One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics

Figure 1 Axial computed tomography. Portal cavernoma, enlarged spleen, and large varices.

Figure 2 Trans-mesenteric portal venography. Showing patent superior mesenteric and splenic veins, large left gastric varicose veins; portal cavernoma and patent intrahepatic portal branches.

Figure 3 Minilaparotomy-assisted transmesenteric pre-dilation with 0. 018’ guide wire inserted 8 mm into the portal trunk after portal cavernoma recanalization with hydrophilic guide wire.

Figure 4 Venography with injection into the splenic vein after left gastric vein embolization and portal trunk pre-dilation. No residual flow in varices. Guiding catheter parallel to the safety wire in the portal trunk.

Figure 5 Follow-up angiography. Hepatopetal flow in the right portal branch. Hourglass shape of the under-dilated transjugular intrahepatic portosystemic shunt. Free fluid around the liver (before removal with suction and sponges).

Figure 6 Computed tomography MIP multiplanar coronal reconstruction at 1 mo follow up (A and B). A: Residual waist of the TIPS stent, regular portal liver perfusion and preservation of splenic and superior mesenteric venous flow. No residual free fluid in the perihepatic space; B: Volume rendering 3D computed tomography reconstruction: varice exclusion and global perspective of the regular portal flow.