Letters to the Editors Laparoscopic robot-assisted distal splenorenal shunt

To the Editors: Surgical shunts are highly effective in the prevention of recurrence of bleeding from esophagogastric varices, but are associated with significant morbidity.1 Should the morbidity associated with surgical shunts be reduced, their role in the treatment of selected patients with portal hypertension and bleeding varices could be revisited. Robotic assistance improves surgical dexterity and permits laparoscopic operations that were previously considered impossible or exceedingly difficult.2,3 Two patients suffering from noncirrhotic portal fibrosis developed severe portal hypertension and bled from esophagogastric varices. Liver tests were practically normal in both patients, anticipating long-term preservation of good liver function. After multidisciplinary evaluation both patients were selected for laparoscopic robot-assisted distal splenorenal shunt (DSRS). Patients were placed supine with the legs parted. The table was placed 20° in the reverse Trendelenburg position and tilted to the right side. The tower of the da Vinci Surgical System SiHD (Intuitive Surgical, Inc, Sunnyvale, CA) was docked over the head of the patient, with 2 operating arms on the patient’s right side. A total of 5 ports were placed. The robotic surgeon operated from the da Vinci console, and the laparoscopic surgeon stood between the patient’s legs. The left renal vein was exposed first, and widely mobilized. The splenic vein was also exposed, but extensive mobilization was avoided because of the presence of severe portal hypertension. Splenorenal anastomosis was created end-to-side in both patients, according to the standard technique. With the DSRS open, all the veins connecting portal and esophagogastrosplenic compartments were ligated, eventually making the shunt selective. Surgery lasted 410 minutes in patient 1 and 385 minutes in patient 2. The intraoperative and postoperative courses were uneventful in both patients. Estimated blood loss was negligible in patient 1 and 150 mL in patient 2. No transfusion of blood or fresh frozen plasma was required. The amount of ascites was negligible in both patients, and drains were removed 48 hours after the operation. Both patients were discharged on postoperative day 5. At the longest follow-up of 20 and 14 months, patients are alive and well. Both DSRS are patent, esophagogastric varices are decompressed, and liver function is unchanged with respect to preoperative values. Noncirrhotic portal fibrosis is a disease of uncertain etiology characterized by periportal fibrosis causing portal hypertension at a presinusoidal level. Hepatic function is usually preserved long term, even though the liver slowly atrophies. Bleeding from esophagogastric varices is frequent and, although mortality is less than in

patients with cirrhosis, repeat hemorrhage may promote hepatic insufficiency. Therefore, prevention of recurrent bleeding is a priority.4 DSRS is a valid treatment option in patients diagnosed with noncirrhotic portal fibrosis because of its ability to selectively decompress the gastoesophageal compartment while maintaining hepatopetal flow.1 Disincentives to DSRS include the operative risk associated with major surgery and concerns on patient suitability for subsequent liver transplantation. We have shown the feasibility of laparoscopic robotassisted DSRS in patients with noncirrhotic portal fibrosis. Should this procedure be validated in larger series, it could expand the therapeutic armamentarium of hepatologists and liver surgeons. Ugo Boggi, MD, FEBS Mario Antonio Belluomini, MD Linda Barbarello, MD Fabio Caniglia, MD Division of General and Transplant Surgery University of Pisa, Pisa, Italy Maurizia Brunetto, MD Division of Hepatology University of Pisa, Pisa, Italy Gabriella Amorese, MD Division of Anesthesia and Intensive Care University of Pisa, Pisa, Italy E-mail: [email protected]

References 1. Boggi U, Signori S, Vistoli F, D’Imporzano S, Amorese G, Consani G, et al. Laparoscopic robot-assisted pancreas transplantation: first world experience. Transplantation 2012;93:201-6. 2. Boggi U, Signori S, De Lio N, Perrone VG, Vistoli F, Belluomini M, et al. Feasibility of robotic pancreaticoduodenectomy. Br J Surg 2013;100:917-25. 3. Sarin SK, Kumar A, Chawla YK, Baijal SS, Dhiman RK, Jafri W, et al. Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment. Hepatol Int 2007;1:398-413. 4. Livingstone AS, Koniaris LG, Perez EA, Alvarez N, Levi JU, Hutson DG. 507 Warren-Zeppa distal splenorenal shunts: a 34-year experience. Ann Surg 2006;243:884-92. http://dx.doi.org/10.1016/j.surg.2014.07.012

Biofeedback and electrostimulation: Last chance or first choice for obstructed defecation?

To the Editors: We read with interest the article published by Hicks et al1 on the efficacy of biofeedback (BFB) treatment in more than 90 patients with symptoms of rectocele and


Laparoscopic robot-assisted distal splenorenal shunt.

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