Scenario number one: hepatopulmonary syndrome

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.

Trendelenburg positioning and continuous lateral rotation improve oxygenation in hepatopulmonary syndrome after liver transplantation

Hepatopulmonary syndrome (HPS) is characterized by hypoxia, orthodeoxia, and platypnea, associated with severe chronic liver disease. Liver transplantation is generally viewed as the only curative treatment for this syndrome, but it may be complicated by prolonged hypoxia after the procedure. We report on a 58-year-old female patient with alcoholic cirrhosis and HPS who underwent liver transplantation. She developed severe hypoxia after transplantation that improved with the initiation of Trendelenburg's positioning in combination with continuous lateral rotation. Although many techniques for dealing with posttransplant hypoxia for HPS have been described, positioning is a simple maneuver that may correct the pathophysiologic abnormalities seen in HPS by gravitationally shifting blood away from the lung bases to improve oxygenation. Although this represents a single patient, the results were reproducible, and the intervention is simple and associated with minimal potential complications. The authors think this is a useful intervention to apply to the severely hypoxic patient with HPS, and a trial with more patients is warranted.