Partial splenectomy and use of splenic vein as an autograft for meso-Rex bypass: a clinical observational study

Partial splenectomy in children undergoing liver transplantation or venous shunt for severe hypersplenism: A case control comparative study

BACKGROUND AND AIM

Hypersplenism is a consequence of portal hypertension and splenomegaly secondary to cirrhosis or portal cavernoma in children. In order to avoid persistent hypersplenism and splenomegaly after liver transplantation (LT) or venous shunt (VS), partial splenectomy (PS) may represent a relevant therapeutic option. The aim of this retrospective study was to evaluate the results of PS performed in children presenting hypersplenism.

METHODS

The following end-points were evaluated: (1) reversion of hypersplenism and its durability over time, (2) postoperative outcome, (3) courses of spleen size and volume and (4) comparison to a control group in which PS was not performed.

RESULTS

Between 1996 and 2020, 16 children underwent PS associated with LT (8 cases) for cirrhosis or VS (8 cases) for portal cavernoma. From Day 0 to 1 month, mean platelet and white blood cell counts (WBC) dramatically improved from 48 ± 19 at day 0 to 176 ± 70 × 10⁹/L (P < 0.0001) and from 2469 ± 853 to 7198 ± 3982/L (P = 0.001) respectively. PS allowed significant reduction of splenic length and volume from 176 ± 33 to 112 ± 24 cm (P < 0.0001) and from 1228 ± 464 to 450 ± 297 cm³ (P = 0.0003) respectively. After a mean follow-up of 92.6 ± 84.7 months (range: 4.1-210.7), 14 patients are alive with normal platelet and WBC counts and persistent spleen size reduction. Compared to control group, PS was associated with a significant platelet count rise from baseline to one year.

CONCLUSIONS

PS appears to be effective for treatment of hypersplenism and splenomegaly in combination with LT or VS without compromising outcome.

Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein

Cavernous transformation of the portal vein (CTPV) is a sequela of extrahepatic and/or intrahepatic portal vein obstruction caused by a combination of local and risk factors. It was ever taken as a relatively rare disease due to its scant literature, which was mainly based on clinical series and case reports. CTPV often manifests as gastroesophageal variceal bleeding, splenomegaly, and portal biliopathy after the long-term insidious presentation. It is unable for CTPV to be recanalized with anticoagulation because it is a complete obstruction of the mesentericoportal axis. Endoscopic therapy is mainly used for temporary hemostasis in acute variceal bleeding. Meso-Rex shunting characterized by portal-flow-preserving shunts has been widely performed in children with CTPV. The multitude of complications associated with CTPV in adults can be effectively addressed by various interventional vascular therapies. With the ubiquity of radiological examinations, optimal treatment for patients with CTPV becomes important. Multivisceral transplantation, such as liver-small intestinal transplantation, may be lifesaving and should be considered for patients with diffuse mesenteric venous thrombosis.

Rex Shunt for Extra-Hepatic Portal Venous Obstruction in Children

Rex shunt, which was first put in use in 1992, has been considered as an ideal surgical method for the treatment of extra-hepatic portal venous obstruction (EHPVO) due to its reconstruction of the hepatopetal portal blood flow. However, despite its long tradition, there are only a few reports about the application and advances in Rex shunt for the treatment of EHPVO in children. In this paper, we summarized the literature related to Rex shunt and discussed the new advances of Rex shunt in the following aspects: surgical method of Rex shunt, the indications of Rex shunt, the strengths of Rex shunt, the effectiveness of Rex shunt, factors affecting the efficacy of Rex shunt, methods that improve the prognosis of Rex shunt, and treatment strategy for recurrence after Rex shunt.

Meso-Rex bypass shunt vs. transposition shunt for cavernous transformation of portal vein in children

BACKGROUND

Cavernous transformation of the portal vein (CTPV) causes portal hypertension in children. Among Meso-Rex treatments, it is unclear whether the Meso-Rex bypass shunt (MRB) or the Meso-Rex transposition shunt (MRT) offers lower postoperative morbidity. Our objective was to evaluate postoperative outcomes, comparing MRB and MRT for children with CTPV.

METHODS

A retrospective study was conducted on children undergoing Meso-Rex for CTPV from January 2010 to December 2020. The primary outcome was shunt complications, including shunt stenosis and thrombus. The secondary outcome was re-operation.

RESULTS

Of the 43 patients included, 21 underwent MRT and 22 underwent MRB. MRT was associated with a higher rate of shunt complications when compared to MRB (23.8 vs. 9.1%, p = 0.191). The patients exhibited a higher rate of re-operation under the MRT than under the MRB (19 vs. 4.5%, p = 0.138). The operative time in the MRT group was significantly shorter than in the MRB group. Compared to MRT, the reduction in the length and thickness of the spleen was significantly greater in the MRB group. The increases in platelets were significantly higher in the MRB group than in the MRT group. The postoperative shunt velocity of MRB was notably faster than MRT. There was no significant difference in postoperative portal pressure between the two groups (p > 0.05).

CONCLUSION

Both MRB and MRT result in acceptable postoperative outcomes, but MRT is associated with higher post-shunt complications, which often increase the re-operation rate. This study suggests that MRB may offer advantages for children with CTPV.

Modified Meso-Rex bypass with umbilical vein recanalization and intra-operative stenting

PURPOSE

The aim of the study was to evaluate the usefulness of a novel modified Meso-Rex bypass surgical technique with umbilical vein recanalization and intra-operative stenting to treat portal vein cavernous transformation.

METHODS

In total, 13 portal vein cavernous transformation patients underwent Meso-Rex bypass surgery, consisting of bypass grafts between the superior mesenteric vein (SMV) and the recess of Rex as well as through the ligamentum teres hepatis without stent implantation (Group A, n = 9) and umbilical vein recanalization with intra-operative stent implantation (Group B, n = 4).

RESULTS

In Group A, the bypass diameter was 0-6 mm (median 3 mm) and blood flow velocity 25-115 cm/s (median 72 cm/s) 1 month after Meso-Rex bypass surgery, with open bypass times of 0-67 months (median 6 months); 6 patients in this group developed postoperative Meso-Rex bypass occlusions. A patient in Group A treated with ligamentum teres hepatis recanalization needed a thrombectomy and stent implantation during a second surgery 2 days after the Meso-Rex bypass, because of bypass thrombosis and umbilical vein stenosis. In Group B, the average modified Meso-Rex bypass diameter was 5.5-6.5 mm (median 6 mm), and the bypass vessels remained open in all patients, with blood flow rates of 45-100 cm/s (median 76.5 cm/s) 1 month after the modified Meso-Rex bypass, up to the endpoint (15-33 months, median 24 months). The rate of bypass occlusions in Group A and Group B were 22.2% and 0%, 30.0% and 0%, and 55.6% and 0% at 1 month, 3 months, and 1 year, respectively, after bypass surgery.

CONCLUSIONS

Our novel modified Meso-Rex bypass approach for portal vein cavernous transformation treatment was effective with excellent long-term bypass patency.

Surgical shunts for extrahepatic portal vein obstruction in pediatric patients: a systematic review

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) causes portal hypertension in noncirrhotic children. Among surgical treatments, it is unclear whether the meso-Rex shunt (MRS) or portosystemic shunt (PSS) offers lower post-operative morbidity and superior patency over time. Our objective was to evaluate long-term outcomes comparing MRS and PSS for pediatric patients with EHPVO.

METHODS

A systematic review was conducted of articles reporting children undergoing surgical shunts for EHPVO from 1/2000-2/2020. Of 87 articles screened, 22 were eligible for inclusion. The primary outcome was shunt thrombosis and secondary outcomes included non-operative complications, stenosis, and re-operation.

RESULTS

Eighteen of 22 studies were of good quality and four had fair quality. Of 461 patients included, 340 underwent MRS and 121 underwent PSS. MRS were associated with a higher rate of post-operative thrombosis when compared to PSS (14.1% vs 5.8%, p = 0.021). There were 40/340 MRS patients (11.8%) that required at least one re-operation for either shunt thrombosis or stenosis, versus 5/121 PSS patients (4.1%), p = 0.019.

CONCLUSION

Both MRS and PSS result in acceptable long-term patency rates, but the more technically demanding MRS is associated with higher post-shunt thrombosis, often requiring further operative intervention. This study suggests that PSS may offer advantages for pediatric patients with EHPVO.

Trombosis venosa portal extrahepática, manejo quirúrgico con derivación meso-Rex. Serie de 3 casos

La vena porta es un conducto que drena el flujo esplácnico al hígado y se puede ocluir por diferentes patologías, variando su presentación clínica de acuerdo con la causa de la obstrucción. Es muy importante diferenciar la trombosis portal asociada o no a la cirrosis, ya que su tratamiento y pronóstico es diferente. La trombosis venosa portal extrahepática es una condición netamente de origen vascular, y es la principal causa de trombosis portal en niños y adultos. Presentamos tres casos tratados con derivación meso-Rex, con seguimiento a 6 meses.

Sonographic features of umbilical vein recanalization for a Rex shunt on cavernous transformation of portal vein in children

BACKGROUND

The Rex shunt was widely used as the preferred surgical approach for cavernous transformation of the portal vein (CTPV) in children that creates a bypass between the superior mesenteric vein and the intrahepatic left portal vein (LPV). This procedure can relieve portal hypertension and restore physiological hepatopetal flow. However, the modified procedure is technically demanding because it is difficult to make an end-to-end anastomosis of a bypass to a hypoplastic LPV. Many studies reported using a recanalized umbilical vein as a conduit to resolve this problem. However, the feasibility of umbilical vein recanalization for a Rex shunt has not been fully investigated.

AIM

To investigate the efficacy of a recanalized umbilical vein as a conduit for a Rex shunt on CTPV in children by ultrasonography.

METHODS

A total of 47 children who were diagnosed with CTPV with prehepatic portal hypertension in the Second Hospital, Cheeloo College of Medicine, Shandong University, were enrolled in this study. Fifteen children received a recanalized umbilical vein as a conduit for a Rex shunt surgery and were enrolled in group I. Thirty-two children received the classic Rex shunt surgery and were enrolled in group II. The sonographic features of the two groups related to intraoperative and postoperative variation in terms of bypass vessel and the LPV were compared.

RESULTS

The patency rate of group I (60.0%, 9/15) was significantly lower than that of group II (87.5%, 28/32) 7 d after (on the 8^th d) operation (P < 0.05). After clinical anticoagulation treatment for 3 mo, there was no significant difference in the patency rate between group I (86.7%, 13/15) and group II (90.6%, 29/32) (P > 0.05). Moreover, 3 mo after (at the beginning of the 4^th mo) surgery, the inner diameter significantly widened and flow velocity notably increased for the bypass vessels and the sagittal part of the LPV compared to intraoperative values in both shunt groups (P < 0.05). However, there was no significant difference between the two surgical groups 3 mo after surgery (P > 0.05).

CONCLUSION

For children with hypoplastic LPV in the Rex recessus, using a recanalized umbilical vein as a conduit for a Rex shunt may be an effective procedure for CTPV treatment.

Sonographic Evaluation of a Unique Meso-Rex Shunt: A Case Study

Portal hypertension is a result of an increase in intrahepatic resistance in the main portal vein. The Meso-Rex shunt is used to bypass the obstructed portal vein and restore the venous flow into the liver. This procedure alleviates the need for a hepatic transplant. The Meso-Rex shunt has proven to be an effective treatment for extrahepatic portal vein obstruction, thus saving children from a complete transplant. There are variants to this bypass surgery, and sonography is commonly used to assess the condition pre- and postoperatively. In this case, the shunt was uniquely different from the typical Meso-Rex bypass surgery. Particular vasculature made it imperative for the sonographer to review the prior sonograms and review the chart information before preforming the examination. It should also be noted that sonographers must adapt the protocols to give the utmost treatment.

Imaging features and clinical relevance of portal venous systems shown by extrahepatic portal angiography in children with extrahepatic portal venous obstruction

OBJECTIVE

This study investigated the morphologic changes of portal cavernoma in children with extrahepatic portal venous obstruction and explored the relationship with prognosis.

METHODS

From February 2008 to October 2017, there were 107 patients with cavernous transformation of the portal vein admitted to our hospital. Rex shunts were performed in 99 cases, Warren shunts in 7 cases, and laparoscopic splenic vessel ligation in 1 case. Intraoperative superior mesenteric venography was used to determine the structure of the portal venous system. According to the morphologic features of the portal vein shown by portal venography, groups were assigned as follows: patients with the cotton form of portal cavernoma; patients with visible collateral veins of portal cavernoma; patients with and without a visible left gastric vein; and patients with and without a clearly visible intrahepatic portal vein. The preoperative and postoperative portal pressure, preoperative incidence of esophageal varices, time at onset, incidence of postoperative rebleeding, preoperative and postoperative size of the spleen, and age at time of operation were compared between these groups.

RESULTS

The preoperative incidence of esophageal varices, time at onset, postoperative size of spleen, and age at time of operation were significantly lower in the group with the cotton form than in those with visible collateral veins (P < .05). There was a significant correlation between the visible left gastric vein and esophageal varices (P = .002). The time at onset, preoperative and postoperative size of the spleen, and age at time of operation were markedly lower in the group with a good visible intrahepatic portal vein than in those without a clearly visible intrahepatic portal vein (P < .05). The visible left gastric vein was notably associated with the performance of a gastroportal shunt (P = .000), and the group with a visible left gastric vein had a higher ratio of children undergoing a gastroportal shunt.

CONCLUSIONS

The cotton form, an early-stage manifestation of cavernous transformation of the portal vein, typically occurs in younger children with a shorter time to onset. Children with the cotton form of portal cavernoma typically have a better prognosis after Rex shunt.

Effects of Rex-bypass shunt on the cavernous transformation of the portal vein in children: evaluation by the color Doppler ultrasonography

BACKGROUND

The study was to investigate the role of color Doppler ultrasonography in the evaluation of the effect of Rex-bypass shunt on the cavernous transformation of the portal vein (CTPV) in children.

METHODS

Fifty children with symptomatic extrahepatic portal hypertension who received Rex-bypass shunt were retrospectively reviewed, and they were diagnosed with CTPV by ultrasonography. The clinical characteristics were analyzed before and after operation.

RESULTS

Forty-five patients received color Doppler ultrasonography at 6 months after surgery, and good patency in the bypass vessels was displayed. The platelet count significantly increased (P < 0.001) and the esophagogastric varices were improved significantly (p < 0.001). The patency of bypass vessels on color Doppler ultrasonography was consistent with the changes in the platelet count and the degree of esophagogastric varices on gastroscopy before and after operation. The diameter of bypass vessels at 6 months was slightly larger than that at 7 days after operation, and there was no significant difference in blood flow velocity between two time points (P = 0.507).

CONCLUSIONS

Color Doppler ultrasonography can display the patency, diameter, and flow velocity of bypass vessels. It plays an important role in evaluating the effect of Rex-bypass shunt on the CTPV.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases

BACKGROUND/PURPOSE

In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset.

METHODS

A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy.

RESULTS

Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients.

CONCLUSIONS

Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

IV.

Variant meso-Rex bypass with transposition of abdominal autogenous vein for the management of idiopathic extrahepatic portal vein obstruction: a retrospective observational study

Background

The aim of this study was to evaluate whether variant meso-Rex bypass with transposition of abdominal autogenous vein can be used as an alternative treatment modality for selected patients with symptomatic extrahepatic portal vein obstruction.

Methods

This was a retrospective review of six consecutive patients who received this alternative procedure for the treatment of symptomatic portal hypertension secondary to idiopathic extrahepatic portal vein obstruction. Their clinical characteristics, operative procedures and outcomes were analyzed retrospectively.

Results

The procedure was attempted in six patients, and all had a patent shunt established by intraoperative portography at the end of the procedure; the coronary vein was used in four patients and the inferior mesenteric vein was used in two. During the median period of 23.5 months (range 10–30 months), follow-up was uneventful except one patient; reduced portal hypertension and no new episodes of gastrointestinal bleeding were observed in all patients, with the exception of one patient with shunt stenosis and recurrent varix bleeding who had to undergo endovascular treatment to restore portal vein blood flow. Technical and clinical success was achieved in all patients.

Conclusions

This procedure could be used safely and effectively to treat selected patients with portal hypertension secondary to extrahepatic portal vein obstruction.