Ann Hepatobiliary Pancreat Surg.  2022 May;26(2):204-209. 10.14701/ahbps.21-146.

Successful use of a mesocaval shunt to treat refractory ascites in a chronic pancreatitis induced portal vein thrombosis

• Dutta S
• Pal B
• Ram D
• Shyamprasad SK
• Nelamangala Ramakrishnaiah VP

• KMID: 2530101
• DOI: http://doi.org/10.14701/ahbps.21-146

Abstract

The state of intense peripancreatic inf lammation in chronic pancreatitis can give rise to various vascular complications such as venous thrombosis and arterial pseudoaneurysms. Due to its intimate location with the pancreas, spleno-mesenteric-portal axis suffers the greatest blunt of thrombotic complications. Treatment modalities for such cases of chronic portal vein thrombosis have always been controversial and challenging. Medical management with anticoagulants is both risky and unsatisfactory due to presence of varices, hypersplenism, and persistence of the inf lammatory pathology. Although endovascular techniques have been tried in various case reports, there are definite anatomical challenges in cases of long segment porto-mesenteric thrombosis with massive ascites. Surgical shunts have been historically described for cirrhotic and non-cirrhotic portal hypertensive patients. However, its use in patients with refractory ascites due to chronic pancreatitis induced portal vein thrombosis has not been reported in the medical literature. Here, we present a case of an extensive portal vein thrombosis with massive refractory ascites in a patient with alcohol-induced chronic pancreatitis successfully treated with a surgical mesocaval shunt using an interposition small diameter graft.

Keyword

Hypertension; portal; Ascites; Portasystemic shunt; surgical; Pancreatitis; chronic

Figure

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  Fig. 1 Sections from preoperative contrast-enhanced computed tomography. (A) Axial section showing a pseudocyst along the caudate lobe of liver (white arrow). (B) Axial section showing thrombosed portal vein with periportal collaterals (black arrow). (C, D) Axial sections showing chronic calcific pancreatitis changes in the entire pancreas (yellow arrows). (E, F) Axial and coronal sections showing massive ascites.

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  Fig. 2 Schematic diagram showing the surgical plan to decompress the hypertensive SMV with a mesocaval shunt. SMV, superior mesenteric vein; IVC, inferior vena cava.

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  Fig. 3 Intraoperative photos. (A) After complete dissection of the superior mesenteric vein (SMV). (B) Infrarenal inferior vena cava (IVC) dissected from the retroperitoneum. (C) After completion of IVC-graft anastomosis. (D) After completion of anastomoses on both sides of graft with IVC and SMV. White arrows indicate SMV; black arrows, IVC.

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  Fig. 4 Contrast-enhanced computed tomography images (portal phase) on postoperative day 14. (A) Axial section showing one end of the graft anastomosing with inferior vena cava (arrow). (B) Axial section showing the other end of the graft anastomosing with superior mesenteric vein (arrow). Both images represent patent shunt with proper contrast opacification along its entire length. (C) Coronal section representing decreased ascites in the postoperative period.

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  Fig. 5 (A) Contrast-enhanced computed tomography (CECT) taken on post-operative day 90, showing complete resolution of ascites. (B) Three-dimensional volume reconstruction of the same CECT showing a patent mesocaval shunt. SMV, superior mesenteric vein; IVC, inferior vena cava.

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  Fig. 6 Three-dimensional surface reconstructions of computed tomography scans taken preoperatively (A) and on postoperative day 90 (B) showing complete resolution of the abdominal distension.

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