2013 - ISBTS 2013 Symposium
This page contains exclusive content for the member of the following sections: TTS, IXA, ITA. Log in to view.
Mini-Oral Communications 2
26.354 - Revisiting surgical options for diffuse porto-mesenteric thrombosis in the era of multi-visceral transplantation - a case for conservatism
Presenter: Kishore, Iyer, , United States
Authors: Kishore Iyer1, Riccardo Superina2, Lauren Schwartz1, Thomas Schiano1
Revisiting surgical options for diffuse porto-mesenteric thrombosis in the era of multi-visceral transplantation – a case for conservatism
Kishore Iyer1, Riccardo Superina2, Lauren Schwartz1, Thomas Schiano1
1Intestinal Transplant Program, Mount Sinai Medical Center, New York, NY, United States; 2Transplant Surgery, Children's Memorial Hospital, Chicago, IL, United States
Background:
Patients with diffuse porto-mesenteric venous thrombosis (PMT) are often not candidates for shunt surgery. Multi-visceral transplantation (MVT) is viewed as the only life-saving option despite normal liver and intestinal function. While results of MVT steadily improve, a 5-year survival of the order of 50%, a mortality rate on the waiting list that may be as high as 25% and the need for life-long immuno-suppression forces a search for alternatives whenever possible.
Goal:
To report our initial experience with a conservative, step-wise surgical approach in patients with diffuse PMT referred for MVT.
Method:
For the purpose of this report, PMT was defined as confluent thrombosis of portal, superior mesenteric, splenic and inferior mesenteric veins. We conducted a retrospective review of all patients with PMT referred to a single surgeon for MVT. Surgical options graded along a risk-continuum included traditional shunts followed by make-shift shunts, devascularization procedures (single-stage, modified Sugiura operation with splenectomy, gastric/esophageal devascularization and stapled esophageal transection) and finally isolated liver transplant or MVT.
Results:
Ten patients met criteria for inclusion in this study. There were 4 modified Sugiura procedures, 1 meso-atrial shunt using synthetic graft, 1 isolated liver transplant and 2 MVT. Two patients remain on medical treatment with close monitoring and no evidence of re-bleeding on close follow up.
All 4 patients who underwent modified Sugiura operations, remain alive and bleed-free with normal native liver and intestinal function at 8 years, 5.5 years, 4 years and 9 months following the procedure. The patient with the meso-atrial shunt who was evaluated and declined for MVT because of concerns for active tuberculosis, underwent a meso-atrial shunt with PTFE graft. She died 2.5 years after surgery from massive re-bleeding, following an overseas trip to her home country with loss of follow-up and discontinuation of anticoagulation.
One patient was successfully transplanted with an isolated liver (after a previous aborted liver transplant elsewhere) using a sizable collateral vein and an extension graft for portal venous inflow. He is alive with normal graft function and no re-bleed over 5 years from his transplant. One of the 2 patients who underwent MVT in this series died from sepsis after an uneventful abdominal exenteration with MVT while the remaining MVT patient is alive with excellent graft function 4 years following her MVT.
Conclusion: An individualized step-wise approach to the patient with complete splanchnic venous thrombosis allows avoidance of MVT in some patients. Non-transplant surgical options such as the Sugiura procedure may help combat the high mortality on the waiting list in certain regions while allowing excellent outocmes.
Important Disclaimer
By viewing the material on this site you understand and accept that:
- The opinions and statements expressed on this site reflect the views of the author or authors and do not necessarily reflect those of The Transplantation Society and/or its Sections.
- The hosting of material on The Transplantation Society site does not signify endorsement of this material by The Transplantation Society and/or its Sections.
- The material is solely for educational purposes for qualified health care professionals.
- The Transplantation Society and/or its Sections are not liable for any decision made or action taken based on the information contained in the material on this site.
- The information cannot be used as a substitute for professional care.
- The information does not represent a standard of care.
- No physician-patient relationship is being established.
Contact
Address
The Transplantation Society
International Headquarters
740 Notre-Dame Ouest
Suite 1245
Montréal, QC, H3C 3X6
Canada