Abstract
Meso-Rex shunt (MRS) can relieve portal hypertension and restore a physiological portal
flow in patients with portal vein thrombosis. We describe a technical variant where
the autologous internal jugular vein (IJV) was too short to bridge the superior mesenteric
vein (SMV) and the Rex recessus.
Patient
A 15-year-old boy with portal cavernoma had several episodes of gastrointestinal bleeding
despite repeated sclerotherapy. Preoperative assessment, including retrograde transjugular
portography, showed persistent esophageal and gastric varices, severe hypertensive
gastropathy, obstructed portal vein, patent SMV and splenomesenteric confluence, patent
intrahepatic portal branches, and normal transhepatic pressure gradient. An MRS was
planned. The left IJV was retrieved from its infracranial part to its confluence with
subclavian vein. After performing the Rex recessus to IJV graft anastomosis, the IJV
graft proved to be too short for classical end-to-side anastomosis onto the SMV. After
clamp testing showing good tolerance of the small bowel, the proximal jejunal branches
of the SMV were tied, the proximal SMV was mobilized and transsected 4 cm below the
pancreas, and an end-to-end anastomosis between SMV and IJV was performed. Portal
pressure decreased from 23 to 13 mm Hg, and intraoperative Ultra Sound Doppler (US
Doppler) showed good flows in the shunt. Postoperative course was uneventful, and
1 year after surgery, the child is clinically well, off medication, with a patent
shunt, and no portal hypertension.
Conclusion
This modified MRS technique may be useful when the autologous IJV graft is too short,
avoiding the need for prosthetic conduits and prolonged postoperative anticoagulation.
Key words
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Article info
Publication history
Accepted:
August 4,
2009
Received in revised form:
August 3,
2009
Received:
June 23,
2009
Identification
Copyright
© 2009 Elsevier Inc. Published by Elsevier Inc. All rights reserved.