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Ponce-Dorrego MD, Hernández-Cabrero T, Garzón-Moll G. Endovascular Treatment of Congenital Portosystemic Shunt: A Single-Center Prospective Study. Pediatr Gastroenterol Hepatol Nutr 2022; 25:147-162. [PMID: 35360378 PMCID: PMC8958053 DOI: 10.5223/pghn.2022.25.2.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/16/2022] [Accepted: 02/27/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To design a prospective study on endovascular closure of congenital portosystemic shunts. The primary endpoint was to assess the safety of endovascular closure. The secondary endpoint was to evaluate the clinical, analytical and imaging outcomes of treatment. METHODS Fifteen patients (age range: 2 days to 21 years; 10 male) were referred to our center due to congenital portosystemic shunts. The following data were collected prior to treatment: age, sex, medical history, clinical and analytical data, urine trimethylaminuria, abdominal-US, and body-CT. The following data were collected at the time of intervention: anatomical and hemodynamic characteristics of the shunts, device used, and closure success. The following data were collected at various post-intervention time points: during hospital stay (to confirm shunt closure and detect complications) and at one year after (for clinical, analytical, and imaging purposes). RESULTS The treatment was successful in 12 participants, migration of the device was observed in two, while acute splanchnic thrombosis was observed in one. Off-label devices were used in attempting to close the side-to-side shunts, and success was achieved using Amplatzer™ Ductus-Occluder and Amplatzer™ Muscular-Vascular-Septal-Defect-Occluder. The main changes were: increased prothrombin activity (p=0.043); decreased AST, ALT, GGT, and bilirubin (p=0.007, p=0.056, p=0.036, p=0.013); thrombocytopenia resolution (p=0.131); expansion of portal veins (p=0.005); normalization of Doppler portal flow (100%); regression of liver nodules (p=0.001); ammonia normalization (p=0.003); and disappearance of trimethylaminuria (p=0.285). CONCLUSION Endovascular closure is effective. Our results support the indication of endovascular closure for side-to-side shunts and for cases of congenital absence of portal vein.
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Affiliation(s)
| | | | - Gonzalo Garzón-Moll
- Department of Interventional Radiology, Hospital General Universitario La Paz, Madrid, Spain
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2
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Zhang JS, Li L. Surgical ligation of a portosystemic shunt for the treatment of type II Abernethy malformation in 12 children. J Vasc Surg Venous Lymphat Disord 2020; 9:444-451. [PMID: 32791304 DOI: 10.1016/j.jvsv.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/02/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study aimed to investigate the feasibility and effectiveness of surgical ligation in the treatment of a congenital extrahepatic portosystemic shunt (Abernethy malformation) in children. METHODS Twelve children (aged 10 days to 13.3 years; six boys and six girls) with Abernethy malformation were admitted to the Capital Institute of Pediatrics (Beijing, China) from May 2014 to November 2019 owing to hyperammonemia. Among them, nine suffered from hematochezia, two had elevated liver transaminase levels or jaundice, and one had hypoxemia. Their surgical procedures and outcomes were retrospectively analyzed. Portal pressure measurement and angiography of the portal vein were performed before and after the occlusion of the portosystemic shunt during the surgery. Six patients underwent a single-stage ligation of the portosystemic shunt, five underwent a two-stage ligation of the portosystemic shunt, and one was treated with a partial ligation of the portosystemic shunt. RESULTS Each of the operations was successfully completed with an operative time ranging from 60 to 240 minutes and with an intraoperative blood loss ranging from 50 to 200 mL. Three children had a blood transfusion. The postoperative portal pressure was significantly higher than that before the surgery in all children. The patients were followed for 5 to 70 months. The symptoms of hematochezia were relieved in nine patients after the surgery. The levels of blood bilirubin and transaminase returned to normal after the surgery in two patients. The oxygen saturation returned to normal in one patient. The level of blood ammonia was normal after the surgery in all patients. CONCLUSIONS The surgical ligation of the portosystemic shunt was an effective method to treat a type II Abernethy malformation. According to the portal pressure after the occlusion of the portosystemic shunt, a single or staged procedure was selected.
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Affiliation(s)
- Jin-Shan Zhang
- Department of General Surgery, Capital institute of Pediatrics, Beijing, P.R. China.
| | - Long Li
- Department of General Surgery, Capital institute of Pediatrics, Beijing, P.R. China
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3
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Tang H, Song P, Wang Z, Han B, Meng X, Pan Y, Meng X, Duan W. A basic understanding of congenital extrahepatic portosystemic shunt: incidence, mechanism, complications, diagnosis, and treatment. Intractable Rare Dis Res 2020; 9:64-70. [PMID: 32494552 PMCID: PMC7263991 DOI: 10.5582/irdr.2020.03005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Extrahepatic portosystemic shunt belongs to a family of rare vascular abnormalities. The clinical importance and manifestations of this vascular abnormality range from asymptomatic cases to liver or metabolic dysfunctions of various degrees. Congenital extrahepatic portosystemic shunt, also termed as Abernethy malformation, is a very rare congenital vascular malformation in which splenomesenteric blood drains into a systemic vein, bypassing the liver through a complete or partial extrahepatic shunt. So far, limited cases of congenital extrahepatic portosystemic shunt have been reported. In this review, incidence, mechanisms, complications, diagnoses and treatments of congenital extrahepatic portosystemic shunt are described.
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Affiliation(s)
- Haowen Tang
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Peipei Song
- The Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Zhiqiang Wang
- Department of Hepatobiliary Surgery, Qinghai Red Cross Hospital, Xining, China
| | - Bing Han
- Department of General Surgery, Shanxian Central Hospital, Heze, China
| | - Xiangfei Meng
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Yingwei Pan
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Xuan Meng
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
- Address correspondence to:Weidong Duan and Xuan Meng, Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, 28 Fuxing Road, Haidian, Beijing 100853, China. E-mail: (Duan WD), (Meng X)
| | - Weidong Duan
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
- Address correspondence to:Weidong Duan and Xuan Meng, Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, 28 Fuxing Road, Haidian, Beijing 100853, China. E-mail: (Duan WD), (Meng X)
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4
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DiPaola F, Trout AT, Walther AE, Gupta A, Sheridan R, Campbell KM, Tiao G, Bezerra JA, Bove KE, Patel M, Nathan JD. Congenital Portosystemic Shunts in Children: Associations, Complications, and Outcomes. Dig Dis Sci 2020; 65:1239-1251. [PMID: 31549332 PMCID: PMC8180198 DOI: 10.1007/s10620-019-05834-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Congenital portosystemic shunt (CPSS) is a rare malformation in which splanchnic venous flow bypasses the liver. CPSS is associated with other congenital anomalies and syndromes and can be associated with life-threatening complications. CPSS and their management remain underreported in the literature. Here, we review the clinical characteristics, management, and outcomes of a cohort of children and young adults with CPSS from two pediatric centers. METHODS Cases of CPSS from Cincinnati Children's Hospital Medical Center and C.S. Mott Children's Hospital were reviewed to define CPSS anatomy, associated anomalies, complications, interventions, and outcomes. The imaging features and histopathology of liver lesions were characterized in detail. RESULTS A total of 11 cases were identified. Median age was 10 years (range 0-26); 8 (73%) cases were female. Associated anomalies included six patients with heterotaxy (55%), five patients with congenital heart disease (45%), three patients with Turner syndrome (27%), and two patients with omphalocele, exstrophy, imperforate anus, spinal defects (OEIS) complex (18%). Eight (73%) cases had hyperammonemia ± encephalopathy. A 4-month-old presented with hepatopulmonary syndrome, and 12-year-old presented with pulmonary hypertension. Eight patients (73%) had liver lesions including five with premalignant adenomas and three with well-differentiated hepatocellular carcinoma (HCC). Four children underwent successful CPSS occlusion/ligation. Three children underwent liver transplant (2) or resection (1) for HCC without recurrence at extended follow-up. CONCLUSIONS CPSS is associated with multiple anomalies (heterotaxy, congenital heart disease) and syndromes (Turner syndrome). CPSS liver lesions should be very carefully evaluated due to risk of premalignant adenomas and HCC. Serious complications of CPSS can occur at a young age but can be managed endovascularly or with open surgery.
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Affiliation(s)
- Frank DiPaola
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, C.S. Mott Children’s Hospital, MPB D5200, 1500 East Medical Center Drive, SPC 5718, Ann Arbor, MI 48109-5718, USA
| | - Andrew T. Trout
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, MLC 5031, 3333 Burnet Avenue, Cincinnati, OH 45229, USA,Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Ashley E. Walther
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS #100, Los Angeles, CA 90027, USA
| | - Anita Gupta
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, MLC 1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Rachel Sheridan
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, MLC 1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kathleen M. Campbell
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Greg Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, MLC 2023, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Jorge A. Bezerra
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Kevin E. Bove
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, MLC 1035, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Manish Patel
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, MLC 5031, 3333 Burnet Avenue, Cincinnati, OH 45229, USA,Department of Radiology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Jaimie D. Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, MLC 2023, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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5
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Baiges A, Turon F, Simón-Talero M, Tasayco S, Bueno J, Zekrini K, Plessier A, Franchi-Abella S, Guerin F, Mukund A, Eapen CE, Goel A, Shyamkumar NK, Coenen S, De Gottardi A, Majumdar A, Onali S, Shukla A, Carrilho FJ, Nacif L, Primignani M, Tosetti G, La Mura V, Nevens F, Witters P, Tripathi D, Tellez L, Martínez J, Álvarez-Navascués C, Fraile López ML, Procopet B, Piscaglia F, de Koning B, Llop E, Romero-Cristobal M, Tjwa E, Monescillo-Francia A, Senzolo M, Perez-LaFuente M, Segarra A, Sarin SK, Hernández-Gea V, Patch D, Laleman W, Hartog H, Valla D, Genescà J, García-Pagán JC. Congenital Extrahepatic Portosystemic Shunts (Abernethy Malformation): An International Observational Study. Hepatology 2020; 71:658-669. [PMID: 31211875 DOI: 10.1002/hep.30817] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/21/2019] [Indexed: 12/27/2022]
Abstract
Congenital extrahepatic portosystemic shunt (CEPS) or Abernethy malformation is a rare condition in which splanchnic venous blood bypasses the liver draining directly into systemic circulation through a congenital shunt. Patients may develop hepatic encephalopathy (HE), pulmonary hypertension (PaHT), or liver tumors, among other complications. However, the actual incidence of such complications is unknown, mainly because of the lack of a protocolized approach to these patients. This study characterizes the clinical manifestations and outcome of a large cohort of CEPS patients with the aim of proposing a guide for their management. This is an observational, multicenter, international study. Sixty-six patients were included; median age at the end of follow-up was 30 years. Nineteen patients (28%) presented HE. Ten-, 20-, and 30-year HE incidence rates were 13%, 24%, and 28%, respectively. No clinical factors predicted HE. Twenty-five patients had benign nodular lesions. Ten patients developed adenomas (median age, 18 years), and another 8 developed HCC (median age, 39 years). Of 10 patients with dyspnea, PaHT was diagnosed in 8 and hepatopulmonary syndrome in 2. Pulmonary complications were only screened for in 19 asymptomatic patients, and PaHT was identified in 2. Six patients underwent liver transplantation for hepatocellular carcinoma or adenoma. Shunt closure was performed in 15 patients with improvement/stability/cure of CEPS manifestations. Conclusion: CEPS patients may develop severe complications. Screening for asymptomatic complications and close surveillance is needed. Shunt closure should be considered both as a therapeutic and prophylactic approach.
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Affiliation(s)
- Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stephanie Tasayco
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Bueno
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kamal Zekrini
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Aurélie Plessier
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Stéphanie Franchi-Abella
- Service d'Hépatologie et de Transplantation Hépatique et de radiologie Pédiatriques, Groupement Hospitalier Paris Sud (GHUPS), Hôpital Bicêtre, Le Kremlin Bicetre, France
| | - Florent Guerin
- Service d'Hépatologie et de Transplantation Hépatique et de radiologie Pédiatriques, Groupement Hospitalier Paris Sud (GHUPS), Hôpital Bicêtre, Le Kremlin Bicetre, France
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - C E Eapen
- Hepatology Department, Christian Medical College, Vellore, India
| | - Ashish Goel
- Hepatology Department, Christian Medical College, Vellore, India
| | | | - Sandra Coenen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Andrea De Gottardi
- Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital and Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Avik Majumdar
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Simona Onali
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Akash Shukla
- Department of Gastroenterology, Seth G S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Flair José Carrilho
- Digestive Organ Transplantation Division, Department of Gastroenterology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lucas Nacif
- Digestive Organ Transplantation Division, Department of Gastroenterology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Massimo Primignani
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giulia Tosetti
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Vicenzo La Mura
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale Emostasi e Trombosi, Milano, Italy
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Witters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Dhiraj Tripathi
- Liver Unit, Queen Elisabeth Hospital, Birmingham, United Kingdom
| | - Luis Tellez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBERedh, Madrid, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBERedh, Madrid, Spain
| | | | | | - Bogdan Procopet
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "Iuliu Hatieganu", Regional Institute of Gastroenterology and Hepatology "O Fodor", Cluj-Napoca, Romania
| | - Fabio Piscaglia
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Barbara de Koning
- Division of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elba Llop
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mario Romero-Cristobal
- Digestive Diseases and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Hospital General Universitario Gregorio Marañón Instituto de Investigación Sanitaria Gregorio Marañón Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Alberto Monescillo-Francia
- Digestive Disease Department, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, España
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Mercedes Perez-LaFuente
- Interventional Radiology Unit, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Segarra
- Interventional Radiology Unit, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - David Patch
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Wim Laleman
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale Emostasi e Trombosi, Milano, Italy
| | - Hermien Hartog
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dominique Valla
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
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Zhang JS, Li L, Cheng W, Hou WY. Rex Shunt as a Treatment of Type II Abernethy Malformation with Severe Dysplasia of Portal Vein. Ann Vasc Surg 2018; 53:268.e1-268.e6. [DOI: 10.1016/j.avsg.2018.05.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/11/2018] [Accepted: 05/04/2018] [Indexed: 12/16/2022]
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7
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Sharma S, Bobhate PR, Sable S, Kumar S, Yadav K, Maheshwari S, Amin S, Chauhan A, Varma V, Kapoor S, Kumaran V. Abernethy malformation: Single-center experience from India with review of literature. Indian J Gastroenterol 2018; 37:359-364. [PMID: 30187299 DOI: 10.1007/s12664-018-0884-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/05/2018] [Indexed: 02/04/2023]
Abstract
Abernethy malformation is a rare congenital anomaly in which there is direct communication between the portal and systemic venous circulation. The clinical presentation ranges from asymptomatic with incidental detection on imaging to secondary complications of disease or related to associate anomalies. This is a retrospective analysis of data from nine patients with Abernethy malformation at a single center. This is a referral center for Pediatric Cardiology and for Hepatobiliary and Pancreatic Surgery. The patients presented to the Pulmonary Hypertension Clinic/the Hepatobiliary Surgery Clinic. Out of nine patients, four were male. Type II Abernethy malformation was present in five patients whereas three patients had type I malformation. One of the patients had communication between inferior mesenteric vein and internal iliac vein. Five out of nine patients were erroneously diagnosed as idiopathic primary pulmonary hypertension and were treated with vasodilators. One patient required living donor liver transplant. One patient was managed with surgical shunt closure whereas two patients required transcatheter shunt closure. The rest of the patients were managed conservatively. Abernethy malformation is more common than previously thought and the diagnosis is often missed. There are various management options for Abernethy malformation, which includes surgical or transcatheter shunt closure and liver transplant. Management of Abernethy malformation depends upon type, presentation, and size of shunt.
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Affiliation(s)
- Swapnil Sharma
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India.
| | - Prashant R Bobhate
- Department of Pediatric Cardiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Shailesh Sable
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Suneed Kumar
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Kapildev Yadav
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Sharad Maheshwari
- Department of Radiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Saista Amin
- Department of Pediatric Hepatology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Ashutosh Chauhan
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Vibha Varma
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Sorabh Kapoor
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Vinay Kumaran
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
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8
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Chick JFB, Reddy SN, Yu AC, Kelil T, Srinivasa RN, Cooper KJ, Saad WE. Three-Dimensional Printing Facilitates Successful Endovascular Closure of a Type II Abernethy Malformation Using an Amplatzer Atrial Septal Occluder Device. Ann Vasc Surg 2017; 43:311.e15-311.e23. [DOI: 10.1016/j.avsg.2017.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 02/04/2017] [Indexed: 11/26/2022]
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9
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Lee SH, Yun SJ. A Type II Congenital Extrahepatic Portosystemic Shunt: A Rare Cause of Abdominal Pain Diagnosed by Point-of-Care Ultrasound. J Emerg Med 2017; 52:880-882. [PMID: 28162834 DOI: 10.1016/j.jemermed.2016.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Nowon-gu, Republic of Korea
| | - Seong Jong Yun
- Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea
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10
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Fu L, Wang Q, Wu J, Guo Y, Huang M, Liu T, Chen Q, Li F. Congenital extrahepatic portosystemic shunt: an underdiagnosed but treatable cause of hepatopulmonary syndrome. Eur J Pediatr 2016; 175:195-201. [PMID: 26311567 DOI: 10.1007/s00431-015-2623-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/10/2015] [Accepted: 08/14/2015] [Indexed: 12/30/2022]
Abstract
UNLABELLED Congenital extrahepatic portosystemic shunt (CEPS) is a rare malformation of the mesenteric vasculature, which may lead to severe complications. In this report, we describe a case series of three children with type II CEPS (presenting as hypoxemia) and hepatopulmonary syndrome (HPS). The first patient was a 4-year-old male who did not receive any specific treatment and subsequently died of brain abscess 5 years after the diagnosis. The second patient was a 10-year-old female with a 5-year history of cyanosis and dyspnea on exertion. She had partial regression of hypoxemia and improved exercise tolerance at 8 months after a surgical shunt closure. The third patient was a 4-year-old male with a 3-year history of cyanosis and decreased exercise tolerance. He had full regression of hypoxemia at 3 months after a transcatheter shunt closure. CONCLUSION These results indicate that CEPS may present in children with unexplained hypoxemia, which may lead to devastating clinical consequences. Closure of portosystemic shunts may result in resolution of HPS in type II CEPS and the length of period for resolution varies depending on the severity of HPS. WHAT IS KNOWN Congenital extrahepatic portosystemic shunt (CEPS) is a rare cause of hepatopulmonary syndrome (HPS). There have been few reports in the literature about the management and outcome of HPS in children with CEPS. WHAT IS NEW CEPS may present in children with unexplained hypoxemia, which may lead to devastating clinical consequences. Closure of portosystemic shunts may result in resolution of HPS in type II CEPS.
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Affiliation(s)
- Lijun Fu
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
| | - Qian Wang
- Department of Radiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
| | - Jinjin Wu
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
| | - Ying Guo
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
| | - Meirong Huang
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
| | - Tingliang Liu
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
| | - Qimin Chen
- Department of Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
| | - Fen Li
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, No. 1678 Dongfang Road, Shanghai, 200127, China.
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11
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Knirsch W, Benz DC, Bühr P, Quandt D, Weber R, Kellenberger C, Braegger CP, Kretschmar O. Catheter interventional treatment of congenital portosystemic venous shunts in childhood. Catheter Cardiovasc Interv 2015; 87:1281-92. [PMID: 26715199 DOI: 10.1002/ccd.26362] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 10/14/2015] [Accepted: 11/22/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The study aimed on the catheter interventional treatment of congenital portosystemic venous shunt (CPSVS) in childhood and the impact on vascular growth of hypoplastic portal veins. Clinical course and follow up of partial or complete closure of CPSVS are described. BACKGROUND CPSVS is a very rare vascular malformation of the portal venous drainage resulting in potentially life threatening abdominal, pulmonary, cerebral, and cardiac complications. The anatomic type, clinical course, and diagnosis must be determined for optimal management. METHODS Single centre case series. RESULTS Eight (6 female) children with extrahepatic (n = 5) and intrahepatic (n = 3) CPSVS were diagnosed invasively by catheterization, including test balloon occlusion of the shunt and simultaneous retrograde angiography, and treated by catheter interventions (n = 5) with partial (n = 2) and complete (n = 3) occlusion of CPSVS at a median age of 3.9 years (range 0.7-21). Congenital heart disease (CHD) was the most frequent associated organ manifestation (n = 5) followed by mild to severe pulmonary arterial hypertension (n = 4), hepatopulmonary syndrome (n = 2), and portosystemic encephalopathy (n = 1). CHD was simple (n = 3) or complex type (n = 2). Three patients were untreated so far, because they were in excellent clinical condition at an age <1 year, refused treatment, or planned for later treatment. CONCLUSIONS Accurate invasive diagnosis of CPSVS with test balloon occlusion of the shunt is mandatory to depict the anatomic situation. Catheter interventional treatment of CPSVS offers a feasible and safe approach with complete or partial closure of the vascular malformation inducing potentially significant vascular growth of a former hypoplastic portal venous system. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Walter Knirsch
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Dominik C Benz
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Patrick Bühr
- Department of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Daniel Quandt
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Roland Weber
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Christian Kellenberger
- Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Christian P Braegger
- Department of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
| | - Oliver Kretschmar
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland.,Children's Research Center, University Children's Hospital, Zurich, Switzerland
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12
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Abstract
BACKGROUND Chronic hypoxemia is generally attributed to primary cardiac or pulmonary entities. CASE CHARACTERISTICS A 9-year-old boy presenting with cyanosis, clubbing and hypoxemia, without icterus or hepatosplenomegaly. Cardiovascular and respiratory system examinations were normal. OUTCOME He was diagnosed as type IB Abernethy malformation, a rare cause of hepatopulmonary syndrome. MESSAGE Pediatricians should consider hepatopulmonary syndrome in the differential diagnosis of chronic hypoxemia, even in the absence of jaundice or hepatosplenomegaly.
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13
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Soni N, Ambesh P, Sunil K, Jena M. Abernethy malformation with Inferior Vena Cava stenosis: A cryptic cause of cyanosis. Indian Heart J 2015; 67:543-5. [PMID: 26702682 DOI: 10.1016/j.ihj.2015.06.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/17/2015] [Accepted: 06/29/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Neetu Soni
- Assistant Professor, Radiology Department, SGPGIMS, Lucknow, Uttar Pradesh, India.
| | - Paurush Ambesh
- Department of Internal Medicine, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
| | - Kumar Sunil
- Professor, Radiology Department, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Manas Jena
- Department of Radiodiagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
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14
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Saulters K, Hittle K. Hepatopulmonary syndrome in the presence of abernethy malformation: a pediatric case report. J Pediatr Health Care 2015; 29:104-7. [PMID: 24986474 DOI: 10.1016/j.pedhc.2014.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/09/2014] [Accepted: 05/15/2014] [Indexed: 12/28/2022]
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15
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Congenital absence of the portal vein associated with focal nodular hyperplasia of the liver and congenital heart disease (Abernethy malformation): A case report and literature review. Oncol Lett 2014; 9:695-700. [PMID: 25624897 PMCID: PMC4301562 DOI: 10.3892/ol.2014.2767] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 10/29/2014] [Indexed: 11/13/2022] Open
Abstract
Abernethy malformation is a rare congenital malformation defined by an extrahepatic portosystemic shunt. The majority of affected patients are young (<18 years of age) and experience various symptoms, including vomiting, jaundice, dyspnea and coma. The current study presents a case of Abernethy malformation in an asymptomatic adult male patient. The patient exhibited congenital absence of the portal vein, congenital heart disease (postoperative ventricular septal defect status), and multiple liver lesions, confirmed to be focal nodular hyperplasia by biopsy. Ultrasonography and magnetic resonance imaging findings revealing the liver lesions, type II congenital absence of the portal vein and the portosystemic shunt are presented. In addition, the common clinical presentations, associated anomalies, diagnostic workup and treatment options of this disorder are investigated by reviewing 101 previously reported cases.
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16
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Squires RH, Ng V, Romero R, Ekong U, Hardikar W, Emre S, Mazariegos GV. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology 2014; 60:362-98. [PMID: 24782219 DOI: 10.1002/hep.27191] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Robert H Squires
- Department of Pediatrics, University of Pittsburgh School of Medicine; Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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17
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Staged Transcatheter Treatment of Portal Hypoplasia and Congenital Portosystemic Shunts in Children. Cardiovasc Intervent Radiol 2013; 36:1580-1585. [DOI: 10.1007/s00270-013-0581-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 01/12/2013] [Indexed: 10/27/2022]
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18
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Abstract
Hepatopulmonary syndrome (HPS) is a serious vascular complication of liver disease that occurs in 5-32% of patients with cirrhosis. The presence of HPS markedly increases mortality. No effective medical therapies are currently available and liver transplantation is the only established treatment option for HPS. The definition and diagnosis of HPS are established by the presence of a triad of liver disease with intrapulmonary vascular dilation that causes abnormal arterial gas exchange. Experimental biliary cirrhosis induced by common bile duct ligation in the rat reproduces the pulmonary vascular and gas exchange abnormalities of human HPS and serves as a pertinent animal model. Pulmonary microvascular dilation and angiogenesis are two central pathogenic features that drive abnormal pulmonary gas exchange in experimental HPS, and thus might underlie HPS in humans. Defining the mechanisms involved in the microvascular alterations of HPS has the potential to lead to effective medical therapies. This Review focuses on the current understanding of the pathogenesis, clinical features and management of HPS.
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Affiliation(s)
- Junlan Zhang
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030-1501, USA
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19
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Evolution of congenital malformations of the umbilical-portal-hepatic venous system. J Pediatr Surg 2012; 47:1490-5. [PMID: 22901905 DOI: 10.1016/j.jpedsurg.2012.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 12/20/2011] [Accepted: 02/02/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of this study is to describe the evolution of 8 cases of congenital malformations of the umbilical-portal-hepatic venous system diagnosed before the first month of life. MATERIALS AND METHODS All cases of congenital malformation of the portal and hepatic venous system diagnosed prenatally or during the first month of life in our institution were systematically reviewed since November 2000. Clinical features, imaging, and anatomical findings were reviewed, focusing primarily on clinical and radiologic evolution. RESULTS Eight cases of congenital malformation of the umbilical-portal-hepatic venous system were studied. Fifty percent of these malformations were diagnosed prenatally. We report 4 portosystemic shunts. Three involuted spontaneously, and the fourth one required surgical treatment. We report a variation of the usual anatomy of portal and hepatic veins that remained asymptomatic, an aneurysmal dilatation of a vitelline vein causing portal vein thrombosis that needed prompt surgical treatment with good result, a complex portal and hepatic venous malformation treated operatively, and a persistent right umbilical vein that remained asymptomatic. CONCLUSION Prenatal diagnosis of malformations of the umbilical-portal-hepatic venous network is uncommon. Little is known about the postnatal prognosis. Clinical, biologic, and radiologic follow-up by ultrasonography is essential to distinguish pathologic situations from normal anatomical variants.
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20
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Passalacqua M, Lie KT, Yarmohammadi H. Congenital extrahepatic portosystemic shunt (Abernethy malformation) treated endovascularly with vascular plug shunt closure. Pediatr Surg Int 2012; 28:79-83. [PMID: 21739127 DOI: 10.1007/s00383-011-2944-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2011] [Indexed: 12/30/2022]
Abstract
A 3-year-old boy, who presented with progressive cyanosis and hypoxia, was diagnosed with a large congenital extrahepatic portosystemic shunt, interrupted IVC with azygos continuation, and multiple congenital anomalies. Traditionally open and laparoscopic surgical techniques have been used to treat this malformation. Endovascular repair using a 16-mm Amplatzer vascular plug (AGA Medical Corporation, Golden Valley, Minnesota, USA) was used to occlude the shunt. Immediate post-placement venography demonstrated cessation of flow within the shunt and increased portal venous flow. The patient's hypoxia and cyanosis decreased significantly, and he was discharged on the 5th post-procedure day in stable clinical condition. Three months follow-up evaluation demonstrated the vascular plug in place, unchanged in position.
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Affiliation(s)
- Matthew Passalacqua
- Division of Vascular and Interventional Radiology, Department of Diagnostic Radiology, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5056, USA
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21
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Portal venous remodeling after endovascular reduction of pediatric autogenous portosystemic shunts. J Vasc Interv Radiol 2011; 22:1199-205. [PMID: 21801995 DOI: 10.1016/j.jvir.2011.01.438] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/12/2011] [Accepted: 01/24/2011] [Indexed: 11/20/2022] Open
Abstract
Patients with autogenous native vessel portosystemic shunts, whether surgical or congenital, may experience complications of excess shunt flow, including hepatopulmonary syndrome (HPS), hepatic encephalopathy (HE), and hepatic insufficiency. The authors explored endovascular reduction or occlusion of autogenous portosystemic shunts using methods commonly employed in transjugular intrahepatic portosystemic shunt (TIPS) reduction in four pediatric patients. Before treatment, the patients had hypoplastic, atrophic, or thrombosed portal veins. Following intervention, symptoms of overshunting resolved or improved in all patients without major complications. The innate plasticity of the pediatric portal venous system allowed for hypertrophy or development and maturation of cavernous transformations to accommodate increased hepatopetal blood flow and pressure.
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22
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Osorio MJ, Bonow A, Bond GJ, Rivera MR, Vaughan KG, Shah A, Shneider BL. Abernethy malformation complicated by hepatopulmonary syndrome and a liver mass successfully treated by liver transplantation. Pediatr Transplant 2011; 15:E149-51. [PMID: 20565695 DOI: 10.1111/j.1399-3046.2010.01337.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A seven-yr-old boy presented with persistent oxygen requirement following a respiratory infection. Physical exam was remarkable for orthodeoxia and digital clubbing. Laboratory evaluation showed elevated A-a oxygen gradient of 48 mmHg and mildly elevated transaminases. Sonography showed a 13 cm multilobulated liver mass and a biopsy revealed histological findings consistent with focal nodular hyperplasia. MAA scan revealed 23% right to left shunting. Abdominal CTA and MRV demonstrated the absence of the intrahepatic portal vein with an extrahepatic portocaval shunt. Abernethy malformation is a rare anomalous intra- or extrahepatic communication between portal blood flow and systemic venous return. In rare cases, Abernethy malformation results in HPS. Ours is the sixth case report to describe the co-existence of these two entities. Surgical correction of anomalous hepatic vasculature or liver transplant is imperative to restoration of lung function and also to prevent progression of possible malignant liver tumors. We describe the second patient with Abernethy and HPS who underwent liver transplant with complete resolution of HPS.
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Affiliation(s)
- Maria Joana Osorio
- Pediatrics and Child Neurology Resident PGY3, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.
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23
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Konstas AA, Digumarthy SR, Avery LL, Wallace KL, Lisovsky M, Misdraji J, Hahn PF. Congenital portosystemic shunts: Imaging findings and clinical presentations in 11 patients. Eur J Radiol 2011; 80:175-81. [DOI: 10.1016/j.ejrad.2009.12.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 12/30/2009] [Indexed: 11/26/2022]
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Schiller O, Avitzur Y, Kadmon G, Nahum E, Steinberg RM, Nachmias V, Schonfeld T. Nitric oxide for post-liver-transplantation hypoxemia in pediatric hepatopulmonary syndrome: case report and review. Pediatr Transplant 2011; 15:E130-4. [PMID: 20408994 DOI: 10.1111/j.1399-3046.2010.01313.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HPS is rare in the pediatric population. Liver transplantation is the ultimate treatment for severe HPS. There are only a few case reports and one series of children in whom HPS was the main indication for liver transplantation. Outcome was good in most of them, with full regression of the pulmonary process. However, hypoxemia in the early post-operative course can have severe consequences, and effective treatment modalities are needed. There are rare instances of the use of iNO for the treatment of post-operative hypoxemia. We describe a 10.5-yr-old boy with severe HPS owing to chronic liver disease after bone marrow transplantation. Liver transplantation from a living related donor (the same sister who donated the bone marrow) was complicated by severe hypoxemia on POD 2. iNO was administered via the ventilator circuit and, after extubation, through nasal prongs. It was slowly tapered down and stopped on POD 10. The child had an otherwise uneventful course and was discharged home on POD 21 with normal oxygen saturation. Liver transplantation should be offered to children with severe HPS. iNO can reverse the hypoxemia that may occur after the operation.
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Affiliation(s)
- Ofer Schiller
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tiqwa 49202, Israel.
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25
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Sanada Y, Urahashi T, Ihara Y, Wakiya T, Okada N, Yamada N, Egami S, Hishikawa S, Kawano Y, Ushijima K, Otomo S, Sakamoto K, Nakata M, Yasuda Y, Mizuta K. The role of operative intervention in management of congenital extrahepatic portosystemic shunt. Surgery 2011; 151:404-11. [PMID: 21962400 DOI: 10.1016/j.surg.2011.07.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 07/08/2011] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Congenital extrahepatic portosystemic shunt (CEPS) is a rare venous malformation in which mesenteric venous blood drains directly into the systemic circulation. It is still a matter of debate whether conservative or operative strategies should be used to treat symptomatic CEPS. The aim of this study was to evaluate the role of operative intervention in the management of CEPS. METHODS Between June 2004 and August 2010, 6 consecutive patients with symptomatic CEPS were treated in our department. There were 3 male and 3 female patients, with a median age of 3.5 years (range, 1-8). Their demographic, clinical, and laboratory data were analyzed. All patients were scheduled to undergo shunt ligation or liver transplantation (LT). RESULTS Living donor LT was carried out in 4 patients, and shunt ligation in 2. After a median follow-up of 25 months, all the patients are alive currently with marked relief of symptoms. CONCLUSION Shunt ligation or LT for symptomatic CEPS is potentially curative.
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Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, Tochigi, Japan.
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26
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Shen O, Valsky DV, Messing B, Cohen SM, Lipschuetz M, Yagel S. Shunt diameter in agenesis of the ductus venosus with extrahepatic portosystemic shunt impacts on prognosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:184-190. [PMID: 20521238 DOI: 10.1002/uog.7702] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/20/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVES Agenesis of the ductus venosus (ADV) is a rare condition in which there are two variants of umbilical vein drainage: intrahepatic shunt or extrahepatic (portosystemic) shunt. It has been posited that the extrahepatic variant carries a poorer prognosis. However, in the absence of associated anomalies there is still a wide variation in outcome. We evaluated the portal system in cases of ADV and aimed to identify parameters that might predict outcome. METHODS We conducted a retrospective study of cases of ADV with extrahepatic shunt that had been examined in two centers, and collected new cases prospectively. The route of the shunt was depicted using two-dimensional (2D) and three-dimensional (3D) ultrasound imaging. In an attempt to characterize portal system and shunt developmental variations and their possible impact on outcome, the diameter of the shunt was compared with the diameter of the umbilical vein and the entire portal vasculature was assessed. Poor outcome was defined as persistent morbidity or fetal or neonatal death. RESULTS Twenty-two cases of ADV were identified: nine retrospectively and 13 prospectively. Aberrant shunts from the umbilical vein were identified to the right atrium, coronary sinus, inferior vena cava (IVC) and iliac vein. In seven of 22 cases (32%) a wide connection was observed. In six of these seven cases (86%) the outcome was poor, including four with severe associated anomalies and two with hepatic dysfunction. In five of these cases, cardiomegaly with tricuspid regurgitation was observed, as well as underdevelopment of the portal system. In only five of 15 cases with a narrow shunt (33%) was the outcome poor, and in all five cases the poor outcome was related to associated anomalies. CONCLUSION In cases of ADV with extrahepatic shunt, portal system development is impacted by the diameter of the shunt. If the shunt is narrow, the portal system will have developed normally. A wide shunt is associated with underdevelopment or absence of the portal system. In cases of ADV with extrahepatic shunt, prognosis is determined by the severity of associated anomalies, the diameter of the shunt and development of the portal system.
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Affiliation(s)
- O Shen
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Centers, Jerusalem, Israel
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27
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Lautz TB, Tantemsapya N, Rowell E, Superina RA. Management and classification of type II congenital portosystemic shunts. J Pediatr Surg 2011; 46:308-14. [PMID: 21292079 DOI: 10.1016/j.jpedsurg.2010.11.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Congenital portosystemic shunts (PSS) with preserved intrahepatic portal flow (type II) present with a range of clinical signs. The indications for and benefits of repair of PSS remain incompletely understood. A more comprehensive classification may also benefit comparative analyses from different institutions. METHODS All children treated at our institution for type II congenital PSS from 1999 through 2009 were reviewed for presentation, treatment, and outcome. RESULTS Ten children (7 boys) with type II PSS were identified at a median age of 5.5 years. Hyperammonemia with varying degrees of neurocognitive dysfunction occurred in 80%. The shunt arose from a branch of the portal vein (type IIa; n = 2), from the main portal vein (type IIb; n = 7), or from a splenic or mesenteric vein (type IIc; n = 1). Management included operative ligation (n = 6), endovascular occlusion (n = 3), or a combined approach (n = 1). Shunt occlusion was successful in all cases. Serum ammonia decreased from 130 ± 115 μmol/L preoperatively to 31 ± 15 μmol/L postoperatively (P = .03). Additional benefits included resolution of neurocognitive dysfunction (n = 3), liver nodules (n = 1), and vaginal bleeding (n = 1). CONCLUSION Correction of type II PSS relieves a wide array of symptoms. Surgery is indicated for patients with clinically significant shunting. A refined classification system will permit future comparison of patients with similar physiology.
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Affiliation(s)
- Timothy B Lautz
- Department of Surgery, Children's Memorial Hospital, Feinberg School of Medicine of Northwestern University, Box 57, Chicago, IL 60614, USA
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28
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A rare cause of cyanosis: hepatopulmonary syndrome caused by congenital extrahepatic portosystemic shunt. Case Rep Vasc Med 2011; 2011:508171. [PMID: 22937464 PMCID: PMC3420761 DOI: 10.1155/2011/508171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 12/05/2011] [Indexed: 11/18/2022] Open
Abstract
A 19-year-old male patient presented cyanosis and dyspnoea because of the presence of multiple pulmonary arteriovenous fistulas resulting in oxygen desaturation. The CTA revealed that intestinal and splenic venous blood bypasses the liver and drains into the inferior vena cava. This is the first reported case of hepatopulmonary syndrome caused by congenital extrahepatic portosystemic shunt in which intestinal and splenic venous blood bypasses the liver and drains into the inferior vena cava.
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29
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Kuo MD, Miller FJ, Lavine JE, Peterson M, Finch M. Exploiting Phenotypic Plasticity for the Treatment of Hepatopulmonary Shunting in Abernethy Malformation. J Vasc Interv Radiol 2010; 21:917-22. [DOI: 10.1016/j.jvir.2010.01.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 01/10/2010] [Accepted: 01/18/2010] [Indexed: 10/19/2022] Open
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Nii A, Takehara HO, Kuyama H, Shimada M. Successful preemptive surgical division of type 2-congenital extrahepatic portosystemic shunt in children. THE JOURNAL OF MEDICAL INVESTIGATION 2009; 56:49-54. [DOI: 10.2152/jmi.56.49] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Akira Nii
- Department of Pediatric Surgery and Pediatric Endoscopic Surgery, Tokushima University Hospital
| | - Hiro-o Takehara
- Department of Pediatric Surgery and Pediatric Endoscopic Surgery, Tokushima University Hospital
| | - Hisako Kuyama
- Department of Pediatric Surgery and Pediatric Endoscopic Surgery, Tokushima University Hospital
| | - Mitsuo Shimada
- Department of Digestive Surgery and Transplantation, Institute of Health Biosciences, the University of Tokushima Graduate School
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