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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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Yeh YT, Chen CY, Tseng HS, Wang HK, Tsai HL, Lin NC, Wei CF, Liu C. Enlarging vascular stents after pediatric liver transplantation. J Pediatr Surg 2017; 52:1934-1939. [PMID: 28927979 DOI: 10.1016/j.jpedsurg.2017.08.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 08/28/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Endovascular intervention with stent placement to treat portal vein (PV) and hepatic vein (HV) stenosis after pediatric liver transplantation (LT) is still controversial in small children owing to the potential risk of functional stenosis after growth. The aim of this study is to evaluate the safety and efficacy of stent placement in this population. METHODS Between 2004 and 2016, 6 children (all <3 years) received HV (n = 2) and PV (n = 4) stents placement among 46 pediatric LT patients at our institution. The clinical outcome and patency rate were followed. Morphologic changes of stents were assessed from plain films by a new index: the stent diameter ratio (SDR). RESULTS The median age of the patients at LT was 8.9 months. The patency rate was 100% without functional stenosis during a median follow-up period of 65.5 months. The "stent growth" phenomenon was demonstrated by SDR with significant resolution of hourglass deformity 2 years after stent placement (p for trend <.001). CONCLUSION Vascular stent placement is a safe and effective method for the management of PV and HV stenosis following pediatric LT because these stents will enlarge as children grow. TYPE OF STUDY Case Series with no Comparison Group LEVEL OF EVIDENCE: Level IV.
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Affiliation(s)
- Yi-Ting Yeh
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Cheng-Yen Chen
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsiou-Shan Tseng
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsin-Kai Wang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Hsin-Lin Tsai
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Niang-Cheng Lin
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chou-Fu Wei
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chinsu Liu
- Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming University, Taipei, Taiwan.
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Han D, Tang R, Wang L, Li A, Huang X, Shen S, Dong J. 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. Medicine (Baltimore) 2017; 96:e7208. [PMID: 28640110 PMCID: PMC5484218 DOI: 10.1097/md.0000000000007208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Neto JS, Fonseca EA, Cândido HL, Pugliese R, Feier FH, Kondo M, Azambuja RL, Chapchap P. Alternatives for vascular reconstruction in pediatric living donor liver transplantation. Pediatr Transplant 2016; 20:717-722. [PMID: 27174167 DOI: 10.1111/petr.12720] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2016] [Indexed: 01/10/2023]
Abstract
Many publications discuss the various strategies for vascular reconstruction (VR) in pediatric LDLT. Having knowledge of alternative techniques is helpful in planning transplants. This article presents three case reports that illustrate some of the alternative techniques for HV, PV, and HA reconstruction in pediatric LDLT. It also reviews the available alternative strategies reported for VR in pediatric LDLT. In the first case, a 13-month-old girl presented a PRETEXT III HB with invasion of the retrohepatic vena cava. An LLS graft HV was anastomosed to a DD iliac vein graft and subsequently implanted in a "standard" fashion in the recipient. In the second case, a 44-month-old boy presented with multifocal HB and portomesenteric thrombosis and the portal inflow was done through a renoportal anastomosis. In the third case, a 22-month-old child with a failed Kasai procedure had extensive HA thrombosis. The HA reconstruction was performed with an interposition of the recipient's IMV graft. The use of alternative techniques for VR in pediatric LDLT is paramount to the success of such a complex procedure. Imaging studies can help transplant surgeons outline surgical strategies and define the best technique to be used in each case.
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Affiliation(s)
- Joao Seda Neto
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Eduardo A Fonseca
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Helry L Cândido
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Renata Pugliese
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Flavia H Feier
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Mario Kondo
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil.,A.C. Camargo Cancer Center, São Paulo, Brazil
| | | | - Paulo Chapchap
- Hepatology and Liver Transplantation Unit, Hospital Sírio-Libanês, São Paulo, Brazil
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Cho YP, Kim KM, Ha TY, Ko GY, Hwang JY, Park H, Chung YS, Yoon T, Hwang S, Jun H, Kwon TW, Lee SG. Management of late-onset portal vein complications in pediatric living-donor liver transplantation. Pediatr Transplant 2014; 18:64-71. [PMID: 24341631 DOI: 10.1111/petr.12204] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2013] [Indexed: 12/13/2022]
Abstract
The purpose of this study was to evaluate retrospectively the results of PTA for late-onset PV complications after pediatric LDLT and to assess whether a meso-Rex shunt is a viable option for treating restenosis of the PV after PTA in selected cases. Seventy-five children who underwent adult-to-child LDLT were included in this study, and there were six late-onset PV complications (8.0%). The initial therapeutic approach was PTA, with or without stent: PTA with balloon dilation for three children, PTA with stent placement for one child, and failure to cannulate the occluded PV for two children. A meso-Rex shunt was performed in the two children after failed PTA: One suffered complete obstruction of the main PV, and the other, restenosis with total thrombosis after PTA with stent. The PTA was a technical and clinical success in four with PV stenosis of the six patients (66.7%), and successful application of a meso-Rex shunt in the other two children resulted in restoration of PV flow. In conclusion, PTA is a safe and effective procedure for treating late-onset PV stenosis after pediatric LDLT. However, in growing pediatric recipients with restenosis of the PV after PTA or chronic PV thrombosis, a meso-Rex shunt may be a better choice for late-onset PV complications.
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Affiliation(s)
- Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Chen CY, Tseng HS, Lin NC, Wang JB, Tsai HL, Loong CC, Hsia CY, Liu C. A bidirectional approach for portal vein stent placement in a child with complete portal vein occlusion after living donor liver transplantation. Pediatr Transplant 2013; 17:E137-40. [PMID: 23834675 DOI: 10.1111/petr.12121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 01/10/2023]
Abstract
Delayed PV complications are not rare in pediatric liver transplantation. Although PTPV offers a treatment and minimizes surgical revision, in case of complete PV thrombosis (PVT), the failure rate of PTPV is high. Herein, we report a successful technique of PTPV in a case of complete PVT with a stent placement using a bidirectional approach in a child with living donor liver transplantation.
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Affiliation(s)
- Cheng-Yen Chen
- Division of Pediatric Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
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de Ville de Goyet J, Lo Zupone C, Grimaldi C, D'Ambrosio G, Candusso M, Torre G, Monti L. Meso-Rex bypass as an alternative technique for portal vein reconstruction at or after liver transplantation in children: review and perspectives. Pediatr Transplant 2013; 17:19-26. [PMID: 22943796 DOI: 10.1111/j.1399-3046.2012.01784.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Direct portal revascularization can be achieved by interposing a vascular graft between the SMV and the Rex recessus (left portal vein system): the MRB. To review indications and results of the procedure in the setting of pediatric liver transplantation, reports were selected from the English literature. Previously reported series were updated to analyze long-term outcome. A new series was added and analyzed as a complementary set of cases. A total of 51 cases were analyzed. With a 96% overall patient survival rate and a 100% long-term patency rate when the IJV is used for the bypass, MRB achieves a very successful physiologic cure of chronic portal hypertension and restores the portal flow into and through the liver graft. It also has been used successfully for primary revascularization of liver grafts, as well as for managing early acute portal vein thrombosis episodes. The use of this procedure in conjunction with other strategies and techniques might be of interest for transplant surgeons, particularly those caring for children.
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