A new procedure for management of extrahepatic portal obstruction. Proximal splenic-left intrahepatic portal shunt

Rex Shunt for Extra-Hepatic Portal Venous Obstruction in Children

Rex shunt, which was first put in use in 1992, has been considered as an ideal surgical method for the treatment of extra-hepatic portal venous obstruction (EHPVO) due to its reconstruction of the hepatopetal portal blood flow. However, despite its long tradition, there are only a few reports about the application and advances in Rex shunt for the treatment of EHPVO in children. In this paper, we summarized the literature related to Rex shunt and discussed the new advances of Rex shunt in the following aspects: surgical method of Rex shunt, the indications of Rex shunt, the strengths of Rex shunt, the effectiveness of Rex shunt, factors affecting the efficacy of Rex shunt, methods that improve the prognosis of Rex shunt, and treatment strategy for recurrence after Rex shunt.

Meso-Rex bypass shunt vs. transposition shunt for cavernous transformation of portal vein in children

BACKGROUND

Cavernous transformation of the portal vein (CTPV) causes portal hypertension in children. Among Meso-Rex treatments, it is unclear whether the Meso-Rex bypass shunt (MRB) or the Meso-Rex transposition shunt (MRT) offers lower postoperative morbidity. Our objective was to evaluate postoperative outcomes, comparing MRB and MRT for children with CTPV.

METHODS

A retrospective study was conducted on children undergoing Meso-Rex for CTPV from January 2010 to December 2020. The primary outcome was shunt complications, including shunt stenosis and thrombus. The secondary outcome was re-operation.

RESULTS

Of the 43 patients included, 21 underwent MRT and 22 underwent MRB. MRT was associated with a higher rate of shunt complications when compared to MRB (23.8 vs. 9.1%, p = 0.191). The patients exhibited a higher rate of re-operation under the MRT than under the MRB (19 vs. 4.5%, p = 0.138). The operative time in the MRT group was significantly shorter than in the MRB group. Compared to MRT, the reduction in the length and thickness of the spleen was significantly greater in the MRB group. The increases in platelets were significantly higher in the MRB group than in the MRT group. The postoperative shunt velocity of MRB was notably faster than MRT. There was no significant difference in postoperative portal pressure between the two groups (p > 0.05).

CONCLUSION

Both MRB and MRT result in acceptable postoperative outcomes, but MRT is associated with higher post-shunt complications, which often increase the re-operation rate. This study suggests that MRB may offer advantages for children with CTPV.

Splenectomy with proximal spleno-left portal shunt for extrahepatic portal vein obstruction in children

PURPOSE

To report our initial experience with splenectomy and proximal spleno-left portal shunt as an alternative to the standard Rex shunt, when not applicable, in children with Extrahepatic Portal Vein Obstruction (EHPVO).

METHODS

Patients from March 2015 till September 2018, with EHPVO not suitable for Rex shunt or whose caregivers refused to consent for Internal Jugular Vein (IJV) dissection were assessed and prepared for splenectomy with proximal spleno-left portal shunt. The operative technique includes splenectomy, freeing of the splenic vein from the pancreatic bed till its junction with the inferior mesenteric vein, and then anastomosis with the intrahepatic left portal vein at the Rex recess. A distal lieno-renal shunt was performed in one patient and was excluded from the study.

RESULTS

A total of 14 patients (mean age: 4.6 years) underwent splenectomy with proximal spleno-left portal shunt during the study period. The mean operative time was 246 min, while the mean postoperative hospital stay was 4.1 days. The patients' follow up period ranged from 6 to 42 months (median: 19.6 months). Only two patients had a single attack of variceal bleeding, 2 and 2.5 months postoperative respectively, and required endoscopic management with no further bleeding episodes. While the rest of patients showed an improvement of their variceal grades after the surgery.

CONCLUSION

Splenectomy with proximal spleno-left portal shunt seems to be a valuable alternative to the standard Rex shunt in treatment of children with EHPVO unsuitable for or following unsuccessful Rex shunt.

LEVEL OF EVIDENCE

IV.

Unusual bleeding from hepaticojejunostomy controlled by side-to-side splenorenal shunt: A case report

RATIONALE

Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking.

PATIENT CONCERNS

A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion.

DIAGNOSES

Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis.

INTERVENTIONS

To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis.

OUTCOMES

After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up.

LESSONS

The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.

Postoperative enlargement and prognostic effects of portal venous bypass grafts in children undergoing Rex shunt

OBJECTIVE

Patency of the bypass vein after a Rex shunt is an important indicator of prognosis. However, there is no report about the change of caliber of the bypass vein after a Rex shunt. The aim of this study was to identify postoperative changes of the bypass vein and to assess the relationship with prognosis.

METHODS

Between October 2008 and October 2016 in our center, 114 children were diagnosed with extrahepatic portal venous obstruction. The portal cavernoma-portal bypass with interposition of grafted portal vessels was performed in 31 children, the gastroportal shunt was performed in 54 children, and other Rex shunts were performed in another 29 children. At follow-up, the patency and diameter of the bypass vein were assessed with ultrasound and computed tomography. The intraoperative and postoperative diameters of the bypass vein were compared to identify postoperative changes of the bypass vein. Prognosis was compared between children with and children without an enlarged bypass vein.

RESULTS

The caliber of the bypass vein was enlarged in 50% of children (40/80) at 6 months postoperatively. The postoperative incidences of rebleeding and esophageal varices were significantly lower in children with an enlarged bypass vein than in those without (P < .05). Postoperatively, the reduced splenic size was significantly higher in children with an enlarged bypass vein than in those without (P < .05). The postoperative increase in platelet count in children with an enlarged bypass vein was significantly higher than in those without (P = .006). There was no significant difference in the flow velocity of the bypass vein between children with and children without an enlarged bypass vein (P = .133). The portal pressure was significantly reduced after surgery in children with an enlarged bypass vein than in children without an enlarged bypass vein (P = .017).

CONCLUSIONS

The caliber of the bypass vein increases in 50% of children after a Rex shunt using a grafted portal vessel, which is related to a better prognosis.

Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery

Objective

The study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop.

Materials and Methods

Eleven consecutive patients (age range, 2–79 years; eight men and three women) who underwent portal stenting between April 2009 and December 2015 were included in the study. Preoperative medical history and the postoperative clinical course were reviewed. Characteristics of portal occlusion and details of procedures were also investigated. Technical success, treatment efficacy (defined as disappearance of jejunal varix on follow-up CT), and clinical success were analyzed. Primary stent patency rate was plotted using the Kaplan-Meier method.

Results

All patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Variceal bleeding occurred at 27 months (4 to 72 months) and portal stenting was performed at 37 months (4 to 121 months), on average, postoperatively. Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of 9 months. Neither procedure-related complication nor mortality occurred.

Conclusion

Interventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.

Case report of a modified Meso-Rex bypass as a treatment technique for late-onset portal vein cavernous transformation with portal hypertension after adult deceased-donor liver transplantation

RATIONALE

Portal vein thrombosis is a complication after liver transplantation and cavernous transformation of the portal vein (CTPV) is a result of portal vein thrombosis, with symptoms of portal hypertension revealed by an enhanced CT scan. Meso-Rex bypass is an artificial shunt connecting the left portal vein to the superior mesenteric vein and is mainly used for idiopathic cavernomas. This technique is also used for post-transplant portal vein thrombosis in pediatric patients thereby bypassing obstructed sites of the extrahepatic portal vein. Here we report about an adult patient who was treated by connecting the cystic part of the portal vein to the splenic vein instead of the superior mesenteric vein.

PATIENTS CONCERN

An adult male patient with post-liver transplantation portal vein cavernous transformation suffered from hypersplenism and elevated hepatic enzymes.

DIAGNOSIS

The last follow up revealed irregular and obvious hypersplenism, and splenomegaly had occurred, while an enhanced CT scan revealed serious esophagogastric varices and CTPV in addition to occluded right and common PV trunks.

INTERVENTION

The patient was treated by connecting the cystic part of the portal vein to the splenic vein instead of the superior mesenteric vein.

OUTCOME

After the operation, a satisfactory velocity was confirmed 1 month postoperatively and the shunt still remained patent at the 6-month postoperation follow-up.

LESSONS

A Meso-Rex bypass intervention connecting the left portal vein to the splenic vein instead of the superior mesenteric vein after liver transplantation in an adult patient with right and common portal vein occlusions has been successfully performed as an alternative approach.

Portal Vein Thrombosis: Recent Advance

Portal vein thrombosis is a life-threatening vascular disorder of the liver. In this chapter, I will review the recent advance regarding the epidemiology, etiology, management, and prognosis of portal vein thrombosis.

Spleen-preserving proximal splenic-left intrahepatic portal shunt for the treatment of extrahepatic portal hypertension in children

PURPOSE

The Rex shunt has been employed successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of the internal jugular vein. The authors describe a novel adaptation of spleen-preserving spleno-Rex bypass, successfully carried out in children with extrahepatic portal hypertension.

METHODS

The mean age of the four patients (1 boy, 3 girls) was 46 months at the time of operation. All children had a history of upper gastrointestinal bleeding, and suffered from splenomegaly and hypersplenism. Spleen-preserving proximal splenic-left intrahepatic portal shunt was performed in all patients. The splenic artery and vein were ligated at the splenic hilum, and the splenic vein was completely separated from the bed of the pancreas to its junction with the inferior mesenteric vein. The freed splenic vein was anastomosed to left portal vein. The short gastric and left gastroepiploic vessels were kept intact to supply and drain the spleen. All patients were followed-up for 7-33 months (median: 21.5 months).

RESULTS

The spleen-preserving spleno-Rex bypass was successfully performed in all 4 patients. The median operative time was 225 min (range: 215-260 min). One patient received blood transfusion, and the postoperative length of hospital stay varied from 4 to 6 days (median: 4.5 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized and the biochemistry tests were within normal range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the proximal splenic-portal shunt in each patient. The size of the spleen decreased and there was no recurrence of variceal bleeding.

CONCLUSIONS

The spleen-preserving spleno-Rex bypass is a viable option to treat EHPVO in children.

Partial splenectomy and use of splenic vein as an autograft for meso-Rex bypass: a clinical observational study

Background

Meso-Rex bypass (MRB) surgery is being increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (EPVT) and cavernous transformation (EPVCT) in children. Rather than using the internal jugular vein (IJV, the traditional venous graft), we used an autogenous splenic vein segment graft for MRB.

Material/Methods

We examined 25 children with extrahepatic portal hypertension and a history of recurrent upper gastrointestinal (GI) variceal bleeding despite previous endoscopic sclerotherapy. All patients had melena, splenomegaly, hypersplenism, or some combination thereof. Left portal vein (LPV) patency was verified in 22 patients using intraoperative direct portography through the umbilical vein. Partial splenectomy was performed to enable the harvest of the splenic vein trunk, which was anastomosed between the superior mesenteric vein (SMV) and the left portal vein (LPV). All patients were followed for 12–48 months (mean=25.6 months) and no patients were lost to follow-up.

Results

Preoperative Doppler ultrasound (US) imaging indicated that 18/25 patients had adequate intrahepatic portal veins for shunting, with no blood flow in the LPVs of 7 patients. LPV patency in 22/25 patients was verified using intraoperative direct portography, with successful MRB. Shunting was converted into a portosystemic shunt in the remaining 3/25 patients with thrombosed LPVs. A Doppler US evaluation of the vein conduit revealed excellent postoperative flow. The patients’ mean hemoglobin, platelet, and white blood cell counts increased significantly, and in all cases the endoscopic status obviously improved after shunting. Occlusion or narrowing occurred in 2/22 patients after discharge. At 12 months (for 1 patient) and 24 months (for 1 patient), the shunt was converted into a portosystemic shunt. The cumulative graft patency rate was 91% (20/22).

Conclusions

Partial splenectomy and splenic vein autografting in MRB surgery can successfully resolve prehepatic portal hypertension and hypersplenism in children.

The inferior mesenteric vein to the left gonadal vein shunt for gastroesophageal varices and extrahepatic portal vein thrombosis after living donor liver transplantation: a case report

This 59-year-old woman underwent living donor liver transplantation using a left lobe graft as an aid for autoimmune hepatitis in 2003. Splenectomy was also performed because of blood type incompatibility. Follow-up endoscopic and computed tomography examinations showed gastroesophageal varices with extra hepatic portal vein thrombosis in 2007 that increased (esophageal varices [EV]: locus superior [Ls], moderately enlarged, beady varices [F2], Blue varices [Cb], presence of small in number and localized red color sign [RC1] and telangiectasia [TE+], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderately enlarged, beady varices [F2], white varices [Cw], absence of red color sign [RC-]). Portal venous flow to the gastroesophageal varices was also confirmed from a large right gastric vein. The splenic vein was thrombosed. Blood flow to the liver graft was totally supplied from the hepatic artery. The graft was functioning well. Because these gastroesophageal varices had a high risk of variceal bleeding, we decided to proceed with a portal reconstruction of a surgical portosystemic shunt in 2008. Severe adhesions were observed around the portal vein. It was impossible to perform portal reconstruction. There were relatively fewes adhesious in the left lower side of the abdominal cavity. We decided to create an inferior mesenteric vein to left gonadal vein shunt. The portal vein pressure decreased from 31.0 to 21.5 cm H2O thereafter. The postoperative course was smooth without any complication. This patient was discharged on the postoperative day 15. Follow-up endoscopic study showed the improvement in the gastroesophageal varices (EV: Ls, F2, Cb, RC(-), GV: Lg-c, F2, Cw, RC-) at 3 months after the operation. We also comfirmed the patency of the shunt by serial computed tomography examinations.

The utility of recanalized umbilical vein graft to the hepato-pancreato-biliary surgeon

BACKGROUND

The authors recently published their experience of recanalizing umbilical veins in deceased liver donors, with recanalized umbilical veins as vascular conduits for meso-Rex bypass procedures. They have since found recanalized umbilical veins to be an excellent, easy to harvest vascular conduit that can be used for multiple vascular procedures and repair. Here, they report their experience using this vessel for bypass and vascular reconstruction.

METHODS

They have recanalized umbilical veins and used them in a total of 5 Meso-Rex bypasses; 5 pancreaticoduodenectomies; 1 left hepatic trisegmentectomy with right portal vein (PV) resection and reconstruction; 1 right hepatectomy and 1 adrenalectomy, both with partial inferior vena cava (IVC) resection and reconstruction; 1 coronary-Rex bypass shunt for extrahepatic PV thrombosis; and 1 orthotopic liver transplantation with infrahepatic IVC anastomotic dehiscence patched with umbilical vein graft. Umbilical veins were dilated mechanically and used in situ for the meso-Rex bypass surgery; they were ligated in the space of Rex and then dilated ex vivo otherwise to be used as interposition grafts or a vein patch.

RESULTS

A total of 15 hepato-pancreato-biliary procedures were done using the recanalized umbilical vein as graft; 2 patients required thrombectomy postoperatively with reexploration, venotomy, thrombectomy with fogarty catheter, and venotomy closure.

CONCLUSION

The umbilical vein graft is a fine vascular conduit and can serve many purposes in hepatobiliary surgery.

Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

Gastroportal shunt for portal hypertension in children

PURPOSE

Extrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension.

METHODS

The mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months).

RESULTS

The gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding.

CONCLUSIONS

The gastroportal shunt is an effective treatment of extrahepatic portal hypertension.

Variation of the Rex shunt for treating concurrent obstruction of the portal and superior mesenteric veins

Children with extrahepatic portal vein obstruction can be managed successfully by surgical intervention and should be evaluated for potential meso-Rex bypass. A Rex shunt variation is described to treat portal and superior mesenteric vein thrombosis. This technique uses the internal jugular vein as a conduit between the splenic vein and the left portal vein with splenic preservation.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.

Mesoportal bypass for extrahepatic portal vein obstruction in children: close to a cure for most!

AIM

Extrahepatic portal vein obstruction (EPVO) is a common cause of portal hypertension in children and can lead to life-threatening bleeding, thrombocytopenia, and coagulation disorders. Mesoportal bypass (MPB) restores normal physiologic portal flow to the liver and corrects portal hypertension. There is, however, little long-term outcome data after MPB. The aim of our study was to analyze the long-term outcome after MPB in children.

METHODS

Retrospective single-center review of all MPB with more than 5-year follow-up was performed in children between 1998 and 2003.

RESULTS

Thirty children underwent MPB, which was successful in 29. Long-term follow-up is available for 24. Median age at the time of bypass was 8.5 years (range, 0.4-14.2 years). Material used for bypass was as follows: left internal jugular vein (n = 20), recanalized umbilical vein (n = 2), gastric vein, and a large colic vein (n = 2). Median time since MPB is 8 years (range, 5.3-8.8 years). One MPB using recanalized umbilical vein thrombosed at 4 months but was successfully refashioned using Gortex. One MPB with left internal jugular vein was thrombosed at 1 year after cardiac surgery. Overall, 23 of 24 children have a patent bypass and resolution of portal hypertension. All showed an decrease in spleen size. Recurrent blood flow in the cavernoma with secondary increase in spleen size occurred in 5 children (median time, 3.4 years after MPB). Further evaluation of these 5 revealed no recurrence of portal hypertension.

CONCLUSION

The MPB provides long-term correction of portal hypertension owing to EPVO. Where technically feasible, MPB is the preferred surgical procedure for treatment of EPVO.

Modified technique of meso-Rex shunt in case of insufficient length of the jugular vein graft

Meso-Rex shunt (MRS) can relieve portal hypertension and restore a physiological portal flow in patients with portal vein thrombosis. We describe a technical variant where the autologous internal jugular vein (IJV) was too short to bridge the superior mesenteric vein (SMV) and the Rex recessus.

PATIENT

A 15-year-old boy with portal cavernoma had several episodes of gastrointestinal bleeding despite repeated sclerotherapy. Preoperative assessment, including retrograde transjugular portography, showed persistent esophageal and gastric varices, severe hypertensive gastropathy, obstructed portal vein, patent SMV and splenomesenteric confluence, patent intrahepatic portal branches, and normal transhepatic pressure gradient. An MRS was planned. The left IJV was retrieved from its infracranial part to its confluence with subclavian vein. After performing the Rex recessus to IJV graft anastomosis, the IJV graft proved to be too short for classical end-to-side anastomosis onto the SMV. After clamp testing showing good tolerance of the small bowel, the proximal jejunal branches of the SMV were tied, the proximal SMV was mobilized and transsected 4 cm below the pancreas, and an end-to-end anastomosis between SMV and IJV was performed. Portal pressure decreased from 23 to 13 mm Hg, and intraoperative Ultra Sound Doppler (US Doppler) showed good flows in the shunt. Postoperative course was uneventful, and 1 year after surgery, the child is clinically well, off medication, with a patent shunt, and no portal hypertension.

CONCLUSION

This modified MRS technique may be useful when the autologous IJV graft is too short, avoiding the need for prosthetic conduits and prolonged postoperative anticoagulation.

Recanalized umbilical vein conduit for meso-Rex bypass in extrahepatic portal vein obstruction

BACKGROUND

Meso-Rex bypass is used to treat patients with clinically important extrahepatic portal vein obstruction (EHPVO). Usually, an autologous left internal jugular vein graft is used to bypass the portal blood circulation from the superior mesenteric vein to the left portal vein. Other vascular conduits have included the autogenous saphenous vein, splenic vein, right gastroepiploic vein, and inferior mesenteric vein.

METHODS

A total of 20 umbilical veins with attached livers were harvested from 20 deceased liver donors. Umbilical veins were dilated mechanically and checked for patency and communication with the left portal vein. Vein length and diameter after dilatation were recorded. Cross-sections of 15 recanalized umbilical veins were processed by routine histologic examination and stained with hematoxylin and eosin, as well as processed by immunohistochemistry for CD31 and factor VIII antigens. Subsequently, 3 children with EHPVO underwent this modified meso-Rex bypass using the umbilical vein as a vascular conduit.

RESULTS

The mean length of harvested umbilical veins was 15 cm (range, 7-21); the mean length of recanalized and usable umbilical veins was 10 cm (range, 5-15). Recanalization was successful in 16 (80%) of the 20 donor umbilical veins. The mean diameter of the umbilical veins after serial dilatation and recanalization was 1.2 cm (range, 1-2). In 11 (73%) of the 15 recanalized vein specimens, the lumen was lined by endothelial cells. In 2 children, the vascular conduit was constructed entirely with native umbilical vein. In the remaining child, 3 cm of umbilical vein was preserved and anastomosed to a mobilized inferior mesenteric vein due to inadequate length. All 3 children had patent bypass and resolution of clinical manifestations of portal hypertension at a mean follow-up of 21 months.

CONCLUSION

Meso-Rex bypass may prove to be a definitive treatment for patients with EHPVO. The use of native umbilical vein as a vein conduit achieved decompression of the splanchnic venous system and should be considered a natural alternative to other interposition vein grafts.

Experience with alternate sources of venous inflow in the meso-Rex bypass operation: the coronary and splenic veins

The meso-Rex bypass procedure has been used to treat patients with portal hypertension from extrahepatic portal vein obstruction. This report describes modifications of this procedure in 5 patients. Either the splenic or coronary vein was used as the venous inflow point, and the bypass was performed either directly through transposition of the vein or with the use of a venous conduit.

Use of autogenous saphenous vein as a conduit for mesenterico-left portal vein bypass

The authors describe a case of extrahepatic portal vein (EHPV) thrombosis and portal hypertension treated with a variant of mesenterico-left portal vein bypass (MLPVB) or Rex shunt. In this case, a segment of autogenous greater saphenous vein was used to bridge the distance between the left gastric vein inflow and the left portal vein. Use of such nontraditional conduit in similar circumstances may expand the application of portal revascularization/decompression procedures in treating these patients.

Improved body mass index after mesenterico-portal bypass

Extrahepatic portal hypertension in children secondary to portal vein obstruction is frequently associated with impaired somatic growth. The aim of this study was to assess growth and nutritional status, as reflected by the body mass index (BMI), before and after mesenterico-portal bypass (Rex shunt). Eleven children with a portal vein cavernoma underwent mesenterico-portal bypass using autologous jugular vein. All shunts have remained patent during follow-up periods of 7 months to 5 years. All except one child, who had a normal BMI prior to surgery, demonstrated an increase in their BMI standard deviation scores after surgery. Mean BMI standard deviation scores increased from -0.44 +/- 1.28 (95% CI -1.30 to 0.42) to 0.46 +/- 1.08 (95% CI -0.27 to 1.19), a highly statistically significant increase (P=0.003). Restoration of hepatopetal portal blood flow by mesenterico-portal bypass surgery improves nutrition and growth in children with extrahepatic portal hypertension.

Stent placement is effective on both postoperative hepatic arterial pseudoaneurysm and subsequent portal vein stricture: A case report

To treat postoperative bleeding after hepato-pancreato-biliary surgery, interventional radiology has become essential. We report a case of coincidental pseudoaneurysm and jejunal varices that were both successfully treated by stent-grafts. After a pancreaticoduodenectomy, the patient developed a pseudoaneurysm in the hepatic artery and a stenosis in its periphery. After establishing hepatic arterial flow by placing stent-grafts over both the pseudoaneurysm and the stenosis, the pseudoaneurysm was embolized with microcoils. Nine months later, the patient developed jejunal varices caused by a severe stricture in the main trunk of the portal vein. Percutaneous transhepatic portography was performed and stent-grafts were placed over the stenotic segment. A venoplasty using stent-grafts normalized the portal blood flow and the jejunal varices vanished. Although stenosis occurred due to scarred tissues from leakage after pancreaticoduodenectomy, stent-grafts were useful for managing jejunal bleeding post-operatively.

Mesenterico left portal bypass for variceal bleeding owing to extrahepatic portal hypertension caused by portal vein thrombosis

BACKGROUND/PURPOSE

Portosystemic shunt operations are indicated in patients with extrahepatic portal hypertension owing to portal vein thrombosis (EPH-PVT) suffering from recurrent variceal bleeding despite endoscopic sclerotherapy. Mesenterico left portal bypass procedure (MLPB) is an alternative procedure to the portosystemic shunt operations in patients with EPH-PVT. MLPB operation reestablishes hepatopetal portal blood flow. We herein present our experience with MLPB in children with EPH-PVT.

METHODS

Six patients were treated for EPH-PVT with recurrent bleeding despite endoscopic sclerotherapy (2 boys and 4 girls) in our unit. All patients were evaluated preoperatively with complete blood count, portal duplex system Doppler ultrasonography, magnetic resonance angiography, and upper gastrointestinal (GI) endoscopy. MLPB operation was performed as described by de Ville de Goyet. During the postoperative period, patients were evaluated with complete blood count, portal duplex system Doppler ultrasonography, upper GI endoscopy, and magnetic resonance angiography.

RESULTS

Six patients were assessed to be candidates for MLPB procedure and were operated to perform the MLPB procedure. Left portal veins were found to be patent during the operation in 4 patients, and the MLPB procedure was performed. Internal jugular vein was used in 3 patients and enlarged inferior mesenteric vein in 1 patient. Left portal veins of the remaining 2 patients were found to be obliterated; therefore, mesocaval shunt was performed. The postoperative course of the patients was uneventful except for 1 patient. During the following period, the leukocyte and the platelet counts were significantly increased in 3 of the 4 patients after the MLPB procedure. Upper GI bleeding occurred in the early postoperative period in 1 patient with MLPB procedure because of prepyloric ulcer that was successfully treated by endoscopic sclerotherapy. Internal jugular vein graft thrombosis was detected on the 10th postoperative day. This patient underwent a second laparotomy, the distal half of the graft was found to be sclerosed and narrowed that the graft was revised with a synthetic allograft.

CONCLUSIONS

Based on a review of the literature, the MLPB functions well in patients with portal hypertension caused by portal vein thrombosis and appears to have a physiologic advance over shunts that decompress but do not return blood directly to the liver. Because intra-abdominal veins appear to function well as a conduit in this operation, it may be favored by eliminating additional incision and increased risk in such patients.

Mesogonadal shunts for extrahepatic portal vein thrombosis and variceal hemorrhage

Extrahepatic portal vein thrombosis (EHPVT) may occur in children or adults and usually comes to clinical attention due to complications of portal hypertension such as variceal hemorrhage. A variety of standard surgical techniques exist to manage these patients, but when these fail surgical options are limited. We describe two novel portosystemic shunts that utilize the gonadal vein as an autologous conduit. Four patients were evaluated for EHPVT with variceal bleeding. None of the patients were candidates for a standard splenorenal shunt due to prior surgical procedures. The first patient underwent a left mesogonadal shunt and the remaining 3 patients underwent a right mesogonadal shunt. Postoperative ultrasound or computed tomography (CT) scan confirmed early patency of the shunt in each patient. There have been no further episodes of variceal hemorrhage with follow-up of 3.5 years in the child who underwent the left mesogonadal shunt, and 17, 19, and 20 months in the patients who underwent the right mesogonadal shunt. Three of the 4 shunts remain patent. One shunt thrombosis occurred in a patient homozygous for the Factor V Leiden mutation despite anticoagulation with coumadin. This is the first report of the successful use of the gonadal vein as an in situ conduit for constructing a portosystemic shunt. In conclusion, the right and left mesogonadal shunts may be useful as salvage operations for patients with EHPVT who have failed standard surgical shunt procedures.

Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus

For the treatment of recurrent bleeding despite sclerotherapy or clinically significant hypersplenism, portosystemic shunt procedures should be performed in cases of extrahepatic portal hypertension caused by extrahepatic portal vein thrombosis. A novel alternative to portosystemic shunt procedures in extrahepatic portal hypertension is mesenterico-left portal bypass. Portal vein thrombosis is bypassed by an autologous vein graft (usually left internal jugular vein) interposed between superior mesenteric vein and left portal vein. In the presence of an enlarged right gastroepiploic vein, the distal end of this vein can be anastomosed to left portal vein without disturbing its proximal end. Herein, the authors report a case of extrahepatic portal hypertension treated by anastomosing enlarged inferior mesenteric vein to left portal vein to bypass portal vein thrombosis.

Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach

OBJECTIVES

Current management of extrahepatic portal vein thrombosis (EPVT) comprises endoscopic eradication therapy of esophageal varices and conventional shunt surgery. The authors have used the novel technique of mesenterico-left portal bypass (Rex shunt) in seven children with symptomatic EPVT, and report their results here.

METHODS

Median age of the children was 12 years (range, 2-16 years). All children had portal hypertension with hypersplenism and recurrent bleeding from esophageal varices. Furthermore, one patient suffered from a severe hepatopulmonary syndrome. Preoperative evaluation included liver function tests, liver biopsy, hepatic duplex ultrasonography, and radiologic evaluation of the intrahepatic and extrahepatic vascular anatomy. The internal jugular vein was used as vein graft in all patients.

RESULTS

Median follow-up period was 15 months (range, 3-28 months). Ultrasound scans revealed sufficient perfusion in all shunts (median, 35 cm/s; range, 28-60 cm/s). The intrahepatic portal perfusion in segment 4 improved from a median of 6 cm/s before surgery to 18 cm/s postoperatively. The platelet count increased within 3 months from a mean of 50,625/microL to 137,750/microL. The clinical signs of hypoxemia in the child with hepatopulmonary syndrome disappeared within 6 months.

CONCLUSIONS

In accordance with the limited experience published by others, the authors' data confirmed the mesenterico-portal Rex shunt as the therapy of choice for children with EPVT. Furthermore, this report is the first to show that a hepatopulmonary syndrome can be abolished by mesenterico-portal Rex shunt.

Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension

BACKGROUND

Decompression of extrahepatic portal hypertension by directly bypassing the thrombosed portal vein has never been reported in cases of children with idiopathic (or neonatal) portal vein obstruction and cavernoma.

METHODS

Seven children (15 years or younger) with portal vein obstruction requiring surgical decompression (urgently in two cases), and in whom preoperative Doppler had shown that the intrahepatic portal branches were hypoplastic but free of thrombus, were included in a pilot study. The cavernoma was bypassed by interposing a venous jugular autograft between the superior mesenteric vein and the distal portion of the left portal vein. Patients received follow-up using routine clinical parameters, upper gastrointestinal endoscopy, and Doppler ultrasound.

RESULTS

The mesenterico-portal bypass restored a direct (physiological) hepatopetal portal flow. The operation resulted in effective portal decompression as demonstrated by decrease of the pressure gradient, rapid regression of clinical signs of portal hypertension, and definitive control of bleeding.

CONCLUSIONS

This study shows that direct bypassing of portal cavernoma is possible and results in effective portal decompression. Restoration of the hepatic portal flow is a major advantage compared with conventional surgical shunting procedures. This new technique is potentially applicable to two thirds of children with portal vein thrombosis and should be considered when shunting procedures are indicated.