Surgical shunts usage has become less common over the years as advancements in endoscopic therapy, TIPS (transjugular intrahepatic portosystemic shunt) procedure, and liver transplantation has depressed its use.  The surgical shunts can still be an option in patients with refractory variceal bleeding with preserved liver function as well as in patients with portal hypertension. Shunts can be categorized as selective, partial, or total.  The purpose of a shunt is to allow for decompression of gastroesophageal varices and portal system, but the various categories differ in the maintenance of portal flow that is provided to the liver. 

The choice of the shunt is largely dependent on the surgeon's familiarity with the procedure, along with the patient's portal venous anatomy. Total portosystemic shunts are large-caliber connections between the systemic circulation and the portal circulation with either an end-to-side or a side-to-side portacaval shunt.  A mesocaval shunt can also be utilized with an interposed graft. Total portosystemic shunts, including portacaval shunt, prevent variceal bleeding and help to control ascites in an advantageous matter as the construction of such as easy and durable. 

 This Of note, portocaval shunts are discouraged in a patient who has potential for a liver transplant as scarring from dissection in the porta hepatis, and the dismantling of the shunt increases the complex nature of the overall transplant operation.  An association with portocaval shunts is the development of a sclerotic portal vein, which increases the difficulty to use for vascular anastomoses when performing a transplant.

 Indications

A primary indication for a portacaval shunt is in relation to upper gastrointestinal haemorrhage. The portacaval shunt is utilized to control massive upper gastrointestinal haemorrhage due to varices that cannot be trolled with endoscopic ablation and transjugular intrahepatic portosystemic shunt, TIPS, the procedure is not available. Oftentimes, a portacaval shunt is the preferred surgical option when a patient has undergone a prior splenectomy, splenic vein thrombosis, throughout post splenorenal shunt, ascites, the reversal of flow in the portal vein, or hepatic vein thrombosis. To select for patients for a direct portacaval shunt procedure, demonstration of a patent portal vein whether preoperatively or via laparotomy should be done.

Shunting procedures are also performed for portal hypertension. Indications for such include portal decompression in patients who have had portal hypertension that is complicated by haemorrhage due to oesophageal varices uncontrolled with sclerotherapy. Procedures cannot completely interrupt the portal venous flow provided to the liver such as an end-to-side portacaval shunt, while selective decompression of the portal system using a collateral shunt like a side-to-side portacaval shunt.

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Eliza Grace

Journal Manager

Journal of Surgical Pathology and Diagnosis