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Zhang YQ, Wang Q, Wu M, Li Y, Wei XL, Zhang FX, Li Y, Shao GR, Xiao J. Sonographic features of umbilical vein recanalization for a Rex shunt on cavernous transformation of portal vein in children. World J Clin Cases 2020; 8:5555-5563. [PMID: 33344546 PMCID: PMC7716299 DOI: 10.12998/wjcc.v8.i22.5555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/16/2020] [Accepted: 10/01/2020] [Indexed: 02/05/2023] Open
Abstract
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 8th 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 4th 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.
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Affiliation(s)
- Yu-Qing Zhang
- Department of Ultrasound, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Qing Wang
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong Province, China
| | - Mei Wu
- Department of Ultrasound, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Ya Li
- Department of Ultrasound, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Xiu-Liang Wei
- Department of Ultrasound, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Fei-Xue Zhang
- Department of Ultrasound, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Yan Li
- Department of Nuclear Medicine, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Guang-Rui Shao
- Department of Radiology, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
| | - Juan Xiao
- Center of Evidence-Based Medicine, Institute of Medical Sciences, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250033, Shandong Province, China
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Imaging of the intrahepatic portal vein in children with extrahepatic portal vein thrombosis - Comparison of magnetic resonance imaging and retrograde portography. J Pediatr Surg 2019; 54:1686-1690. [PMID: 30497819 DOI: 10.1016/j.jpedsurg.2018.10.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE Extrahepatic portal vein thrombosis (EPVT) is one major cause of portal hypertension in children. Surgical reinstallation of portal venous flow can be achieved in patients with patent intrahepatic portal venous system/Rex recess. Our study aimed to compare the ability of magnetic resonance imaging (MRI) and retrograde portography (RP) to assess patency of the intrahepatic portal venous system in children with EPVT. METHODS All pediatric patients with EPVT who were examined with contrast enhanced MRI (1.5 T) and invasive RP between 2013 and 2017 were included in this retrospective study. Medical records were reviewed for demographic, biochemical and clinical data. Patency of the Rex recess as detected by MRI and RP was retrospectively reviewed. RESULTS Sixteen children (7.6 ± 5.0 years) with EPVT were included. Sensitivity, specificity, positive and negative predictive value for the detection of patent Rex recess by MRI compared to RP were 55%, 57%, 63% and 50%. Diagnostic accuracy was 56%. Diagnostic failure of MRI compared to RP was explained by the following: I. Problems differentiating collaterals from portal venous vessels II. Incapability showing dynamic blood flow in compromised portal venous flow III. Poor spatial resolution, especially in small children. CONCLUSION RP is a reliable method for the visualization of the Rex recess and the intrahepatic portal venous system in children with EPVT, whereas MRI has shown to be unsuitable for the assessment of the intrahepatic portal vein in these patients. In the preoperative setup, we recommend both procedures, RP and MRI for the visualization of the intrahepatic portal venous system, and the extrahepatic vessels, respectively. LEVEL OF EVIDENCE Level III.
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Carollo V, Marrone G, Cortis K, Mamone G, Caruso S, Milazzo M, Maruzzelli L, di Francesco F, Delle M, Miraglia R, de Ville de Goyet J. Multimodality imaging of the Meso-Rex bypass. Abdom Radiol (NY) 2019; 44:1379-1394. [PMID: 30467724 DOI: 10.1007/s00261-018-1836-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Extrahepatic portal vein obstruction (EHPVO) is the most common cause of upper gastrointestinal bleeding in children. It is defined as thrombosis of the extrahepatic portal vein with or without extension to the intrahepatic portal veins. The Meso-Rex shunt is the gold standard treatment in children with favorable anatomy since it restores physiological portal liver reperfusion. This is achieved by rerouting the splanchnic venous blood through an autologous graft from the superior mesenteric vein (SMV) into the Rex recess of the left portal vein, curing portal hypertension by doing so. General and hepatobiliary radiologists must be familiar with multimodality imaging appearances of EHPVO and with the role of imaging in identifying suitable candidates for Meso-Rex bypass surgery. Imaging might also detect complications of this procedure, some of which might be treated via interventional radiology.
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Affiliation(s)
- Vincenzo Carollo
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Gianluca Marrone
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Kelvin Cortis
- Department of Medical Imaging, Mater Dei Hospital, Msida, MSD 2090, Malta.
| | - Giuseppe Mamone
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Settimo Caruso
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Mariapina Milazzo
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Luigi Maruzzelli
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Fabrizio di Francesco
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Martin Delle
- Department of Radiology, Karolinska University Hospital, Huddinge, Sweden
| | - Roberto Miraglia
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
| | - Jean de Ville de Goyet
- Diagnostic and Therapeutic Services Department, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via Ernesto Tricomi 5, 90127, Palermo, Italy
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Wang RY, Wang JF, Liu Q, Ma N, Chen WX, Li JL. Combined Rex-bypass shunt with pericardial devascularization alleviated prehepatic portal hypertension caused by cavernomatous transformation of portal vein. Postgrad Med 2017. [PMID: 28643575 DOI: 10.1080/00325481.2017.1343646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Ruo-Yi Wang
- a Department of Pediatric Surgery , The Second Hospital of Shandong University , Jinan , China
| | - Jun-Feng Wang
- a Department of Pediatric Surgery , The Second Hospital of Shandong University , Jinan , China
| | - Qian Liu
- a Department of Pediatric Surgery , The Second Hospital of Shandong University , Jinan , China
| | - Nan Ma
- a Department of Pediatric Surgery , The Second Hospital of Shandong University , Jinan , China
| | - Wei-Xiu Chen
- a Department of Pediatric Surgery , The Second Hospital of Shandong University , Jinan , China
| | - Jin-Liang Li
- a Department of Pediatric Surgery , The Second Hospital of Shandong University , Jinan , China
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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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Ketelsen D, Warmann SW, Schaefer JF, Haber P, Fuchs J, Claussen CD, Brechtel K. Percutaneous revascularization of reoccluded meso-Rex shunts in extrahepatic portal vein obstruction. J Pediatr Surg 2012; 47:E23-8. [PMID: 22974631 DOI: 10.1016/j.jpedsurg.2012.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 03/11/2012] [Accepted: 04/07/2012] [Indexed: 12/13/2022]
Abstract
Extrahepatic portal vein (PV) obstruction (EHPVO) is a rare disorder in early childhood with unknown incidence and mostly unknown etiology. In children with EHPVO, the hepatopedal flow of the mesenteric venous blood is hindered by an obstruction of the PV resulting in prehepatic portal hypertension. The curative treatment with a meso-Rex shunt connects the superior mesenteric vein to the left PV by a venous autograft. Despite good primary patency, reocclusion of a meso-Rex bypass and its treatment can be challenging. We present 2 patients with EHPVO with subtotal functional occlusion of a meso-Rex shunt treated by percutaneous interventions with short- and mid-term follow-up.
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Affiliation(s)
- Dominik Ketelsen
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
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Pre- and postoperative imaging of the Rex shunt in children: what radiologists should know. AJR Am J Roentgenol 2012; 198:1032-7. [PMID: 22528892 DOI: 10.2214/ajr.11.7963] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this article is to illustrate the imaging features of patients with extrahepatic portal venous obstruction who are evaluated before or after a Rex shunt surgery. CONCLUSION The Rex shunt is a potentially curative surgical procedure that reestablishes physiologic hepatopetal portal flow. It is typically accomplished by interposing a vascular conduit between the superior mesenteric vein to the still patent intrahepatic portal venous system. This procedure results in resolution of portal hypertension.
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Chaves IJ, Rigsby CK, Schoeneman SE, Kim ST, Superina RA, Ben-Ami T. Pre- and postoperative imaging and interventions for the meso-Rex bypass in children and young adults. Pediatr Radiol 2012; 42:220-32; quiz 271-2. [PMID: 22037931 DOI: 10.1007/s00247-011-2283-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 09/16/2011] [Accepted: 09/28/2011] [Indexed: 02/06/2023]
Abstract
The meso-Rex bypass is a physiological and anatomical bypass procedure for relief of extrahepatic portal vein obstruction and restoration of mesenteric venous return to the liver. Most patients who are candidates for the bypass are children or young adults with portal hypertension and hypersplenism secondary to cavernous transformation of the portal vein. Most frequently, the bypass utilizes an autologous venous graft to connect the intrahepatic left portal vein to the infrapancreatic superior mesenteric vein (SMV) re-establishing first-pass portal perfusion. We describe the preoperative imaging of the 92 bypass candidates, the surgical anatomy as reflected in postoperative imaging, and the imaging of bypass complications at our institution.Preoperative imaging with US, CT and MR is directed to demonstrate patency and size of the left portal vein and SMV, to define the extent of cavernous transformation and splanchnic collaterals, and to assess for any associated abdominal vascular or solid organ abnormalities. Postoperative imaging is aimed at diagnosing meso-Rex bypass stenosis or occlusion and the interventional management of these complications.
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Affiliation(s)
- Ian J Chaves
- Department of Medical Imaging, Children's Memorial Hospital, 2300 Children's Plaza, Box 9, Chicago, IL 60614, USA
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