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Huang X, Lu Q, Zhang YW, Zhang L, Ren ZZ, Yang XW, Liu Y, Tang R. Intrahepatic portal venous systems in adult patients with cavernous transformation of portal vein: Imaging features and a new classification. Hepatobiliary Pancreat Dis Int 2024; 23:481-486. [PMID: 36693772 DOI: 10.1016/j.hbpd.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 12/09/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cavernous transformation of the portal vein (CTPV) due to portal vein obstruction is a rare vascular anomaly defined as the formation of multiple collateral vessels in the hepatic hilum. This study aimed to investigate the imaging features of intrahepatic portal vein in adult patients with CTPV and establish the relationship between the manifestations of intrahepatic portal vein and the progression of CTPV. METHODS We retrospectively analyzed 14 CTPV patients in Beijing Tsinghua Changgung Hospital. All patients underwent both direct portal venography (DPV) and computed tomography angiography (CTA) to reveal the manifestations of the portal venous system. The vessels measured included the left portal vein (LPV), right portal vein (RPV), main portal vein (MPV) and the portal vein bifurcation (PVB). RESULTS Nine males and 5 females, with a median age of 40.5 years, were included in the study. No significant difference was found in the diameters of the LPV or RPV measured by DPV and CTA. The visualization in terms of LPV, RPV and PVB measured by DPV was higher than that by CTA. There was a significant association between LPV/RPV and PVB/MPV in term of visibility revealed with DPV (P = 0.01), while this association was not observed with CTA. According to the imaging features of the portal vein measured by DPV, CTPV was classified into three categories to facilitate the diagnosis and treatment. CONCLUSIONS DPV was more accurate than CTA for revealing the course of the intrahepatic portal vein in patients with CTPV. The classification of CTPV, that originated from the imaging features of the portal vein revealed by DPV, may provide a new perspective for the diagnosis and treatment of CTPV.
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Affiliation(s)
- Xin Huang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Qian Lu
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Yue-Wei Zhang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Lin Zhang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Zhi-Zhong Ren
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Xiao-Wei Yang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Ying Liu
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Rui Tang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China.
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Zhang J, Li L. Effectiveness of anticoagulant therapy using heparin combined with Plavix after Rex shunt. Front Pediatr 2024; 12:1339348. [PMID: 38374877 PMCID: PMC10875122 DOI: 10.3389/fped.2024.1339348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/23/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose Rex shunt is an optimal surgery for the treatment of extra-hepatic portal venous obstruction (EHPVO) in children. Anticoagulant therapy has been used to keep the patency of the bypass vein in the Rex shunt. This study was to investigate the effectiveness of anticoagulant therapy using heparin combined with Plavix in improving the prognosis and shunt patency of Rex shunt. Methods From January 2010 to September 2019, 51 children with EHPVO underwent a portal cavernoma- Rex shunt. Based on whether using the anticoagulant therapy after the Rex shunt, all patients were divided into two groups: the anticoagulant group and the non-anticoagulant group. The diameter and flow velocity of the bypass vein were measured by the post-operative ultrasound, which was used to calculate the flow volume of the bypass vein (FV) and standard portal venous flow (SPVF). The bypass venous flow index (BVFI) was used to evaluate the ability of portal blood into the liver through the bypass vein after the Rex shunt, which was a ratio of FV to SPVF. The incidence of post-operative re-bleeding, the postoperative patency rate of the bypass vein, the remission rate of postoperative hypersplenism, the remission rate of postoperative esophagogastric varices and the BVFI were compared between the two groups. Results Of the 51 patients, 12 patients in the anticoagulant group were treated with heparin combined with Plavix after Rex shunt; 39 patients in the non-anticoagulant group were not treated with any anticoagulant therapy. 8 of 51 patients suffered from postoperative re-bleeding, of whom 6 patients with thrombosis of the bypass vein and 2 patients with anastomotic stenosis of the bypass vein. All 8 patients with re-bleeding belonged to the non-anticoagulant group. The remission rate of hypersplenism was no significant difference between the two groups after surgery (91% vs. 58%, P = 0.100). However, 3 patients without hypersplenism before surgery suffered from hypersplenism after surgery, who belonged to the non-anticoagulant group. There was no significant difference in the remission rate of esophagogastric varices (33% vs. 46%, P = 1.000). The BVFI of the anticoagulant group was significantly higher than that of the non-anticoagulant group (5.71 ± 5.89 vs. 1.1 ± 1.52, P = 0.003). Conclusions Anticoagulant therapy using heparin combined with Plavix plays an important role in maintaining the patency of the bypass vein, which improved the portal blood flow into the liver through the bypass vein after the Rex shunt.
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Affiliation(s)
- JinShan Zhang
- Department of General Surgery, Capital Institute of Pediatrics, Beijing, China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences, Beijing, China
| | - Long Li
- Department of General Surgery, Capital Institute of Pediatrics, Beijing, China
- Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences, Beijing, China
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Tang R, Wu G, Yu Q, Tong X, Meng X, Hou Y, Huang X, Aini A, Yu L, Duan W, Lu Q, Yan J. Location and extent of cavernous transformation of the portal vein dictates different visceral side revascularization in Meso-Rex bypass. BMC Surg 2023; 23:276. [PMID: 37705015 PMCID: PMC10500800 DOI: 10.1186/s12893-023-02168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/25/2023] [Indexed: 09/15/2023] Open
Abstract
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.
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Affiliation(s)
- Rui Tang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
- General Surgery Department, Lhasa People's Hospital, Tibet Autonomous Region, Lhasa, China
| | - Guangdong Wu
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
| | - Qiang Yu
- Department of Hepatobiliary and Pancreatic Surgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Xuan Tong
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
| | - Xiangfei Meng
- Department of Hepatobiliary and Pancreatic Surgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Yucheng Hou
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
| | - Xin Huang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
| | - Abudusalamu Aini
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
| | - Lihan Yu
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China
| | - Weidong Duan
- Department of Hepatobiliary and Pancreatic Surgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
| | - Qian Lu
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China.
| | - Jun Yan
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Key Laboratory of Digital Intelligence Hepatology (Chinese Ministry of Education), School of Clinical Medicine, Institute for Precision Medicine, Tsinghua University, No. 168 Litang Road, Beijing, 102218, China.
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Surgical shunts for extrahepatic portal vein obstruction in pediatric patients: a systematic review. HPB (Oxford) 2021; 23:656-665. [PMID: 33388243 DOI: 10.1016/j.hpb.2020.11.1149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
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.
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Jiménez Jiménez CE, Randial Tagliapetra L, Silva Restrepo IE, Hossman-Galindo MA, Bravo M, Moreno Beltrán O. Trombosis venosa portal extrahepática, manejo quirúrgico con derivación meso-Rex. Serie de 3 casos. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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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: 0.2] [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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Wang RY, Wang JF, Sun XG, Liu Q, Xu JL, Lv QG, Chen WX, Li JL. Evaluation of Rex Shunt on Cavernous Transformation of the Portal Vein in Children. World J Surg 2017; 41:1134-1142. [PMID: 27896406 DOI: 10.1007/s00268-016-3838-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Children with cavernous transformation of the portal vein (CTPV) develop severe complications from prehepatic portal hypertension, such as recurrent variceal bleeding and thrombocytopenia. In this study, we reported the results of 30 children with symptomatic CTPV that were treated by a Rex shunt. The effectiveness of this surgical approach was evaluated. METHODS A retrospective review was performed of 30 children aged between 3 and 18 years with CTPV, who underwent a Rex shunt between 2008 and 2015. All children were evaluated based on symptoms, complete blood count, portal system color-flow Doppler ultrasound or computed tomography angiography portography and gastroscopy for gastroesophageal varices pre- and postoperatively. Children were also evaluated during follow-up. Intraoperative evaluations included liver biopsy, portography and portal pressure. RESULTS Twenty-one patients demonstrated intermittent bleeding from gastroesophageal varices, 3 patients showed hypersplenism with varying degrees of leucopenia, anemia and thrombocytopenia, and in 6 patients both bleeding and hypersplenism were observed. Rex was successful in 28 patients (93.3%). The portal pressure immediately decreased significantly after placing of the shunt (P < 0.01). During the clinical follow-up period within 2-82 months, transaminase levels were maintained in the normal range. Blood flow velocity and diameter of the left portal vein significantly increased after surgery (P < 0.01). In addition, leukocyte and platelet counts increased postoperatively and anemia improved significantly (P < 0.01). Gastroscopy results indicated that the degree of gastroesophageal varices significantly alleviated postoperatively within 3 months and 1 year (P < 0.01). In 2 patients who demonstrated nodular cirrhosis and chronic active hepatitis, success of the Rex shunt was not achieved after operation. We found that for Rex effectiveness hepatic pathology and patient age were major determinants. CONCLUSION Rex shunt is an effective approach for the treatment of children suffering from CTPV at an early stage that do not show additional liver lesions.
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Affiliation(s)
- Ruo-Yi Wang
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Jun-Feng Wang
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Xiao-Gang Sun
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Qian Liu
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Jia-Long Xu
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Qi-Gang Lv
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Wei-Xiu Chen
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China
| | - Jin-Liang Li
- Department of Pediatric Surgery, The Second Hospital of Shandong University, Jinan, 250033, Shandong, People's Republic of China.
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Sumiyoshi T, Shima Y, Okabayashi T, Negoro Y, Kozuki A, Iwata J, Saisaka Y, Tokumaru T, Nakamura T, Morita S. Epiploic gonadal vein as a new bypass route for extrahepatic portal venous obstruction: report of a case. Surg Case Rep 2016; 1:109. [PMID: 26943433 PMCID: PMC4615993 DOI: 10.1186/s40792-015-0112-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 10/16/2015] [Indexed: 11/27/2022] Open
Abstract
A 61-year-old man was referred to our hospital to treat extrahepatic portal venous obstruction. Endoscopic injection sclerotherapy (EIS) was performed for the esophageal varices; however, the patient returned with massive hematemesis from gastric varices 6 months after treatment. Although the varices were treated with EIS, gastric devascularization and splenectomy concomitant with shunt surgery were required to treat uncontrollable, frequent diarrhea and abdominal distension. Because the splenic vein, left gastric vein, left portal vein, and inferior vena cava were inadequate for anastomosis, an epiploic gonadal vein bypass was performed. The bypass graft remains patent 7 months after surgery, and the patient is in good health without any clinical symptoms. We describe a new bypass route for extrahepatic portal venous obstruction.
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Affiliation(s)
- Tatsuaki Sumiyoshi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan.
| | - Yasuo Shima
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Yuji Negoro
- Department of Gastroenterology, Kochi Health Sciences Center, Kochi, Japan
| | - Akihito Kozuki
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Jun Iwata
- Department of Diagnostic Pathology, Kochi Health Sciences Center, Kochi, Japan
| | - Yuichi Saisaka
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Teppei Tokumaru
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Toshio Nakamura
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125 Ike, Kochi City, Kochi, 781-8555, Japan
| | - Sojiro Morita
- Department of Radiology, Kochi Health Sciences Center, Kochi, Japan
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Kokudo T, Bonard E, Gillet M, Kokudo N, Halkic N. Reappraisal of shunt surgery for extrahepatic portal vein obstruction in adults: Report of a single-center case series. Hepatol Res 2015; 45:1307-11. [PMID: 25731583 DOI: 10.1111/hepr.12512] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Revised: 02/12/2015] [Accepted: 02/25/2015] [Indexed: 12/15/2022]
Abstract
AIM Extrahepatic portal venous obstruction (EHPVO) is a relatively rare disease in adults. The clinical significance of shunt surgery for EHPVO in adult cases remains unclear. METHODS We retrospectively analyzed the patient characteristics and the results of shunt surgery in 13 adult cases of EHPVO treated between March 1995 and March 2013 at a tertiary care hospital in Switzerland. The indication for shunt surgery was recurrent bleeding after endoscopic treatment. To update the outcomes of shunt surgery in adult cases of EHPVO, we performed a systematic review of published work to examine this issue. RESULTS The mean age of the 13 patients in the present case series was 41.8 years (range, 20-68), and the mean follow-up duration after surgery was 4.4 years (range, 1-16). The types of shunt surgery performed were mesocaval shunt (n = 8), portacaval shunt (n = 2), splenorenal shunt (n = 1) and mesorenal shunt (n = 2). Two patients (15%) developed postoperative rebleeding, which was successfully treated by endoscopic treatment. None of the patients developed postoperative hepatic encephalopathy. No operative-related deaths occurred in this series. Six studies, including our own, were identified in the published work. The overall mortality rate was 0-3.7%, and no cases of encephalopathy were observed. The rebleeding rate ranged 2.5-23%. CONCLUSION Shunt surgery for EHPVO in adults after the failure of endoscopic treatment is feasible, with acceptable outcomes at specialized centers. This surgical procedure should always be taken into consideration when managing adult cases of EHPVO.
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Affiliation(s)
- Takashi Kokudo
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland.,Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Estelle Bonard
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michel Gillet
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nermin Halkic
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
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Wei Z, Rui SG, Yuan Z, Guo LD, Qian L, Wei LS. Partial splenectomy and use of splenic vein as an autograft for meso-Rex bypass: a clinical observational study. Med Sci Monit 2014; 20:2235-42. [PMID: 25384413 PMCID: PMC4238759 DOI: 10.12659/msm.892482] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Meso-Rex bypass (MRB) surgery is being increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (EPVT) and cavernous transformation (EPVCT) in children. Rather than using the internal jugular vein (IJV, the traditional venous graft), we used an autogenous splenic vein segment graft for MRB. Material/Methods We examined 25 children with extrahepatic portal hypertension and a history of recurrent upper gastrointestinal (GI) variceal bleeding despite previous endoscopic sclerotherapy. All patients had melena, splenomegaly, hypersplenism, or some combination thereof. Left portal vein (LPV) patency was verified in 22 patients using intraoperative direct portography through the umbilical vein. Partial splenectomy was performed to enable the harvest of the splenic vein trunk, which was anastomosed between the superior mesenteric vein (SMV) and the left portal vein (LPV). All patients were followed for 12–48 months (mean=25.6 months) and no patients were lost to follow-up. Results Preoperative Doppler ultrasound (US) imaging indicated that 18/25 patients had adequate intrahepatic portal veins for shunting, with no blood flow in the LPVs of 7 patients. LPV patency in 22/25 patients was verified using intraoperative direct portography, with successful MRB. Shunting was converted into a portosystemic shunt in the remaining 3/25 patients with thrombosed LPVs. A Doppler US evaluation of the vein conduit revealed excellent postoperative flow. The patients’ mean hemoglobin, platelet, and white blood cell counts increased significantly, and in all cases the endoscopic status obviously improved after shunting. Occlusion or narrowing occurred in 2/22 patients after discharge. At 12 months (for 1 patient) and 24 months (for 1 patient), the shunt was converted into a portosystemic shunt. The cumulative graft patency rate was 91% (20/22). Conclusions Partial splenectomy and splenic vein autografting in MRB surgery can successfully resolve prehepatic portal hypertension and hypersplenism in children.
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Affiliation(s)
- Zhang Wei
- Department of Radiology, Second Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Shao Guang Rui
- Department of Radiology, Second Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Zhang Yuan
- Department of Evidence-Based Medicine, Second Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Li Dian Guo
- Department of Pediatric Surgery, Second Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Liu Qian
- Department of Pediatric Surgery, Second Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Liu Shu Wei
- Department of Anatomy, Medical College of Shandong University, Jinan, Shandong, China (mainland)
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11
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Hau HM, Fellmer P, Schoenberg MB, Schmelzle M, Morgul MH, Krenzien F, Wiltberger G, Hoffmeister A, Jonas S. The collateral caval shunt as an alternative to classical shunt procedures in patients with recurrent duodenal varices and extrahepatic portal vein thrombosis. Eur J Med Res 2014; 19:36. [PMID: 24965047 PMCID: PMC4080782 DOI: 10.1186/2047-783x-19-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/12/2014] [Indexed: 11/26/2022] Open
Abstract
Upper gastrointestinal bleeding episodes from variceal structures are severe complications in patients with portal hypertension. Endoscopic sclerotherapy and variceal ligation are the treatment options preferred for upper variceal bleeding owing to extrahepatic portal hypertension due to portal vein thrombosis (PVT). Recurrent duodenal variceal bleeding in non-cirrhotic patients with diffuse porto-splenic vein thrombosis and subsequent portal cavernous transformation represent a clinical challenge if classic shunt surgery is not possible or suitable. In this study, we represent a case of recurrent bleeding of duodenal varices in a non-cirrhotic patient with cavernous transformation of the portal vein that was successfully treated with a collateral caval shunt operation.
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Affiliation(s)
| | - Peter Fellmer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany.
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12
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di Francesco F, Grimaldi C, de Ville de Goyet J. Meso-Rex Bypass—A Procedure to Cure Prehepatic Portal Hypertension: The Insight and the Inside. J Am Coll Surg 2014; 218:e23-36. [DOI: 10.1016/j.jamcollsurg.2013.10.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 10/30/2013] [Accepted: 10/30/2013] [Indexed: 12/22/2022]
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13
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Bhat R, Lautz TB, Superina RA, Liem R. Perioperative strategies and thrombophilia in children with extrahepatic portal vein obstruction undergoing the meso-Rex bypass. J Gastrointest Surg 2013; 17:949-55. [PMID: 23385441 DOI: 10.1007/s11605-013-2155-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/24/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND/PURPOSE Extrahepatic portal vein obstruction (EHPVO) is an important cause of chronic portal hypertension in children. Although usually idiopathic in etiology, genetic and acquired thrombophilia have been implicated in EHPVO. Meso-Rex bypass is increasingly used to treat EHPVO in children. OBJECTIVE The objective of this study is to assess the relationship of postoperative anticoagulation strategies and thrombophilic risk factors to the development of bypass thrombosis following the meso-Rex bypass. METHODS Records of children who underwent meso-Rex bypass for EHPVO at a single institution from 1999 to 2009 were reviewed, and preoperative thrombophilia testing, perioperative anticoagulation strategies, and postoperative bypass patency based on imaging at last follow-up were examined. RESULTS Sixty-five children with EHPVO underwent a first time meso-Rex bypass during the study period, and 9 of 65 (14 %) developed bypass thrombosis. The use of warfarin in the postoperative period was more common among children with thrombosed shunts than among those with open shunts [63 % vs. 20 %; OR, 6.5 (95 % CI, 1.3-31.5), p = 0.022]. The contribution of genetic or acquired thrombophilia to shunt thrombosis was inconclusive given variability in testing. CONCLUSIONS Choice of anticoagulation following meso-Rex bypass may affect postoperative incidence of bypass thrombosis. Role of thrombophilic risk factors in the development of shunt thrombosis remains unclear.
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Affiliation(s)
- Rukhmi Bhat
- Division of Hematology, Oncology & Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, IL 60611, USA.
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14
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Luoto T, Pakarinen M, Mattila I, Rintala R. Mesoportal bypass using a constructed saphenous vein graft for extrahepatic portal vein obstruction--technique, feasibility, and outcomes. J Pediatr Surg 2012; 47:688-93. [PMID: 22498382 DOI: 10.1016/j.jpedsurg.2011.10.065] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 10/04/2011] [Accepted: 10/08/2011] [Indexed: 01/15/2023]
Abstract
BACKGROUND The internal jugular vein is routinely used as a graft for the Rex shunt. We analyzed results of mesoportal bypass using an alternative autologous graft. METHODS Twenty-one children with extrahepatic portal vein obstruction were treated with a Rex shunt constructed using both greater saphenous veins. Follow-up included ultrasound and blood count screening at 3, 6, and 12 months and annually thereafter. RESULTS Median age was 8.7 years (range, 3.6-14 years), and follow-up time, 5.3 years (range, 0.6-7.1 years). Occlusion or narrowing occurred in 6 patients after a median of 20 months (range, 2.6-52 months). In 2 cases, patency was restored, giving an overall success rate of 81%. During follow-up, no variceal bleeding occurred while hemoglobin, platelet count, and leukocyte levels increased (P ≤ .02 for all) and spleen size decreased (P = .001). Patients with occlusive shunt complications weighed less (P = .01), had higher preoperative platelet levels (P = .02), and tended to have a smaller spleen preoperatively (P = .06) than patients without shunt complications. Cumulative graft patency at 6 months, 1 year, 3 years, and 5 years was 100%, 89%, 82%, and 74%, respectively. CONCLUSIONS Rex shunt constructed using the greater saphenous veins is a valuable alternative to the internal jugular vein graft, allowing long-term reversal of portal hypertension, splenomegaly, and hypersplenism. Low patient weight and high platelet count predicted shunt occlusion.
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Affiliation(s)
- Topi Luoto
- Section of Paediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, 00029-HUS, Helsinki, Finland.
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15
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Zhang MM, Pu CL, Li YC, Guo CB. Sixty-four-slice computed tomography in surgical strategy of portal vein cavernous transformation. World J Gastroenterol 2011; 17:4334-8. [PMID: 22090790 PMCID: PMC3214709 DOI: 10.3748/wjg.v17.i38.4334] [Citation(s) in RCA: 4] [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: 08/13/2010] [Revised: 11/23/2010] [Accepted: 11/30/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the role of 64-slice computed tomography (CT) in portal vein cavernous transformation to determine surgical strategy.
METHODS: The site of lesions and extent of collateral circulation in 12 pediatric cases of cavernous transformation of the portal vein with surgical treatment were analyzed.
RESULTS: Eleven of 12 children had esophageal varices and were treated with lower esophageal and gastric devascularization and splenectomy, and the other case was only treated with splenectomy. There were eight cases with spontaneous spleen/stomach-renal shunt, four with Retzius vein opening, which was reserved during surgery. Three cases of lesions involving the intrahepatic portal vein (PV) were treated with living donor liver transplantation. One patient died from PV thrombosis after liver transplantation, and the rest had no significant complications.
CONCLUSION: The PV, its branches and collateral circulation were clearly seen by 64-slice spiral CT angiography, which helped with preoperative surgical planning.
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16
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Kwan SW, Fidelman N, Durack JC, Roberts JP, Kerlan RK. Rex shunt preoperative imaging: diagnostic capability of imaging modalities. PLoS One 2011; 6:e22222. [PMID: 21765956 PMCID: PMC3134475 DOI: 10.1371/journal.pone.0022222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 06/21/2011] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to evaluate the diagnostic capability of imaging modalities used for preoperative mesenteric-left portal bypass (“Rex shunt”) planning. Twenty patients with extrahepatic portal vein thrombosis underwent 57 preoperative planning abdominal imaging studies. Two readers retrospectively reviewed these studies for an ability to confidently determine left portal vein (PV) patency, superior mesenteric vein (SMV) patency, and intrahepatic left and right PV contiguity. In this study, computed tomographic arterial portography allowed for confident characterization of left PV patency, SMV patency and left and right PV continuity in 100% of the examinations. Single phase contrast-enhanced CT, multi-phase contrast-enhanced CT, multiphase contrast-enhanced MRI, and transarterial portography answered all key diagnostic questions in 33%, 30%, 0% and 8% of the examinations, respectively. In conclusion, of the variety of imaging modalities that have been employed for Rex shunt preoperative planning, computed tomographic arterial portography most reliably allows for assessment of left PV patency, SMV patency, and left and right PV contiguity in a single study.
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Affiliation(s)
- Sharon W. Kwan
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Nicholas Fidelman
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - Jeremy C. Durack
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
| | - John P. Roberts
- Department of Surgery, University of California San Francisco, San Francisco, California, United States of America
| | - Robert K. Kerlan
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, United States of America
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Reichman TW, Anthony T, Testa G. Treatment of extrahepatic portal hypertension following a whipple procedure with a Rex shunt: report of a case. Surg Today 2011; 41:292-6. [PMID: 21264772 DOI: 10.1007/s00595-009-4236-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Accepted: 08/27/2009] [Indexed: 11/30/2022]
Abstract
The Rex shunt is a mesenteric vein to left portal vein decompressive shunt used for the treatment of portal vein thrombosis and portal hypertension. Its use has been reported primarily in the pediatric population where portal vein thrombosis occurs with some frequency. The shunt is thought to represent a more physiologic shunt, since it restores hepatopedal blood flow through the liver. This report describes the use of this shunt in an adult who had frequent gastrointestinal bleeding secondary to extrahepatic portal vein thrombosis, which occurred as a complication after a pancreaticoduodenectomy.
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Affiliation(s)
- Trevor W Reichman
- Department of Surgery, Division of Transplant Surgery, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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18
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Nemes B, Görög D, Fehérvári I, Mándli T, Sárváry E, Kóbori L, Doros A, Fazakas J. Unusual portal reconstructions after liver transplantation — Case report and review of literature. Interv Med Appl Sci 2010. [DOI: 10.1556/imas.2.2010.3.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Portal vein reconstruction might be a challenge in certain cases of liver transplantation. The problem usually arises due to small vessels in pediatric transplantation and/or living related donor and split liver transplantation, or as a result of extensive PVT in adult recipients. Authors report a case of a 60-year-old alcoholic cirrhotic patient with reverse portal flow. The standard end to end portal anastomosis did not work well, so a mesoportal shunt with a donor iliac vein conduit was performed first, followed by a cavoportal hemitransposition. After unsuccessful attempts of providing good portal flow, the donor umbilical vein and the iliac conduit was used for portal flow reconstruction as meso-Rex graft. The patient has been doing fine for eight months after her liver transplantation. Unusual types of portal reconstructions consist of meso-portal, umbilico-portal, renoportal anastomoses that are primarily used as rescue techniques. However, it is rare that one has to use them sequentially in the same patient.
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Affiliation(s)
- Balázs Nemes
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - D. Görög
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - I. Fehérvári
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - T. Mándli
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - E. Sárváry
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - L. Kóbori
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - A. Doros
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
| | - J. Fazakas
- 1 Department of Transplantation and Surgery, Semmelweis University, Baross u. 23–25, H-1082, Budapest, Hungary
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Maksoud-Filho JG, Gonçalves MEP, Cardoso SR, Gibelli NEM, Tannuri U. Long-term follow-up of children with extrahepatic portal vein obstruction: impact of an endoscopic sclerotherapy program on bleeding episodes, hepatic function, hypersplenism, and mortality. J Pediatr Surg 2009; 44:1877-83. [PMID: 19853741 DOI: 10.1016/j.jpedsurg.2009.02.074] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 02/13/2009] [Accepted: 02/16/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic sclerotherapy (ES) has been the standard treatment for children with idiopathic extrahepatic portal vein obstruction (EHPVO). Portosystemic shunts are indicated when variceal bleeding cannot be controlled by ES. Recently, mesenteric left portal vein bypass was indicated as a surgical intervention and preventative measure for hepatic dysfunction in children with long-term EHPVO. Nevertheless, there is a lack of published data confirming the extent of hepatic dysfunction, hypersplenism, and physical development in children with long-term follow-up. METHOD We retrospectively verified the long-term outcomes in 82 children with EHPVO treated with ES protocol, focusing on mortality, control of bleeding, hypersplenism, and consequent hepatic dysfunction. RESULTS Of the children, 56% were free from bleeding after the initiation of ES. The most frequent cause of rebleeding was gastric varices (30%). Four patients had recurrent bleeding from esophageal varices (4.6%). Four patients underwent surgery as a consequence of uncontrolled gastric varices. There were no deaths. Most patients showed good physical development. We observed a mild but statistically significant drop in factor V motion, as well as leukocyte and platelet count. CONCLUSION Endoscopic sclerotherapy is an efficient treatment for children with EHPVO. The incidence of rebleeding is low, and there was no mortality. Children develop mild liver dysfunction and hypersplenism with long-term follow-up. Only a few patients manifest symptoms of hypersplenism, portal biliopathy, or liver dysfunction before adolescence.
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Guérin F, Porras J, Fabre M, Guettier C, Pariente D, Bernard O, Gauthier F. Liver nodules after portal systemic shunt surgery for extrahepatic portal vein obstruction in children. J Pediatr Surg 2009; 44:1337-43. [PMID: 19573658 DOI: 10.1016/j.jpedsurg.2008.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 10/07/2008] [Accepted: 11/03/2008] [Indexed: 12/30/2022]
Abstract
BACKGROUND Liver nodules have been reported after portal systemic shunt surgery (PSSS) in animal experiments or in humans with liver cirrhosis. The aim of our study was to assess the incidence of liver nodules after surgery for extrahepatic portal vein obstruction (EHPVO) in children without associated liver disease. METHODS We retrospectively reviewed the charts of 45 children who had surgery from 1979 to 2005 for EHPVO in our institution, consisting of 38 PSSS and 7 portal reperfusion procedures (PRPs). We assessed the presence of liver nodules on ultrasonography. RESULTS Of 45 patients, 7 (15%) had liver nodules during a median of 80 months of follow-up. All the nodules occurred after PSSS. Five nodules were subjected to biopsy; we found 2 liver cell adenomas and 3 focal nodular hyperplasias. CONCLUSIONS In this study, liver nodules occurred in 18% of cases after PSSS for EHPVO in children and not after PRP. As many children have undergone PSSS throughout the world, the presence of liver nodules should be considered during the follow-up of those patients.
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Affiliation(s)
- Florent Guérin
- Department of Pediatric Surgery, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, University Paris XI, F94270 Le Kremlin-Bicêtre, France.
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Yamamoto S, Sato Y, Oya H, Nakatsuka H, Watanabe T, Takizawa K, Hatakeyama K. Splenic-intrahepatic left portal shunt in an adult patient with extrahepatic portal vein obstruction without recurrence after pancreaticoduodenectomy. ACTA ACUST UNITED AC 2008; 16:86-9. [PMID: 19096753 DOI: 10.1007/s00534-008-0002-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Accepted: 11/19/2007] [Indexed: 11/28/2022]
Abstract
In the last decade, a superior mesenteric-intrahepatic left portal shunt (Rex shunt) has been reported for successful management of extrahepatic portal vein obstruction in children. However, in adults, a mesocaval shunt has been generally performed for the surgical management of extrahepatic portal vein obstruction because of the complexity of the underlying disease and the difficulty of the superior mesenteric-intrahepatic left portal shunt. We herein report an adult patient who was successfully treated by splenic-intrahepatic left portal shunt with an artificial graft (6-mm polytetrafluoroethylene) for complete obstruction of the extrahepatic portal vein following pancreaticoduodenectomy. The shunt procedure not only relieved portal hypertension but also restored hepatic portal flow. In the near future, the Rex shunt should be considered for a beneficial management of extrahepatic portal vein obstruction, even in adults.
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Affiliation(s)
- Satoshi Yamamoto
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Asahimachi-dori, Niigata, Japan.
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