 3] and [Figure 4].
Figure 3: Left adrenal vein followed to expose the left renal vein

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Figure 4: Tension-free end-to-side anastomosis between splenic vein and left renal vein

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Control of the left renal vein was achieved. The splenic vein was mobilised by ligating its pancreatic branches. Adequate length of the splenic vein mobilised to achieve a tension-free anastomosis [Figure 5].

End-to-side splenorenal anastomosis was done to create a proximal splenorenal shunt [Figure 4].

The patient had a smooth post-operative recovery and was discharged home on day 5. Histology of the adrenal tumour showed a benign adrenal adenoma.


  Discussion Top


Variceal bleeding is a complication of increased portal venous pressure, which could be due to either increased portal vascular resistance or increased portal inflow.[3] Narrowing or obstruction of the portal venous system leads to portal hypertension. Another major mechanism is the increase in splanchnic blood flow due to imbalance in vasoactive mediators.[4] The main strategy in the management of portal hypertension is to offer early identification, aetiological evaluation, primary prophylaxis, secondary prophylaxis once bleeding occurred and definitive treatment in the form of liver transplantation in cirrhotic patients. Rebleeding rates of up to 80% have been demonstrated in the absence of secondary prophylaxis.[5] Primary prophylaxis and secondary prophylaxis are offered in the form of pharmacological, endoscopic, interventional radiological and surgical techniques.[1] Surgical shunt procedures have shown to provide better long-term results in non-cirrhotic portal hypertensive patients.[6]

Surgical techniques include oesophagogastric devascularisation, non-selective portosystemic shunts and selective portosystemic shunts. Non-selective portosystemic shunts include side-to-side portocaval shunts, proximal splenorenal shunt, side-to-side splenorenal shunt without splenectomy. Selective portosystemic shunts include distal splenorenal shunt, Sarfeh's small diameter interposition portocaval shunt and Inokuchi's coronary caval shunt.[7]

Non-selective portosystemic shunts connect all the portal blood flow with the systemic venous circulation, while selective shunts only divert part of the portal blood flow to the systemic circulation; thus non-selective shunts can theoretically lead to significant portal haemodynamic effects.[7],[8] We decided to perform a proximal splenorenal shunt after performing a splenectomy due to technical easiness. She did not show any features of hepatic encephalopathy post-operatively despite performing a non-selective portosystemic shunt.


  Conclusion Top


Proximal splenorenal shunt procedure was successfully performed in the patient presented to provide long-term relief from variceal bleeding. The incidentally found left adrenal tumour was too removed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015;64:1680-704.  Back to cited text no. 1
    
2.
Schouten JN, Verheij J, Seijo S. Idiopathic non-cirrhotic portal hypertension: A review. Orphanet J Rare Dis 2015;10:67.  Back to cited text no. 2
    
3.
Maruyama H, Yokosuka O. Pathophysiology of portal hypertension and esophageal varices. Int J Hepatol Hindawi 2012;2012:e895787. Available from: https://www.hindawi.com/journals/ijh/2012/895787/. [Last accessed on 2020 Jul 12].  Back to cited text no. 3
    
4.
Iwakiri Y. Pathophysiology of portal hypertension. Clin Liver Dis 2014;18:281-91.  Back to cited text no. 4
    
5.
Mallet M, Rudler M, Thabut D. Variceal bleeding in cirrhotic patients. Gastroenterol Rep (Oxf) 2017;5:185-92.  Back to cited text no. 5
    
6.
Marti J, Gunasekaran G, Iyer K, Schwartz M. Surgical management of noncirrhotic portal hypertension. Clin Liver Dis (Hoboken) 2015;5:112-5.  Back to cited text no. 6
    
7.
Pal S. Current role of surgery in portal hypertension. Indian J Surg 2012;74:55-66.  Back to cited text no. 7
    
8.
Orozco H, Mercado MA. The evolution of portal hypertension surgery: Lessons from 1000 operations and 50 Years' experience. Arch Surg 2000;135:1389-93.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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