Unusual Case
Spontaneous intrahepatic portosystemic shunt managed by laparoscopic hepatic vein closure Jung-Nam Kwon, Yong Sun Jeon1, Soon-Gu Cho1, Keon-Young Lee2, Kee Chun Hong2 Department of Surgery, Division of Vascular Surgery, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, 1Departments of Radiology and 2Surgery, Inha University School of Medicine, Incheon, Republic of Korea Address for Correspondence: Prof. Keon-Young Lee, Department of Surgery, Inha University School of Medicine, 7-206, 3-Ga SinheungDong, Jung-Gu, Incheon, 400-711, Republic of Korea. E-mail: [email protected]
Abstract Intrahepatic portosystemic shunt (IPSS) is uncommon and usually follows trauma or iatrogenic injury, but spontaneous shunts may also occur, in patients without the evidence of chronic liver disease. Although interventional endovascular management of the shunts is the treatment of choice, a surgical approach can be used when the percutaneous approach fails. We report here a case of symptomatic spontaneous IPSS between the posteroinferior branch of right portal vein and the right inferior hepatic vein, which was successfully managed with laparoscopic closure of the hepatic vein. To the best of our knowledge, this is the first case report of laparoscopic management of spontaneous IPSS. Key words: Hepatic vein, intrahepatic, laparoscopy, portosystemic shunt, spontaneous
INTRODUCTION Spontaneous intrahepatic portosystemic shunt (IPSS) is uncommon, but when it occurs it can cause symptoms mimicking hepatic encephalopathy.[1,2] When symptoms are mild, the patients can be managed conservatively, with medication and dietary control.[2] However, in intractable cases, surgical removal of the IPSS or shunt disconnection should be considered.[3] In recent times, less invasive percutaneous interventional treatment has Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.141528
been widely adopted instead of open surgery.[4,5] In addition, a laparoscopic approach can be an attractive option in cases when interventional procedures are considered unlikely to be successful, although the reported experience with these procedures is extremely limited and confined to cases of extrahepatic portosystemic shunts.[6-8] We report here a case of symptomatic spontaneous IPSS successfully managed by laparoscopic closure of the right inferior hepatic vein.
CASE REPORT A 62-year-old woman, with a history of hypertension and diabetes, presented with recurrent episodes of the reduced level of consciousness and the altered mentality, which lasted for 2 months. A computed tomography (CT) and magnetic resonance imaging of the brain revealed no abnormalities. She was managed conservatively under the impression of metabolic encephalopathy, only to suffer from repeated attacks of encephalopathy. She denied any history of liver trauma, biopsy, disease, including cirrhosis, or abdominal surgery. On admission, her blood chemistry tests revealed elevated values of serum ammonia (146 μg/dL; normal
Spontaneous intrahepatic portosystemic shunt managed by laparoscopic hepatic vein closure Jung-Nam Kwon, Yong Sun Jeon1, Soon-Gu Cho1, Keon-Young Lee2, Kee Chun Hong2 Department of Surgery, Division of Vascular Surgery, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, 1Departments of Radiology and 2Surgery, Inha University School of Medicine, Incheon, Republic of Korea Address for Correspondence: Prof. Keon-Young Lee, Department of Surgery, Inha University School of Medicine, 7-206, 3-Ga SinheungDong, Jung-Gu, Incheon, 400-711, Republic of Korea. E-mail: [email protected]
Abstract Intrahepatic portosystemic shunt (IPSS) is uncommon and usually follows trauma or iatrogenic injury, but spontaneous shunts may also occur, in patients without the evidence of chronic liver disease. Although interventional endovascular management of the shunts is the treatment of choice, a surgical approach can be used when the percutaneous approach fails. We report here a case of symptomatic spontaneous IPSS between the posteroinferior branch of right portal vein and the right inferior hepatic vein, which was successfully managed with laparoscopic closure of the hepatic vein. To the best of our knowledge, this is the first case report of laparoscopic management of spontaneous IPSS. Key words: Hepatic vein, intrahepatic, laparoscopy, portosystemic shunt, spontaneous
INTRODUCTION Spontaneous intrahepatic portosystemic shunt (IPSS) is uncommon, but when it occurs it can cause symptoms mimicking hepatic encephalopathy.[1,2] When symptoms are mild, the patients can be managed conservatively, with medication and dietary control.[2] However, in intractable cases, surgical removal of the IPSS or shunt disconnection should be considered.[3] In recent times, less invasive percutaneous interventional treatment has Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.141528
been widely adopted instead of open surgery.[4,5] In addition, a laparoscopic approach can be an attractive option in cases when interventional procedures are considered unlikely to be successful, although the reported experience with these procedures is extremely limited and confined to cases of extrahepatic portosystemic shunts.[6-8] We report here a case of symptomatic spontaneous IPSS successfully managed by laparoscopic closure of the right inferior hepatic vein.
CASE REPORT A 62-year-old woman, with a history of hypertension and diabetes, presented with recurrent episodes of the reduced level of consciousness and the altered mentality, which lasted for 2 months. A computed tomography (CT) and magnetic resonance imaging of the brain revealed no abnormalities. She was managed conservatively under the impression of metabolic encephalopathy, only to suffer from repeated attacks of encephalopathy. She denied any history of liver trauma, biopsy, disease, including cirrhosis, or abdominal surgery. On admission, her blood chemistry tests revealed elevated values of serum ammonia (146 μg/dL; normal
