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Lemoine CP, Yang S, Brandt KA, Carra S, Superina RA. A History of Umbilical Vein Catheterization Does Not Preclude Children from a Successful Meso-Rex Bypass. Eur J Pediatr Surg 2024; 34:28-35. [PMID: 37487509 DOI: 10.1055/s-0043-1771225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Umbilical vein catheterization (UVC) can cause portal venous thrombosis, leading to the development of extrahepatic portal venous obstruction (EHPVO) and portal hypertension (PHT). The feasibility of the Meso-Rex bypass (MRB) for the treatment of EHPVO in patients with a history of UVC has been questioned. We compared the feasibility of performing an MRB in patients with or without a history of previous UVC. METHODS A retrospective review of patients with EHPVO and known UVC status explored for a possible MRB at our institution was performed (1997-2022). Patients were categorized in two groups: with (UVC(+)) or without (UVC(-)) a history of UVC for comparison. A p-value less than 0.05 was considered significant. RESULTS One hundred and eighty-seven patients were included (n = 57 in UVC(+); n = 130 in UVC(-)). Patients in the UVC group were significantly younger at surgery and the incidence of prematurity was higher. Other risk factors for the development of EHPVO were similar between the groups, but only history of UVC could predict the ability to receive MRB (odds ratio [OR]: 7.4 [3.5-15.4]; p < 0.001). The success rate of MRB was significantly higher in patients with no history of UVC (28/57 [49.1%] in UVC(+) vs. 114/130 [87.7%] in UVC(-); p < 0.001). However, MRB patency at discharge (25/28 [89.3%] in UVC(+) vs. 106/114 [94.7%] in UVC(-); p = 0.3) was equally high in both groups. CONCLUSION Our results indicate that a history of UVC is not a contraindication to MRB. Half of the patients were able to successfully receive an MRB. Patients with symptomatic PHT from EHPVO should not be excluded from consideration for MRB based on UVC history.
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Affiliation(s)
- Caroline P Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Stephanie Yang
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Katherine A Brandt
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Sydney Carra
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Riccardo A Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
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Deniz S, Schinner R, Monroe EJ, Horslen S, Srinivasa RN, Lv Y, Fan D, Han G, Sarma MS, Srivastava A, Poddar U, Yadav R, Hoang TPT, Lange CM, Öcal O, Ricke J, Seidensticker M, Lurz E, Di Giorgio A, D'Antiga L, Wildgruber M. Outcome of Children with Transjugular Intrahepatic Portosystemic Shunt: A Meta-Analysis of Individual Patient Data. Cardiovasc Intervent Radiol 2023; 46:1203-1213. [PMID: 37532945 PMCID: PMC10471675 DOI: 10.1007/s00270-023-03520-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE The purpose of the study was to investigate outcome after pediatric transjugular intrahepatic portosystemic shunt (TIPS) with respect to survival MATERIAL AND METHODS: After searching for studies on TIPS in children in Ovid, Medline, Embase, Scopus and Cochrane published between 2000 and 2022, individual patient data were retrieved from five retrospective cohorts. Overall survival (OS) and transplant-free survival (TFS) were calculated using Kaplan-Meier analysis and log-rank test and compared to the indication (ascites vs. variceal bleeding) as well as to the level of obstruction (pre-hepatic vs. hepatic vs. post-hepatic). Additionally, TIPS patency was analyzed. RESULTS n = 135 pediatric patients were included in the final analysis. Indication for pediatric TIPS creation was heterogeneous among the included studies. TIPS patency decreased from 6 to 24 months, subsequent pediatric liver transplantation was performed in 22/135 (16.3%) of cases. The presence of ascites was related with poorer TFS (HR 2.3, p = 0.023), while variceal bleeding was not associated with impaired survival. Analysis of the level of obstruction (pre-hepatic, hepatic and post-hepatic) failed to prove significantly reduced OS for post-hepatic obstruction (HR 3.2, p = 0.092) and TFS (HR 1.3, p = 0.057). There was no difference in OS and TFS according to age at time of TIPS placement. CONCLUSIONS The presence of ascites associates with impaired survival after TIPS in children, with no differences in survival according to the age of the child. Interventional shunt procedures can be considered feasible for all ages. LEVEL OF EVIDENCE Level 2a.
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Affiliation(s)
- Sinan Deniz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Regina Schinner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin, Madison, WA, USA
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ravi N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Yong Lv
- Military Medical Innovation Center, State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Moinak Sen Sarma
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anshu Srivastava
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ujjal Poddar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rajanikant Yadav
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Thi Phuong Thao Hoang
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian M Lange
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Osman Öcal
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Eberhard Lurz
- Division for Pediatric Gastroenterology, Hepatology and Transplantation, Department for Pediatrics, Dr. Von Haunersches Kinderspital, University Hospital, LMU Munich, Munich, Germany
| | - Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Wen Z, Wang J, Yang C, Liu T, Liang Q, Liang J, Ning Y, You F, Bai X, Hong M. Is re-Rex shunt a better choice for patients with failed Rex shunt? Front Pediatr 2023; 11:1135059. [PMID: 37435166 PMCID: PMC10331016 DOI: 10.3389/fped.2023.1135059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 06/12/2023] [Indexed: 07/13/2023] Open
Abstract
Purpose To review our single-center surgical outcomes of redo operations after failed Rex shunt procedures. Methods From September 2017 to October 2021, a total of 20 patients (11 males, 9 females; median age: 8.6 years) with Rex shunt occlusions were admitted to our hospital. Two of these patients were previously operated on in our hospital, and the remaining 18 were from other centers. All patients underwent repeat operations after detailed preoperative evaluations. Results Preoperative wedged hepatic vein portography (WHVP) was conducted for 18 patients. Thirteen patients exhibited well-developed Rex recessus and intrahepatic portal vein during WHPV examination, consistent with the intraoperative exploration results. Fifteen patients (75%, 15/20) underwent redo-Rex shunt, four underwent Warren shunt and one underwent devascularization surgery. During the redo-Rex shunt operations, the left internal jugular veins (IJV) were used as bypass grafts in 11 patients; the intra-abdominal veins were used in 4 patients. The patients were followed up for 12-59 months (mean, 24.8 months). After redo Rex shunts, the grafts were patent in 14 patients (93.3%, 14/15), but 1 graft had thrombosis (6.7%, 1/15). Three patients suffered from postoperative anastomotic stenosis, and all of the stenosis was relieved with balloon dilatations. After re-Rex shunts, esophageal varices and spleen size were substantially reduced, and the platelet count significantly increased. Postoperative graft thrombosis was found in 1 patient after Warren shunt (1/4, 25%), and there was no graft stenosis. Compared with Warren surgery, patients who underwent re-Rex shunt had a significantly higher rate of platelet increase. Conclusions Redo-rex shunts can be finished in most patients with failed Rex shunts. Re-Rex shunt is a preferred surgical choice after a failed Rex shunt when a good bypass graft is available, and the surgical success rate can reach more than 90%. A suitable bypass graft is essential for a successful redo Rex shunt. Preoperative WHVP is recommended for the design of a redo surgical plan preoperatively.
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Affiliation(s)
- Zhe Wen
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Jieqin Wang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Chao Yang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Tao Liu
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Qifeng Liang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Jiankun Liang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Yu Ning
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Fuyu You
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Xiaoling Bai
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Medical University, Guangzhou, China
| | - Miao Hong
- Clinical Data Center, Guangzhou Women and Children's Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Institute of Pediatrics, Guangzhou Medical University, Guangzhou, China
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Khamag O, Numanoglu A, Rode H, Millar A, Cox S. Surgical management of extrahepatic portal vein obstruction in children: advantages of MesoRex shunt compared with distal splenorenal shunt. Pediatr Surg Int 2023; 39:128. [PMID: 36795156 PMCID: PMC9935711 DOI: 10.1007/s00383-023-05411-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS). METHODS This is a single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts were performed, 15 MRS and 7 DSRS, over an 18-year period. Patients were followed up for a mean of 11 years (range 2-18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalised ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2 years after shunt surgery. RESULTS One MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration. CONCLUSION In EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails.
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Affiliation(s)
- Omar Khamag
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Alp Numanoglu
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa
| | - Heinz Rode
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa
| | - Alastair Millar
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa
| | - Sharon Cox
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa
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Muacevic A, Adler JR, Omar ZTO, Mungu EB, Aiyadurai S, Una IS, Sunday GC, Ajekigbe O, Chaudhry HA, Khan A. A Rare Case of Extrahepatic Portal Venous Obstruction in a Nine-Year-Old Female and Its Management: A Case Report. Cureus 2022; 14:e32150. [PMID: 36601204 PMCID: PMC9806945 DOI: 10.7759/cureus.32150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2022] [Indexed: 12/07/2022] Open
Abstract
Extrahepatic portal vein obstruction (EHPVO) is a kind of liver vascular disease that causes structural abnormalities in the portal veins, including cavernomatous metamorphosis and obstruction. It is the most common cause of esophageal varices-related hematemesis in youngsters. Significant risk factors include congenital abnormalities, dehydration, sepsis, trauma, hypercoagulable conditions, and multiple transfusions. Acute extrahepatic portal vein blockage is often ignored because patients are usually asymptomatic. Subacute and chronic stages can cause symptoms including splenomegaly and hematemesis without hepatic decompensation. Imaging studies aid in the diagnosis; Doppler imaging is added to ultrasonography to visualize portal vein blood flow. MRI and CT scans are used to visualize portal vein blockage. Prevention of acute bleeding is the cornerstone in the management. Studies have shown that transhepatic thrombolysis is the preferred choice to avoid systemic side effects. Transjugular intrahepatic portosystemic shunt (TIPS) treats extrahepatic portal venous thrombosis and is typically followed by conservative variceal hemorrhage treatment. Liver transplantation is performed when other management measures fail. Here, we present a rare case of EHPVO in a nine-year-old female who was lost to follow-up for a long time and later showed signs of portal biliopathy and non-visualization of a surgically created splenorenal shunt. Re-shunting was performed after detailed conservative management, and the patient responded well to the treatment given.
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Dalzell C, Vargas PA, Soltys K, Di Paola F, Mazariegos G, Goldaracena N. Technical Aspects and Considerations of Meso-Rex Bypass Following Liver Transplantation With Left Lateral Segment Grafts: Case Report and Review of the Literature. Front Pediatr 2022; 10:868582. [PMID: 35547536 PMCID: PMC9081796 DOI: 10.3389/fped.2022.868582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/17/2022] [Indexed: 01/01/2023] Open
Abstract
In pediatric patients with extrahepatic portal vein obstruction and complications of portal hypertension, but with normal liver function, a meso-Rex bypass (MRB) connecting the superior mesenteric vein to the intrahepatic left portal is the favored surgical management. Pediatric patients with a history of a partial liver transplant (LT), especially living donors, are at greater risk for portal vein complications. Hence, an adequate knowledge of this technique and its additional challenges in the post-LT patient setting is crucial. We provide an overview of the available literature on technical aspects for an MRB post-LT. Preoperative considerations are highlighted, along with intraoperative considerations and postoperative management. Special attention is given to the even-more-demanding aspect of performing an MRB post-liver transplantation with a left lateral segment. Surgical alternatives are also discussed. In addition, we report here a unique case in which this surgical technique was performed on a complex pediatric patient with a history of a living-donor LT with a left lateral segment graft over a decade ago.
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Affiliation(s)
- Christina Dalzell
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Kyle Soltys
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States.,Department of Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Frank Di Paola
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - George Mazariegos
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States.,Department of Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
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