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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References
- Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension.J Pediatr Surg. 1998; 33: 597-601
- Mesenterico-left intrahepatic portal vein shunt: original technique to treat symptomatic extrahepatic portal hypertension.Acta Gastroenterol Belg. 1998; 61: 13-16
- Pulmonary arteriovenous shunting in children with liver disease.J Pediatr. 1995; 126: 571-579
- Portal cavenorma: diagnosis, aetiologies and consequences.Ann Chir. 2002; 127: 745-750
- Protein C, protein S and antithrombin III in children with portal vein obstruction.J Hepatol. 1997; 27: 132-135
- Aetiology and management of extrahepatic portal vein obstruction in children: King's College Hospital experience.J Pediatr Gastroenterol Nutr. 2008; 47: 630-634
- Risk of gastrointestinal bleeding during adolescence and early adulthood in children with portal vein obstruction.J Pediatr. 2000; 136: 805-808
- Recent concepts regarding extra-hepatic portal hypertension.Semin Pediatr Surg. 2005; 14: 216-225
- Benign nodular hepatocellular lesions caused by abnormal hepatic circulation: etiological analysis and introduction of a new concept.J Gastroenterol Hepatol. 2001; 16: 1319-1328
- Nodular transformation of the liver associated with portal and pulmonary arterial hypertension.Gastroenterology. 1993; 104: 616-621
- Portal obstruction in children. I. Clinical investigation and hemorrhage risk.J Pediatr. 1983; 103: 696-702
- Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction.Hepatology. 2002; 36: 666-672
- Shunt surgery for treatment of portal hypertension in children.World J Surg. 1985; 9: 258-268
- Extrahilar mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplant.Transplantation. 1992; 53: 231-232
- Original extrahilar approach for hepatic portal revascularization and relief of extrahepatic portal hypertension related to later portal vein thrombosis after pediatric liver transplantation. Long term results.Transplantation. 1996; 62: 71-75
- Surgical guidelines for the management of extra-hepatic portal vein obstruction.Pediatr Transplant. 2006; 10: 908-913
- Experience with mesocaval shunt with jugular vein interposition for treatment of portal hypertension in children (author's transl).Chir Pediatr. 1982; 23: 211-213
- Preserved vascular homograft for revascularization of pediatric liver transplant: a clinical, histological, and bacteriological study.Transplantation. 1999; 68: 672-677
- Immediate and long-term portal hemodynamic consequences of small-diameter H-graft portacaval shunt.J Surg Res. 1998; 74: 71-75
- Interposition grafting for portal hypertension.Am J Surg. 1975; 130: 733-738
- Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus.J Pediatr Surg. 2003; 38: E10-E11
- A new procedure for management of extrahepatic portal obstruction. Proximal splenic-left intrahepatic portal shunt.Arch Surg. 1992; 127: 1358-1360
- Experience with alternate sources of venous inflow in the meso-Rex bypass operation: the coronary and splenic veins.J Pediatr Surg. 2007; 42: 1199-1202
- Use of autogenous saphenous vein as a conduit for mesenterico-left portal vein bypass.J Pediatr Surg. 2007; 42: 1137-1140
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.
