Abstract
Purpose
Mesenterico-left portal vein (meso-Rex) bypass is as an effective modality for restoring intrahepatic portal perfusion in patients with extrahepatic portal vein obstruction. Achieving sufficient patency is difficult with end-to-side anastomosis of a bypass graft to a small or hypoplastic left portal vein in the Rex recessus. Here, we describe the use of a recanalized umbilical vein in the round ligament as a conduit for bypass construction in two patients.
Methods
Case 1 was an 11-year-old boy diagnosed with rupture of the esophageal varices and hypersplenism due to congenital extrahepatic portal hypertension. Because of persistent hypersplenism and thrombocytopenia, he underwent meso-Rex bypassing with a left iliac vein graft interposed between the umbilical vein and the superior mesenteric vein. Case 2 was a neonate with a large hepatic tumor (mesenchymal hamartoma) that developed abdominal compartment syndrome at birth. The tumor was removed by right hepatectomy with excision of the portal vein bifurcation at 3 days of age. Porto-Rex bypassing was accomplished by end-to-end anastomosis between the portal vein trunk and the umbilical vein.
Results
Sufficient hepatopetal portal flow through the umbilical vein was achieved in both patients and maintained for over 16 and 13 months, respectively. Although hypersplenism remained in Case 1, intrahepatic portal vein branches gradually widened and the cavernoma in the hepatic hilum disappeared within 2 months. Neither patient had symptoms or signs of portal hypertension at the most recent follow-up.
Conclusion
Using the umbilical vein as a vein conduit may facilitate construction of a meso/porto-Rex bypass and restore intrahepatic portal vein perfusion in patients with extrahepatic portal vein obstruction.
Similar content being viewed by others
References
Botha JF, Campos BD, Grant WJ et al (2004) Portosystemic shunts in children: a 15-year experience. J Am Coll Surg 199:179–185
Emre S, Dugan C, Frankenberg T et al (2009) Surgical portosystemic shunts and the Rex bypass in children: a single-center experience. HPB 11:252–257
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
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
Fuchs J, Warmann S, Kardoff 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
Krebs-Schmitt D, Briem-Richiter A, Grabhorn E et al (2009) Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension. Pediatr Transplant 13:540–544
Kumada K, Ozawa K, Shimahara Y et al (1990) Truncoumbilical bypass of the portal vein in radical resection of biliary tract tumour involving the hepatic duct confluence. Br J Surg 77:749–751
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(1):71–75
Ogita K, Taguchi T, Soejima Y et al (2005) Fatty liver caused by portal vein thrombosis after living donor liver transplantation: a case report. J Pediatr Surg 40:E7–E9
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(4):597–601
Kuroda Y, Tanioka Y, Ku Y et al (1996) Centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein during portal vein resection. Surg Today Jpn J Surg 26:762–764
Soejima Y, Shimada M, Suehiro T et al (2006) Reconstruction of the middle hepatic vein tributaries using the recipient’s recanalized umbilical vein in right-lobe living-donor liver transplantation. Surgery 139:442–445
Mergental H, Gouw ASH, Slooff MJH et al (2007) Venous outflow reconstruction with surgical reopened obliterated umbilical vein in domino liver transplantation. Liver Transplant 13:769–772
Facciuto ME, Rodrigeuex-Davalos MI, Singh MK et al (2009) Recanalized umbilical vein conduit for meso-Rex bypass in extrahepatic portal vein obstruction. Surgery 145:406–410
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
Vlessis AA, Hovaguimian H, Arntson E et al (1995) Use of autologous umbilical artery and vein for vascular reconstruction in the newborn. J Thorac Cardiovasc Surg 109:854–857
Dunning J, Versteegh M, Fabbri A et al (2008) Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg 34:73–92
Duffy JP, Hong JC, Farmer DG et al (2009) Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients. J Am Coll Surg 208:896–905
Acknowledgment
The authors declare no conflicts of interest. No financial or pharmaceutical support was given to any of the authors.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Shinkai, M., Ohhama, Y., Honda, S. et al. Recanalized umbilical vein as a conduit for mesenterico/porto-Rex bypass for patients with extrahepatic portal vein obstruction. Pediatr Surg Int 27, 315–319 (2011). https://doi.org/10.1007/s00383-010-2742-y
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00383-010-2742-y