Preeminence of Lesser Splanchnic BloodFlow in Selected Patients WithGeneralized Portal Hypertension

摘要

Although restricted transhepatic portal flow is necessary for development of generalized portalhypertension (GPH), increased splanchnic arterial inflow also contributes to GPH and its clinicalsequelae. In this context, we describe 7 male and 6 female patients (mean age 48 years) in whom thelesser splanchnic (gastrosplenic) system played a key role in the signs and symptoms of GPH. These 13patients (9 with hepatic cirrhosis, 3 with primary myeloproliferative disorder, and 1 with extrahepaticportal block) shared common features of massive splenomegaly, huge splenofundic gastric varices, oftenwith a prominent natural shunt to the left renal vein. Total or near total splenectomy alone or combinedwhere appropriate with coronary vein ligation was effective in controlling varix hemorrhage (10patients), ascites (3), or complications of an enlarged spleen-anorexia and abdominal pain (3),hemolytic anemia (1) and profound thrombocytopenia with severe epistaxis (1). Intraoperative jejunalportal venography was crucial in operative management in order to establish definitively the presence orabsence of coronary venous collaterals, and when present, to verify their operative ligation.These distinctive patients illustrate: 1) GPH is a heterogeneous syndrome of divergent splanchniccirculatory patterns, a feature which should be taken into account in selecting operative treatment; 2)one well-defined subgroup displays prominent hyperdynamic lesser splanchnic and specifically, splenicblood flow as a major contributor to clinical complications; and 3) within this subgroup, splenectomycombined with documented absence or surgical interruption of coronary venous collaterals as corroboratedby intraoperative portography is effective alternative treatment.