• Yoshinori Ishikawa, Hiroshi Yoshida, Yasuhiro Mamada, Nobuhiko Taniai, Koichi Bando, Yoshiaki Mizuguchi, Daisuke Kakinuma, Tomohiro Kanda, Koho Akimaru, and Takashi Tajiri.
• Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo, Japan.
• J Nippon Med Sch. 2008 Jun 1; 75 (3): 152-6.

BackgroundRefractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE.PatientsFour patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE.Surgical ProcedurePartial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery.ResultThe mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 +/- 56.4 mug/dL, mean +/- SD) than after surgery (41.8 +/- 20.2 mug/dL; p=0.0299). No patient had symptoms of HE.ConclusionLigation of the patent PUV is an effective treatment for patients with refractory HE.

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