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Schema of meso-Rex bypass versus portosystemic shunt. a Porte-systemic shunt (Spleno-Cava shunt). b Porte-systemic shunt (proximal splenorenal shunt). c Meso-porte Rex bypass
Source publication
PurposeExtrahepatic portal vein obstruction (EHPVO) is a major cause of non-cirrhotic portal hypertension in children. Surgical procedures for EHPVO include portosystemic shunts (PSS) and meso-Rex bypass (MRB). We conducted a systematic review and meta-analysis to compare the effectiveness of MRB versus PSS in EHPVO patients.MethodsA systematic lit...
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Objective
Transjugular intrahepatic portosystemic shunt (TIPS) is a useful approach in managing complications caused by severe portal hypertension (PH) in adults. In children, TIPS is technically challenging, and previous studies of TIPS in children have yielded inconsistent results. This study aimed to elucidate the feasibility and clinical effect...
Citations
... Частота повторных операций или эндоваскулярных вмешательств также была статистически значимо (p = 0,019) больше после МПШ, чем после ПСШ (11,8 и 4,1%). Во втором метаанализе показаны практически идентичные в отношении тромбоза шунта результаты [45]. МПШ выполнено 131 ребенку, а ПСШ -126. ...
The study involved literature review of history and current state of surgical treatment in extrahepatic portal hypertension in children and adults. The author analyzed Russian and foreign publications on surgical repair of hepatopetal blood flow in extrahepatic portal hypertension. The issue is a high priority in Russia, which is confirmed by the fact that the author found out the pioneer studies of Russian authors, which were published earlier than the works of foreign researchers. It was found that the role of hepatopetal blood flow restoration in extrahepatic portal hypertension in adults had been much less studied than in children. More clinical material is to be gathered to determine the feasibility of such interventions in adults.
... Twenty-one patients, with an average age of 5 years (range 2-12) were included in the study. This patient population is younger than most series in the literature that report ages at the time of shunt between 6 and 8 years of age [33,38]. ...
... However, MRS demonstrated superiority regarding the alleviation of hypersplenism and offered additional metabolic benefits. These findings contrast with the recently published meta-analysis [38], which did not reveal superiority for either MRS or Portosystemic shunts, however, in this meta-analysis, only one study compared directly between both shunts and confirmed the better results of MRS regarding the metabolic outcome [33]. The paucity of well-conducted trials in this area justifies future multicentre studies and studies that examine long-term outcomes and directly compare MRS with DSRS. ...
Purpose
To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children’s Hospital and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS).
Methods
This is a single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts were performed, 15 MRS and 7 DSRS, over an 18-year period. Patients were followed up for a mean of 11 years (range 2–18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalised ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2 years after shunt surgery.
Results
One MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration.
Conclusion
In EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails.
... In addition, no differences were reported in shunt complications, mortality, or gastrointestinal bleeding after surgery between meso-Rex shunt and portosystemic shunt in a meta-analysis, which indicated that meso-Rex shunt did not increase shunt complications, mortality, or gastrointestinal bleeding after surgery [38]. ...
... By summarizing the efficacy of Rex shunt reported by various centers (Table 1), it was found that the failure rate after Rex shunt was about 10-20%. The complications include obstruction, thrombus, and stenosis of shunt after Rex shunt, and 24.2% (16/66) of post-operative complication was reported by a meta-analysis review [38]. Although patients may die after Rex shunt, a meta-analysis review showed 0% of mortality after Rex shunt [38]. ...
... The complications include obstruction, thrombus, and stenosis of shunt after Rex shunt, and 24.2% (16/66) of post-operative complication was reported by a meta-analysis review [38]. Although patients may die after Rex shunt, a meta-analysis review showed 0% of mortality after Rex shunt [38]. In addition, no one don't want to undergo a treatment after suffering from portal hypertension, which may be the reason that there is no report about survival of EHPVO patients without any treatment. ...
Rex shunt, which was first put in use in 1992, has been considered as an ideal surgical method for the treatment of extra-hepatic portal venous obstruction (EHPVO) due to its reconstruction of the hepatopetal portal blood flow. However, despite its long tradition, there are only a few reports about the application and advances in Rex shunt for the treatment of EHPVO in children. In this paper, we summarized the literature related to Rex shunt and discussed the new advances of Rex shunt in the following aspects: surgical method of Rex shunt, the indications of Rex shunt, the strengths of Rex shunt, the effectiveness of Rex shunt, factors affecting the efficacy of Rex shunt, methods that improve the prognosis of Rex shunt, and treatment strategy for recurrence after Rex shunt.
BACKGROUND: The prehepatic form of portal hypertension is the most common cause of portal hypertension in children. Nowadays mesoportal shunting is the most optimal therapy for such pathology. In the world literature, there are only few publications describing application of such surgical technique in children of the first year of life. CLINICAL CASE DESCRIPTION: The article describes a case of a 7-month old child with prehepatic portal hypertension who had mesoportal bypass surgery. A month before the surgery, the child had an episode of gastrointestinal bleeding which was treated conservatively. Additional diagnostics before surgery included liver and spleen ultrasound examination, transarterial mesenteric portography, and esophagogastroduodenoscopy. The child was discharged home on the 6th postoperative day. For three months after the surgery, he received antiplatelet therapy and proton pump inhibitors. In 3-months, follow-up ultrasound showed satisfactory blood flow through the shunt. Patient’s weight gain had also a positive trend. CONCLUSION: Mesoportal bypass surgery is technically achievable in children of the first year of life. In our opinion, patient’s age has a positive impact on creating a functioning mesoportal shunt: the younger the patient, the greater the likelihood of favorable outcome.
Liver transplantation (LT) is a common solid organ transplant in the pediatric population. The common indications for LT, as well as its complications, differ between adults and children. This difference necessitates unique pediatric interventional radiology (IR) interventions. This article focuses on unique vascular complications occurring post-pediatric LT and highlights the importance of IR in their management. It explores IR's involvement in the workup of patients' pre-LT and management of complications following portosystemic shunts. We discuss advantages and disadvantages of different access routes as well as the prevalence, clinical picture, diagnosis, and management of complications after pediatric LT. These complications encompass portal vein stenosis, portal vein thrombosis, hepatic artery stenosis, hepatic artery thrombosis, hepatic artery pseudoaneurysm, arterioportal fistula, hepatic vein stenosis, and inferior vena cava stenosis. The choice of endovascular technique for a clinical indication depends on vascular anatomy, time since LT, and patient-specific factors. Transsplenic access is a useful alternative to transhepatic or transjugular access. The decision to place a stent in a child is influenced by the expected growth of the child and risk of focal narrowing at stent edge (because of recipient growth). Technical challenges in pediatric patient management, including uncooperative patients and sedation issues, must be considered. Pediatric LT complications can present with significant challenges in the posttransplant care of recipients and may lead to serious morbidity and graft failure if not managed effectively. IR techniques like balloon angioplasty, stent placement, thrombolysis, and embolization have demonstrated success in treating these complications, improving patient outcomes, and reducing long-term morbidity and mortality. By enhancing the understanding of medical practitioners and interventional radiologists about complex vascular complications, this article aims to contribute to better posttransplant care and improved outcomes for LT in pediatric populations. Continued collaboration between specialties and research will advance the field of pediatric LT and IR, to create even more effective treatment strategies.
Introduction Umbilical vein catheterization (UVC) can cause portal venous thrombosis, leading to the development of extrahepatic portal venous obstruction (EHPVO) and portal hypertension (PHT). The feasibility of the Meso-Rex bypass (MRB) for the treatment of EHPVO in patients with a history of UVC has been questioned. We compared the feasibility of performing an MRB in patients with or without a history of previous UVC.
Methods A retrospective review of patients with EHPVO and known UVC status explored for a possible MRB at our institution was performed (1997–2022). Patients were categorized in two groups: with (UVC(+)) or without (UVC(–)) a history of UVC for comparison. A p-value less than 0.05 was considered significant.
Results One hundred and eighty-seven patients were included (n = 57 in UVC(+); n = 130 in UVC(–)). Patients in the UVC group were significantly younger at surgery and the incidence of prematurity was higher. Other risk factors for the development of EHPVO were similar between the groups, but only history of UVC could predict the ability to receive MRB (odds ratio [OR]: 7.4 [3.5–15.4]; p < 0.001). The success rate of MRB was significantly higher in patients with no history of UVC (28/57 [49.1%] in UVC(+) vs. 114/130 [87.7%] in UVC(–); p < 0.001). However, MRB patency at discharge (25/28 [89.3%] in UVC(+) vs. 106/114 [94.7%] in UVC(–); p = 0.3) was equally high in both groups.
Conclusion Our results indicate that a history of UVC is not a contraindication to MRB. Half of the patients were able to successfully receive an MRB. Patients with symptomatic PHT from EHPVO should not be excluded from consideration for MRB based on UVC history.
Purpose of Review
Non-cirrhotic portal hypertension (NCPH) is primarily comprised of extrahepatic portal venous obstruction (EHPVO), followed by congenital hepatic fibrosis (CHF) and non-cirrhotic portal fibrosis (NCPF). Various complications besides variceal bleeding pose a management challenge. This review summarizes the best evidence-based management practices for children with NCPH.
Recent Findings
Endotherapy in EHPVO eradicates esophageal varices but does not tackle problems like ectopic varices, portal biliopathy, massive splenomegaly, growth failure, etc. Meso-Rex shunt is a physiological shunt that ameliorates nearly all complications in EHPVO. In children with NCPF and isolated CHF, endotherapy remains the mainstay of management, with shunt surgery useful when indicated.
Summary
Beyond variceal eradication, endotherapy has a limited role, and evaluation for meso-Rex shunt should be done at the beginning in EHPVO. Endotherapy constitutes the major therapeutic option in NCPF and CHF, except in a small subset who may require liver or a combined liver-kidney transplantation.
PURPOSE
To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children’s Hospital and compare Meso-Rex shunt (MRS) with distal splenorenal shunt (DSRS).
METHODS
A single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts performed, 15 MRS and 7 DSRS over 18-year period. Patients were followed up for a mean of 11 years (range: 2–18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalized ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2-years after shunt surgery.
RESULTS
One MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration.
CONCLUSION
In EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails.
