Cavernous transformation of the portal vein associated to multiorgan developmental abnormalities

Location and extent of cavernous transformation of the portal vein dictates different visceral side revascularization in Meso-Rex bypass

BACKGROUND

As an emerging standard of care for portal vein cavernous transformation (PVCT), Meso-Rex bypass (MRB) has been complicated and variated. The study aim was to propose a new classification of PVCT to guide MRB operations.

METHODS

Demographic data, the extent of extrahepatic PVCT, surgical methods for visceral side revascularization, intraoperative blood loss, operating time, changes in visceral venous pressure before and after MRB, postoperative complications and the condition of bypass vessels after MRB were extracted retrospectively from the medical records of 19 patients.

RESULTS

The median age of the patients (13 males and 6 females) was 32.5 years, while two patients were underage. Causes of PVCT can be summarized as follows: thrombophilia such as dysfunction of antithrombin III or proteins C; secondary to abdominal surgeries; secondary to abdominal infection or traumatic intestinal obstruction, and unknown causes. Intraoperatively, the median operation time was 9.5 h (7-13 h), and the intraoperative blood loss was 300 mL (100-1,600 mL). Ten cases used autologous blood vessels while 10 used allogeneic blood vessels. The vascular anastomosis was divided into the following types according to the site and approach: Type (T) 1-PV pedicel type, T2-confluence type, T3-major visceral vascular type; and T4-collateral visceral vascular type. Furthermore, the visceral venous pressure before and after MRB dropped significantly from 36 cmH2O (28-44) to 24.5 cmH2O (15-31) (P < 0.01). Postoperatively, one patient had delayed wound healing, two developed biochemical pancreatic fistulae, one experienced lymphatic leakage, the former caused by heat damage of the pancreatic tissues, the latter by cutting lymphatic vessels in the mesentery or removing the local lymph nodes during the process of separating the superior mesenteric vein, and one was re-operated on for an intervening intestinal fistulae. Postoperative enhanced CT scans revealed a significant improvement in abdominal varix in the patients with patent bypass, and at the 1-year postoperative follow-up, enhanced CT scans of six patients showed that the long axis of the spleen was reduced by ≥ 2 cm.

CONCLUSIONS

MRB can effectively reduce visceral venous pressure in patients with PVCT. It is feasible to determine the PVCT type according to the extent of involvement and to choose individualized visceral side revascularization performances.

Detection of Cavernous Transformation of the Portal Vein in a 22-year-old Male with Upper Gastrointestinal Bleeding by Abdominal Duplex Ultrasonography: A Case Report

Introduction

Cavernous transformation of the portal vein, although a hepatic condition, may manifest with clinical features similar to those in patients with gastrointestinal pathologies. Particularly in young patients with no prior history of alcoholism or hepatic pathology, the diagnosis of cavernous transformation of the portal vein may be missed in an emergency setting where patients' reported symptoms may be mimicking those associated with bleeding peptic ulcer or other gastrointestinal pathologies.

Case Report

We present a case of a 22-year-old male with no prior history of hepatic or pancreatic pathology who presented to the emergency room with some episodes of haematemesis, melena and slight dizziness, in whom a cavernous transformation of the portal vein was identified by abdominal duplex ultrasonography.

Discussion

The clinical diagnosis of cavernous transformation of the portal vein can be challenging and easily missed especially in instances where a patient with no history of chronic alcoholism, liver cirrhosis, hepatoma, pancreatitis or prior abdominal surgery presents to the emergency room with haematemesis and anaemia. Ultrasonography presents as a reliable radiological tool in the diagnosis of rare and unforeseen conditions like cavernous transformation of the portal vein to allow for prompt management and prevention of adverse patients' outcomes.

Conclusion

Abdominal duplex ultrasonography can reliably aid in the prompt diagnosis and management of patients with unforeseen rare hepatic pathologies such as cavernous transformation of the portal vein who present with upper gastrointestinal bleeding.

Cavernous Transformation of the Portal Vein in a 26-Month Old Boy Treated by Transjugular Intrahepatic Portosystemic Shunt: A Case Report

Cavernous transformation of portal vein (CTPV) is the main cause of portal hypertension and its related variceal bleeding in children. Transjugular intrahepatic portosystemic shunt (TIPS) was not reported to treat CTPV for children younger than 5 years old. In this case report, the patient was a 26-month-old boy who presented with hematemesis and melena due to CTPV. Even after azygoportal disconnection, repeated hematemesis as well-melena still occurred. After careful evaluation, we performed TIPS under general anesthesia for him. The procedure was uneventful, and 6-mm stents were inserted. Six months after TIPS, there was no recurrence of bleeding, and no procedure-related event happened. The follow-up esophagogastroduodenoscopy proved dramatic remission of varices, indicating a successful outcome. We believe TIPS could be safely placed for young children to manage variceal bleeding due to CTPV.

Combined Rex-bypass shunt with pericardial devascularization alleviated prehepatic portal hypertension caused by cavernomatous transformation of portal vein

OBJECTIVE

To evaluate the effects of combined Rex-bypass shunt and pericardial devascularization on prehepatic portal hypertension secondary to cavernomatous transformation of portal vein (CTPV).

METHODS

Forty-two patients aged from 3 years to 49 years (divided into 3 groups), 26 cases male and 16 female, with prehepatic vascular hepertention were treated with Rex-bypass shunt combined with pericardial devascularization. In each patient, preoperative assessment included ultrasound and computed tomographic angiography of the portal vein and blood analysis. The procedure was Rex-bypass shunt (with or without graft), and patients with moderate or severe gastroesophageal varices required additional paraesophagogastric devascularization. Splenectomy or subtotal splenectomy was performed if combined hypersplenism co-existed. All data were analyzed retrospectively.

RESULTS

No intraoperative death occurred, blood routine analysis improved (P < 0.05), the blood flow velocity (P < 0.05) and diameter (P < 0.05) of the left portal vein (LPV) significantly increased, the esophageal and gastric varices significantly relieved in 34 patients (P < 0.05), and better effects of earlier operations were demonstrated than the delayed ones (P < 0.05). During the period of follow-up from 6 to 64 months, the overall patency rate was 85.7% and the younger the age the better of the effect.

CONCLUSION

Rex-bypass shunt combined with pericardial devascularization is a safe and effective procedure for prehepatic portal hypertension caused by CTPV.

Intrahepatic portal venous systems in children with noncirrhotic prehepatic portal hypertension: anatomy and clinical relevance

BACKGROUND

Children with extrahepatic portal hypertension typically present with cavernomatous transformation of the portal vein and a poorly defined intrahepatic portal vein system on conventional imaging. With the Meso-Rex Bypass becoming the gold-standard intervention for a cure, a precise assessment of the intrahepatic portal vein system provides helpful data for deciding whether a Meso-Rex Bypass is feasible or not.

METHODS

All children with extrahepatic portal hypertension were prospectively assessed by wedged hepatic venous portography. Venous anatomy was categorized into five subtypes (A to E), depending on the presence of thrombosis in the Rex recessus, or not, and its extension within the intrahepatic portal venous system.

RESULTS

Eighty-nine children entered the study. Previous umbilical vein catheterization is usually associated with Rex thrombosis, while the Rex recessus and the intrahepatic portal venous system are patent in idiopathic cases, thus allowing for the performance of a Meso-Rex Bypass with a good outcome.

CONCLUSIONS

Wedged hepatic venous portography is a very effective tool for detailed preoperative assessment and identification of children being considered for Meso-Rex Bypass surgery. An anatomic-radiological classification is useful in selecting patients for Meso-Rex Bypass with anticipation of a high rate of success.

Spleno-adrenal shunt: a novel alternative for portosystemic decompression in children with portal vein cavernous transformation

PURPOSE

Children with portal vein cavernous transformation (PVCT) can develop life-threatening variceal hemorrhage from progressive portal hypertension. While spleno-renal shunt ± splenectomy is the most common portosystemic decompression surgery performed in children, we have adopted a modified spleno-adrenal (SA) shunt for complicated PVCT. We describe our 10 year experience focusing on technique evolution and treatment efficacy.

METHODS

Between 2001 and 2011, 15 children (9 girls and 6 boys, ages 3-11 years, median: 6 years) with PVCT, portal hypertension, and hypersplenism were treated with SA shunt with splenectomy in Shanghai Children's Medical Center. All children in the study had endoscopy proven active esophageal variceal bleeding requiring multiple transfusions (mean: 4.2 units) with failed sclerotherapy (mean: 2.6 times). Greater omental vein pressure (GVP) approximating portal venous pressure was measured pre- and post-SA shunt. Pre- and post-operative ammonia levels were obtained. Follow-up ranged from 6 months to 10 years (mean: 4.2 ± 2 years).

RESULTS

Intra-operative adrenal vein diameter and length ranged from 0.7 to 1.8 cm and 2 to 3 cm, respectively. Intra-operative GVPs pre-and post-SA shunt were (30 ± 11) and (22 ± 7) mmHg, respectively (p<0.01). On follow-up, there have been no recurrences of GI bleeding. Liver function tests remained normal in all children with the exception of elevated post-operative mean blood ammonia levels [Pre (18 ± 7) mmol/L, post (60 ± 17) mmol/L (p<0.05)] in all children. Ammonia levels normalized in all cases on outpatient follow-up. There have been no cases of hepatic encephalopathy, and all have normal age appropriate neurodevelopment (Bayley's assessment). Barium swallow and/or upper endoscopy showed interval resolution of esophageal varices in all children, and vascular ultrasound showed patent shunt anastomosis without stricture in 14 (93%).

CONCLUSIONS

The left adrenal vein is a viable conduit for effective selective portosystemic decompression. Similar to the more traditional spleno-renal shunt, SA appears also to have the advantage of preventing hepatic encephalopathy preserving neurodevelopment, although the rise in post-operative ammonia levels was unexpected. Longer follow-up is needed to look for late signs of encephalopathy assessing neurodevelopment long term.

Cavernous transformation of portal vein secondary to portal vein thrombosis: a case report

There are few reported cases of cavernous transformation of the portal vein (CTPV) in adults. We present a case of a 58 year-old male who was found to have this complication due to portal vein thrombosis (PVT). A 58-year old African American male with chronic alcohol and tobacco use presented with a 25-day history of weakness, generalized malaise, nausea and vomiting associated with progressively worsening anorexia and weight loss. The patient was admitted for severe anemia in conjunction with abnormal liver function tests and electrolyte abnormalities, and to rule out end stage liver disease or hepatic malignancy. The work-up for anemia showed no significant colon abnormalities, cholecystitis, liver cirrhosis, or liver abnormalities but could not rule out malignancy. An esophageogastroduodenoscopy (EGD) was suspicious for a mass compressing the stomach and small bowel. After further work-up, the hepatic mass has been diagnosed as a cavernous transformation of the portal vein (CTPV), a very rare complication of portal vein thrombosis (PVT). Cavernous Transformation of the Portal Vein (CTPV) is a rare and incurable complication of portal vein thrombosis (PVT) that should be considered as one of the differential diagnoses of a hepatic mass.

Subtotal laparoscopic splenectomy and esophagogastric devascularization for the thrombocytopenia because of portal cavernoma--case report

An 8-year-old girl presented with a history of pain in the right hypocondrium, multiple petechiae in the skin, and ecchimoses at sites of minor trauma. Laboratory investigations showed severe thrombocytopenia. Doppler ultrasonography and magnetic resonance imaging showed portal and splenic vein cavernomatous transformation and splenomegaly. The patient underwent laparoscopic subtotal splenectomy with lower pole preservation and esophagogastric devascularization. The postoperative course was uneventful. No gastrointestinal bleeding occurred within the first 34 months after surgery.

CONCLUSIONS

Thrombocytopenia associated with splenomegaly is a rare form of presentation in portal cavernoma. Preserving the spleen immune function must be a goal in surgical management, especially in children. Laparoscopic subtotal splenectomy combined with esophagogastric devascularization is a difficult procedure, but it can be useful in patients with portal cavernoma and severe thrombocytopenia without gastrointestinal bleeding.

Updates in the pathogenesis, diagnosis and management of ectopic varices

Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.