Download PDF
Digestive Disease Interventions 2019; 03(03): 227-239
DOI: 10.1055/s-0039-1697025
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Surgical Mesoportal Bypass and Portosystemic Shunt Interventions

Arthie Jeyakumar
1   Section of Interventional Radiology, Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
,
Jeffrey Forris Beecham Chick
2   Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
,
Patrick J. Healey
3   Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
,
Eric J. Monroe
1   Section of Interventional Radiology, Department of Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
› Author Affiliations
Further Information

Publication History

28 March 2019

27 June 2019

Publication Date:
12 September 2019 (online)

Also available at
    Permissions and Reprints

Abstract

Extrahepatic portal vein obstruction is defined by obstruction of the extrahepatic portal vein with or without involvement of the intrahepatic veins and does not include isolated thrombosis of the splenic vein or superior mesenteric vein. The etiology may be congenital versus acquired and acute versus chronic. Historically, surgical intervention has been reserved for patients with symptoms refractory to medical or endoscopic management. Over time, however, advances in surgical technique and research have caused a shift in practice. The interventionalists' role is primarily to address clinically significant shunt dysfunction, including shunt stenosis and thrombosis. In this article, the authors discuss the classification and indications of surgical portosystemic conduits, pre-and postoperative imaging, and clinical signs, and endovascular techniques to address shunt dysfunction.

Keywords

extrahepatic portal venous obstruction - pediatric - children - meso-Rex surgical shunt - bypass and selective shunts - nonselective shunts - transjugular intrahepatic portosystemic shunt - interventional radiology
 

  • References

  • 1 de Franchis R. ; Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
    CrossrefPubMedGoogle Scholar
  • 2 Pariente D, Franchi-Abella S. Paediatric chronic liver diseases: how to investigate and follow up? Role of imaging in the diagnosis of fibrosis. Pediatr Radiol 2010; 40 (06) 906-919
    CrossrefPubMedGoogle Scholar
  • 3 Poddar U, Thapa BR, Rao KL, Singh K. Etiological spectrum of esophageal varices due to portal hypertension in Indian children: is it different from the West?. J Gastroenterol Hepatol 2008; 23 (09) 1354-1357
    CrossrefPubMedGoogle Scholar
  • 4 Chaudhary A, Dhar P, Sarin SK. , et al. Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: surgical management. Br J Surg 1998; 85 (03) 326-329
    CrossrefPubMedGoogle Scholar
  • 5 Arora NK, Das MK. Extra hepatic portal venous obstruction in children. In: Garbuzenko DV. Portal Hypertension: Cases and Complications. Rijeka, Croatia: InTech; 2012: 41-64
    Google Scholar
  • 6 Feldman AG, Sokol RJ. Noncirrhotic portal hypertension in the pediatric population. Clin Liver Dis (Hoboken) 2015; 5 (05) 116-119
    CrossrefPubMedGoogle Scholar
  • 7 Rangari M, Gupta R, Jain M, Malhotra V, Sarin SK. Hepatic dysfunction in patients with extrahepatic portal venous obstruction. Liver Int 2003; 23 (06) 434-439
    CrossrefPubMedGoogle Scholar
  • 8 Dasgupta R, Roberts E, Superina RA, Kim PC. Effectiveness of Rex shunt in the treatment of portal hypertension. J Pediatr Surg 2006; 41 (01) 108-112 , discussion 108–112
    CrossrefPubMedGoogle Scholar
  • 9 de Ville de Goyet J, Alberti D, Clapuyt P. , et al. 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 (04) 597-601
    CrossrefPubMedGoogle Scholar
  • 10 Mack CL, Superina RA, Whitington PF. Surgical restoration of portal flow corrects procoagulant and anticoagulant deficiencies associated with extrahepatic portal vein thrombosis. J Pediatr 2003; 142 (02) 197-199
    CrossrefPubMedGoogle Scholar
  • 11 Superina R, Shneider B, Emre S, Sarin S, de Ville de Goyet J. Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant 2006; 10 (08) 908-913
    CrossrefPubMedGoogle Scholar
  • 12 Mack CL, Zelko FA, Lokar J. , et al. Surgically restoring portal blood flow to the liver in children with primary extrahepatic portal vein thrombosis improves fluid neurocognitive ability. Pediatrics 2006; 117 (03) e405-e412
    CrossrefPubMedGoogle Scholar
  • 13 Superina R. Portal hypertension. Pediatric Surgery. 7th ed. In: Coran AG, Caldamone A, Adzick NC, Krummel TM, Laberge JM, Shamberger R. Philadelphia, PA: Elsevier; 2012: 1355-1369
    Google Scholar
  • 14 de Ville de Goyet J. Extrahilar Left Portal Vein Revascularization. Innovative Techniques in Pediatric Liver Transplantation. Personal edition 1995: 135-154
    Google Scholar
  • 15 Chiu B, Pillai SB, Sandler AD, Superina RA. Experience with alternate sources of venous inflow in the meso-Rex bypass operation: the coronary and splenic veins. J Pediatr Surg 2007; 42 (07) 1199-1202
    CrossrefPubMedGoogle Scholar
  • 16 Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg 1967; 166 (03) 437-455
    CrossrefPubMedGoogle Scholar
  • 17 Rikkers LF, Sorrell WT, Jin G. Which portosystemic shunt is best?. Gastroenterol Clin North Am 1992; 21 (01) 179-196
    PubMedGoogle Scholar
  • 18 Ahn SS, Yellin A, Sheng FC, Colonna JO, Goldstein LI, Busuttil RW. Selective surgical therapy of the Budd-Chiari syndrome provides superior survivor rates than conservative medical management. J Vasc Surg 1987; 5 (01) 28-37
    CrossrefPubMedGoogle Scholar
  • 19 Cameron JL, Maddrey WC. Mesoatrial shunt: a new treatment for the Budd-Chiari syndrome. Ann Surg 1978; 187 (04) 402-406
    CrossrefPubMedGoogle Scholar
  • 20 Mirković D, Stanković N, Jevtić M, Mitrović M, Jovanović M. [Mesoatrial shunt in Budd-Chiari syndrome]. Vojnosanit Pregl 2009; 66 (01) 69-73
    CrossrefPubMedGoogle Scholar
  • 21 Darwish Murad S, Valla DC, de Groen PC. , et al. Determinants of survival and the effect of portosystemic shunting in patients with Budd-Chiari syndrome. Hepatology 2004; 39 (02) 500-508
    CrossrefPubMedGoogle Scholar
  • 22 Taslakian B, Faraj W, Khalife M. , et al. Assessment of surgical portosystemic shunts and associated complications: The diagnostic and therapeutic role of radiologists. Eur J Radiol 2015; 84 (08) 1525-1539
    CrossrefPubMedGoogle Scholar
  • 23 Chiu B, Superina R. Extrahepatic portal vein thrombosis is associated with an increased incidence of cholelithiasis. J Pediatr Surg 2004; 39 (07) 1059-1061
    CrossrefPubMedGoogle Scholar
  • 24 Cárdenas AM, Epelman M, Darge K, Rand EB, Anupindi SA. Pre- and postoperative imaging of the Rex shunt in children: what radiologists should know. AJR Am J Roentgenol 2012; 198 (05) 1032-1037
    CrossrefPubMedGoogle Scholar
  • 25 Chaves IJ, Rigsby CK, Schoeneman SE, Kim ST, Superina RA, Ben-Ami T. Pre- and postoperative imaging and interventions for the meso-Rex bypass in children and young adults. Pediatr Radiol 2012; 42 (02) 220-232 , quiz 271–272
    CrossrefPubMedGoogle Scholar
  • 26 Kwan SW, Fidelman N, Durack JC, Roberts JP, Kerlan Jr RK. Rex shunt preoperative imaging: diagnostic capability of imaging modalities. PLoS One 2011; 6 (07) e22222
    CrossrefPubMedGoogle Scholar
  • 27 Puppala S, Patel J, Woodley H, Alizai NK, Kessel D. Preoperative imaging of left portal vein at the Rex recess for Rex shunt formation using wedged hepatic vein carbon dioxide portography. J Pediatr Surg 2009; 44 (10) 2043-2047
    CrossrefPubMedGoogle Scholar
  • 28 Lawson AJ, Rischbieter P, Numanoglu A, Wieselthaler N, Beningfield SJ. Imaging the Rex vein preoperatively using wedged hepatic venous portography. Pediatr Radiol 2011; 41 (10) 1246-1249
    CrossrefPubMedGoogle Scholar
  • 29 Orloff MJ, Orloff MS, Rambotti M. Treatment of bleeding esophagogastric varices due to extrahepatic portal hypertension: results of portal-systemic shunts during 35 years. J Pediatr Surg 1994; 29 (02) 142-151 , discussion 151–154
    CrossrefPubMedGoogle Scholar
  • 30 Alagille D, Carlier J-C, Chiva M, Ziadé R, Ziadé M, Moy F. Long-term neuropsychological outcome in children undergoing portal-systemic shunts for portal vein obstruction without liver disease. J Pediatr Gastroenterol Nutr 1986; 5 (06) 861-866
    CrossrefPubMedGoogle Scholar
  • 31 Superina RA, Alonso EM. Medical and surgical management of portal hypertension in children. Curr Treat Options Gastroenterol 2006; 9 (05) 432-443
    CrossrefPubMedGoogle Scholar
  • 32 Lautz TB, Keys LA, Melvin JC, Ito J, Superina RA. Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children. J Am Coll Surg 2013; 216 (01) 83-89
    CrossrefPubMedGoogle Scholar
  • 33 Botha JF, Campos BD, Grant WJ. , et al. Portosystemic shunts in children: a 15-year experience. J Am Coll Surg 2004; 199 (02) 179-185
    CrossrefPubMedGoogle Scholar
  • 34 Evans S, Stovroff M, Heiss K, Ricketts R. Selective distal splenorenal shunts for intractable variceal bleeding in pediatric portal hypertension. J Pediatr Surg 1995; 30 (08) 1115-1118
    CrossrefPubMedGoogle Scholar
  • 35 Johansen LC, McKiernan PJ, Sharif K, McGuirk SP. Transjugular intrahepatic portosystemic shunt insertion for the management of portal hypertension in children. J Pediatr Gastroenterol Nutr 2018; 67 (02) 173-179
    CrossrefPubMedGoogle Scholar
  • 36 Ghannam JS, Cline MR, Hage AN. , et al. Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement: a 20-year experience. Pediatr Radiol 2019; 49 (01) 128-135
    CrossrefPubMedGoogle Scholar
  • 37 Bertino F, Hawkins CM, Shivaram G. , et al. Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients. J Vasc Interv Radiol 2019; 30 (02) 178-186.e5
    CrossrefPubMedGoogle Scholar
  • 38 Monroe EJ, Shin DS, Shivaram GM, Koo KS. Pediatric transjugular intrahepatic portosystemic shunts. Dig Dis Interv 2017; 1 (04) 277-285
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Lv Y, He C, Guo W. , et al. Transjugular intrahepatic portosystemic shunt for extrahepatic portal venous obstruction in children. J Pediatr Gastroenterol Nutr 2016; 62 (02) 233-241
    CrossrefPubMedGoogle Scholar
  • 40 Hong R, Dhanani RS, Louie JD, Sze DY. Intravascular ultrasound-guided mesocaval shunt creation in patients with portal or mesenteric venous occlusion. J Vasc Interv Radiol 2012; 23 (01) 136-141
    CrossrefPubMedGoogle Scholar
  • 41 Srinivasa RN, Majdalany BS, Chick JFB. , et al. Single-session percutaneous endovascular mesocaval shunt creation and balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices. Ann Vasc Surg 2018; 46: 371.e1-371.e6
    CrossrefPubMedGoogle Scholar
  • 42 Woerner A, Shivaram G, Koo KSH, Hsu EK, Dick AAS, Monroe EJ. Clinical and imaging predictors of surgical splenorenal shunt dysfunction in pediatric patients. J Pediatr Gastroenterol Nutr 2018; 66 (06) e139-e145
    CrossrefPubMedGoogle Scholar
  • 43 Lautz TB, Kim ST, Donaldson JS, Superina RA. Outcomes of percutaneous interventions for managing stenosis after meso-Rex bypass for extrahepatic portal vein obstruction. J Vasc Interv Radiol 2012; 23 (03) 377-383
    CrossrefPubMedGoogle Scholar
  • 44 Stefek HA, Rigsby CK, Berhane H, Popescu AR, Rajeswaran S, Superina RA. MR angiography and 2-D phase-contrast imaging for evaluation of meso-rex bypass function. Pediatr Radiol 2019; 49 (02) 168-174
    CrossrefPubMedGoogle Scholar
  • 45 Lillegard JB, Hanna AM, McKenzie TJ, Moir CR, Ishitani MB, Nagorney DM. A single-institution review of portosystemic shunts in children: an ongoing discussion. HPB Surg 2010; 2010: 964597
    PubMedGoogle Scholar
  • 46 Gong GQ, Wang XL, Wang JH. , et al. Percutaneous transsplenic embolization of esophageal and gastrio-fundal varices in 18 patients. World J Gastroenterol 2001; 7 (06) 880-883
    CrossrefPubMedGoogle Scholar
  • 47 Tuite DJ, Rehman J, Davies MH, Patel JV, Nicholson AA, Kessel DO. Percutaneous transsplenic access in the management of bleeding varices from chronic portal vein thrombosis. J Vasc Interv Radiol 2007; 18 (12) 1571-1575
    CrossrefPubMedGoogle Scholar
  • 48 Chu HH, Kim HC, Jae HJ. , et al. Percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver disease. Cardiovasc Intervent Radiol 2012; 35 (06) 1388-1395
    CrossrefPubMedGoogle Scholar
  • 49 Habib A, Desai K, Hickey R. , et al. Portal vein recanalization-transjugularintrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 2015; 26 (04) 499-506
    CrossrefPubMedGoogle Scholar
  • 50 Pimpalwar S, Chinnadurai P, Hernandez A, Kukreja K, Siddiqui S, Justino H. Trans-splenic access for portal venous interventions in children: do benefits outweigh risks?. Cardiovasc Intervent Radiol 2018; 41 (01) 87-95
    CrossrefPubMedGoogle Scholar
  • 51 Monroe EJ, Speir EJ, Hawkins CM, Shivaram G, Koo KSH, Gill AE. Transsplenic splenoportography and portal venous interventions in pediatric patients. Pediatr Radiol 2018; 48 (10) 1441-1450
    CrossrefPubMedGoogle Scholar
  • 52 Monroe EJ, Carney BW, Ingraham CR, Johnson GE, Valji K. An interventionist's guide to endocrine consultations. Radiographics 2017; 37 (04) 1246-1267
    CrossrefPubMedGoogle Scholar
  • 53 Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol 2013; 16 (02) 101-151
    CrossrefPubMedGoogle Scholar
  • 54 Scudamore CH, Erb SR, Morris C. , et al. Medium aperture meso-caval shunts reliably prevent recurrent variceal hemorrhages. Am J Surg 1996; 171 (05) 490-494
    CrossrefPubMedGoogle Scholar
  • 55 Saad WAE. Portal Hypertension: Imaging, Diagnosis, and Endovascular Management. 3rd ed. New York, NY: 2018
    Google Scholar
  • 56 Yabuta M, Shibata T, Shibata T. , et al. Long-term outcome of percutaneous transhepatic balloon angioplasty for portal vein stenosis after pediatric living donor liver transplantation: a single institute's experience. J Vasc Interv Radiol 2014; 25 (09) 1406-1412
    CrossrefPubMedGoogle Scholar
  • 57 Funaki B, Rosenblum JD, Leef JA. , et al. Percutaneous treatment of portal venous stenosis in children and adolescents with segmental hepatic transplants: long-term results. Radiology 2000; 215 (01) 147-151
    CrossrefPubMedGoogle Scholar
  • 58 Stein EJ, Shivaram GM, Koo KSH, Dick AAS, Healey PJ, Monroe EJ. Endovascular treatment of dysfunctional surgical mesoportal and portosystemic shunt dysfunction in pediatric patients. Pediatr Radiol 2019; 49 (10) 1344-1353
    CrossrefPubMedGoogle Scholar