Saphenoperitoneal anastomosis for resistant ascites in patients with cirrhosis

Restriction of salt intake and diuretics combined with repeated paracentesis has been the mainstay of managing longstanding ascites. Peritoneal-venous shunts have been employed in refractory ascites but are not without complication. We evaluated an autologous reversed segment of proximal long saphenous vein anastomosed to the peritoneum in management of patients with resistant ascites.

Eleven patients (8 male, median age 48 years, range 37 to 68) with tense refractory ascites associated with cirrhosis of the liver and portal hypertension underwent saphenous vein-peritoneal anastomosis by rotating the proximal vein cephalad which was anastomosed to peritoneum in the posterior wall of the inguinal canal. Ten of 11 procedures were performed under general anesthetic.

Thirty-day mortality was 1 patient. Morbidity included transient hepatic encephalopathy in 4 (36%), minor wound hemorrhage in 3 (27%), fluid leakage in 7 (64%), and wound infection in 7 (64%). Hospital stay (median) was 16 days (range 11 to 23). In the short term (median of 9 months) significant reduction in body weight and abdominal girth was seen in 9 (90%), 6 (60%) were not on diuretics while 3 (30%) continued to remain on reduced doses of diuretic. Furthermore, 7 (70%) did not require paracentesis. At 2-year follow-up, 5 (45%) patients had died and 3 were lost to follow-up. The remaining 3 were all in active employment, 1 was off diuretics, and 2 were on reduced doses. All 3 patients maintained reduced body weights and abdominal girths compared with preoperative values.

Saphenous-peritoneal anastomosis appears a simple, safe, and effective method of achieving long-term control of refractory ascites. The use of a biological shunt is an added advantage over prosthetic shunts for drainage of ascitic fluid.