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Pre- and postoperative imaging and interventions for the meso-Rex bypass in children and young adults

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Abstract

The meso-Rex bypass is a physiological and anatomical bypass procedure for relief of extrahepatic portal vein obstruction and restoration of mesenteric venous return to the liver. Most patients who are candidates for the bypass are children or young adults with portal hypertension and hypersplenism secondary to cavernous transformation of the portal vein. Most frequently, the bypass utilizes an autologous venous graft to connect the intrahepatic left portal vein to the infrapancreatic superior mesenteric vein (SMV) re-establishing first-pass portal perfusion. We describe the preoperative imaging of the 92 bypass candidates, the surgical anatomy as reflected in postoperative imaging, and the imaging of bypass complications at our institution.

Preoperative imaging with US, CT and MR is directed to demonstrate patency and size of the left portal vein and SMV, to define the extent of cavernous transformation and splanchnic collaterals, and to assess for any associated abdominal vascular or solid organ abnormalities. Postoperative imaging is aimed at diagnosing meso-Rex bypass stenosis or occlusion and the interventional management of these complications.

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References

  1. Balfour GS, Stewart TG (1869) Case of enlarged spleen complicated with ascites, both depending upon varicose dilatation and thrombosis of the portal vein. Edinburgh Med J 14:589–599

    Google Scholar 

  2. De Gaetano AM, Lafortune M, Patriquin H et al (1995) Cavernous transformation of the portal vein: patterns of intrahepatic and splanchnic collateral circulation detected with Doppler sonography. AJR 165:1151–1155

    PubMed  Google Scholar 

  3. Bayraktar Y, Balkanci F, Kayhan B et al (1997) Congenital hepatic fibrosis associated with cavernous transformation of the portal vein. Hepatogastroenterology 44:1588–1594

    PubMed  CAS  Google Scholar 

  4. Guimaraes H, Castelo L, Guimaraes J et al (1998) Does umbilical vein catheterization to exchange transfusion lead to portal vein thrombosis? Eur J Pediatr 157:461–463

    Article  PubMed  CAS  Google Scholar 

  5. Kader HA, Baldassano RN, Harty MP et al (1998) Ruptured retrocecal appendicitis in an adolescent presenting as portal-mesenteric thrombosis and pylephlebitis. J Pediatr Gastroenterol Nutr 27:584–588

    Article  PubMed  CAS  Google Scholar 

  6. Nishimori H, Ezoe E, Ura H et al (2004) Septic thrombophlebitis of the portal and superior mesenteric veins as a complication of appendicitis: report of a case. Surg Today 34:173–176

    Article  PubMed  Google Scholar 

  7. Pacifico L, Panero A, Colarizi P et al (2004) Neonatal Candida albicans septic thrombosis of the portal vein followed by cavernous transformation of the vessel. J Clin Microbiol 42:4379–4382

    Article  PubMed  Google Scholar 

  8. Primignani M, Martinelli I, Bucciarelli P et al (2005) Risk factors for thrombophilia in extrahepatic portal vein obstruction. Hepatology 41:603–608

    Article  PubMed  CAS  Google Scholar 

  9. Sarin SK, Sollano JD, Chawla YK et al (2006) Consensus on extra-hepatic portal vein obstruction. Liver Int 26:512–519

    Article  PubMed  Google Scholar 

  10. Stiller RJ, Neale D, Schwartz D et al (2003) Prenatal diagnosis of portal vein thrombosis by ultrasound. Ultrasound Obstet Gynecol 22:295–298

    Article  PubMed  CAS  Google Scholar 

  11. Tung JY, Johnson JL, Liacouras CA (1996) Portal-mesenteric pylephlebitis with hepatic abscesses in a patient with Crohn’s disease treated successfully with anticoagulation and antibiotics. J Pediatr Gastroenterol Nutr 23:474–478

    Article  PubMed  CAS  Google Scholar 

  12. Vanamo K, Kiekara O (2001) Pylephlebitis after appendicitis in a child. J Pediatr Surg 36:1574–1576

    Article  PubMed  CAS  Google Scholar 

  13. Yachha SK, Khanduri A, Sharma BC et al (1996) Gastrointestinal bleeding in children. J Gastroenterol Hepatol 11:903–907

    PubMed  CAS  Google Scholar 

  14. Superina R, Shneider B, Emre S et al (2006) Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant 10:908–913

    Article  PubMed  Google Scholar 

  15. Superina R, Bambini DA, Lokar J et al (2006) Correction of extrahepatic portal vein thrombosis by the mesenteric to left portal vein bypass. Ann Surg 243:515–521

    Article  PubMed  Google Scholar 

  16. de Ville de Goyet J, Clapuyt P, Otte JB (1992) Extrahilar mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplant. Transplantation 53:231–232

    PubMed  Google Scholar 

  17. de Ville de Goyet J, Alberti D, Clapuyt P et al (1998) 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 33:597–601

    Article  PubMed  Google Scholar 

  18. Dasgupta R, Roberts E, Superina RA et al (2006) Effectiveness of Rex shunt in the treatment of portal hypertension. J Pediatr Surg 41:108–112, discussion 108–112

    Article  PubMed  Google Scholar 

  19. de Ville de Goyet J, Alberti D, Falchetti D et al (1999) Treatment of extrahepatic portal hypertension in children by mesenteric-to-left portal vein bypass: a new physiological procedure. Eur J Surg 165:777–781

    Article  PubMed  Google Scholar 

  20. Gehrke I, John P, Blundell J et al (2003) Meso-portal bypass in children with portal vein thrombosis: rapid increase of the intrahepatic portal venous flow after direct portal hepatic reperfusion. J Pediatr Surg 38:1137–1140

    Article  PubMed  CAS  Google Scholar 

  21. Audet M, Baiocchi GL, Portolani N et al (2003) A surgical solution to extrahepatic portal thrombosis and portal cavernoma: the splanchnic-intrahepatic portal bypass. Dig Liver Dis 35:903–906

    Article  PubMed  CAS  Google Scholar 

  22. Kang HK, Jeong YY, Choi JH et al (2002) Three-dimensional multi-detector row CT portal venography in the evaluation of portosystemic collateral vessels in liver cirrhosis. Radiographics 22:1053–1061

    PubMed  Google Scholar 

  23. Gulati MS, Paul SB, Arora NK et al (2000) Esophageal and gastric vasculature in children with extrahepatic portal hypertension: evaluation by intravenous CT portography. Clin Imaging 24:351–356

    Article  PubMed  CAS  Google Scholar 

  24. Annet L, Materne R, Danse E et al (2003) Hepatic flow parameters measured with MR imaging and Doppler US: correlations with degree of cirrhosis and portal hypertension. Radiology 229:409–414

    Article  PubMed  Google Scholar 

  25. Shinohara T, Ando H, Watanabe Y et al (2006) Extrahepatic portal vein morphology in children with extrahepatic portal hypertension assessed by 3-dimensional computed tomographic portography: a new etiology of extrahepatic portal hypertension. J Pediatr Surg 41:812–816

    Article  PubMed  Google Scholar 

  26. Kwan SW, Fidelman N, Durack JC et al (2011) Rex shunt preoperative imaging: diagnostic capability of imaging modalities. PLoS One 6:e22222

    Article  PubMed  CAS  Google Scholar 

  27. Puppala S, Patel J, Woodley H et al (2009) Preoperative imaging of left portal vein at the Rex recess for Rex shunt formation using wedged hepatic vein carbon dioxide portography. J Pediatr Surg 44:2043–2047

    Article  PubMed  Google Scholar 

  28. de Ville de Goyet J, Gibbs P, Clapuyt P et al (1996) 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 62:71–75

    Article  PubMed  Google Scholar 

  29. Ates O, Hakguder G, Olguner M et al (2003) Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus. J Pediatr Surg 38:E10–11

    Article  PubMed  Google Scholar 

  30. Query JA, Sandler AD, Sharp WJ (2007) Use of autogenous saphenous vein as a conduit for mesenterico-left portal vein bypass. J Pediatr Surg 42:1137–1140

    Article  PubMed  Google Scholar 

  31. Facciuto ME, Rodriguez-Davalos MI, Singh MK et al (2009) Recanalized umbilical vein conduit for meso-Rex bypass in extrahepatic portal vein obstruction. Surgery 145:406–410

    Article  PubMed  Google Scholar 

  32. Rex H (1888) Beiträge zur Morphologie der Säugerleber. Morphol Jahrb 14:517–6161

    Google Scholar 

  33. Bambini DA, Superina R, Almond PS et al (2000) Experience with the Rex shunt (mesenterico-left portal bypass) in children with extrahepatic portal hypertension. J Pediatr Surg 35:13–18, discussion 18–19

    Article  PubMed  CAS  Google Scholar 

  34. Fuchs J, Warmann S, Kardorff R et al (2003) Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach. J Pediatr Gastroenterol Nutr 36:213–216

    Article  PubMed  Google Scholar 

  35. Chen WR-DM, Facciuto M, Rachlin S (2011) Experience with duplex sonographic evaluation of meso-rRex bypass in extrahepatic portal vein obstruction. J Ultrasound Med 30:403–409

    PubMed  Google Scholar 

  36. Berrocal T, Parron M, Alvarez-Luque A et al (2006) Pediatric liver transplantation: a pictorial essay of early and late complications. Radiographics 26:1187–1209

    Article  PubMed  Google Scholar 

  37. Mullan CP, Siewert B, Kane RA et al (2010) Can Doppler sonography discern between hemodynamically significant and insignificant portal vein stenosis after adult liver transplantation? AJR 195:1438–1443

    Article  PubMed  Google Scholar 

  38. Lee J, Ben-Ami T, Yousefzadeh D et al (1996) Extrahepatic portal vein stenosis in recipients of living-donor allografts: Doppler sonography. AJR 167:85–90

    PubMed  CAS  Google Scholar 

  39. Thornton RH, Kerlan RK, Gordon RL et al (2005) Percutaneous salvage of a failing rex shunt. J Vasc Interv Radiol 16:399–402

    Article  PubMed  Google Scholar 

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Acknowledgments

Thank you to Christine Carqueville for her database and literature review contributions.

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Correspondence to Cynthia K. Rigsby.

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CME activity This article has been selected as the CME activity for the current month. Please visit the SPR Web site at www.pedrad.org on the Education page and follow the instructions to complete this CME activity.

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Chaves, I.J., Rigsby, C.K., Schoeneman, S.E. et al. Pre- and postoperative imaging and interventions for the meso-Rex bypass in children and young adults. Pediatr Radiol 42, 220–232 (2012). https://doi.org/10.1007/s00247-011-2283-0

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  • DOI: https://doi.org/10.1007/s00247-011-2283-0

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