| Background:Cavernous transformation of portal vein(CTPV) in children is a rare disorder in early childhood with unknown incidence and mostly unknown etiology. In children with CTPV, the hepatopedal flow of the mesenteric venous blood is hindered by an obstruction of the PV resulting in prehepatic portal hypertension。In the past decades Meso-Rex bypass is used to treat patients with clinically important cavernous transformation of portal vein(CTPV).Usually, an autologous left internal jugular vein graft is used usually to bypass the portal blood circulation from the superior mesenteric vein to the left portal vein. Other vascular conduits including the autogenous saphenous vein, splenic vein, right gastroepiploic vein, and inferiormesenteric vein were applied as shun vesssels.Purpose:Meso-Rex bypass (MRB)is increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (PVT)or cavernous transformation of the portal vein (PVC), in children. Rather than using the internal jugular vein (the traditional venous graft), we used an autogenous splenic vein segment graft for the MRB.At the same time, the role of color Doppler ultrasound and multi-slice spiral CT were explored in the preoperative and follow-up postoperative assessment.Methods:Fourteen children had Meso-Rex bypass with portal hypertension of unknown etiology. Including Ten boys and four girls; mean8.7±2.5years; mean weight32.7±4.3kg.Eleven children had a history of recurrent upper gastrointestinal variceal bleeding and melena despite endoscopic sclerotherapy. Ten children had splenomegaly, and/or hypersplenism, Five children had jaundice.Left portal vein patency was verified with intraoperative direct portography through the umbilical vein in14patients. The splenic vein was harvested and anastomosed between the superior mesenteric vein and the umbilical portion of the left portal vein. All patients were followed for12-48months (mean,26.6±12.7months) and no patients were lost to follow-up.Results:Preoperative Doppler ultrasound imaging indicated that11patients had adequate intrahepatic portal veins for shunting, with no blood flow in the left portal vein in3patients. Left portal vein patency in14patients was verified with intraoperative direct portography, with successful MRB. Shunting was converted to a portosystemic shunt in the remaining4patients with thrombosed Rex recessus and left portal vein. Doppler ultrasound evaluation of the vein conduit revealed excellent flow postoperatively. During follow-up, The portal pressure gradient was measured intraoperatively and decreased from34.5±6.2cm H2O before bypass to17.5±4.3cm H2O after bypass (P<0.01), the mean leukocyte and platelet counts increased dramatically from5.9±1.7to8.9±2.4×109/L(P<0.01)and from63.5±13.6to160.2±28.1×109/L (P<0.01),mean hemoglobin increased from86.2±20.6×109/L to126.2±28.1×109/L (P<0.01) after shunting. The width of portal vein descended from13.5±0.4mm before shunt to11.6±0.3mm after bypass.Occlusion or narrowing occurred in2/14patients after discharge, and at12months in one patient and24months in another, the cumulative graft patency rate was86%(12/14).Conclusions:1. Splenic vein autografting can successfully resolve prehepatic portal hypertension inchildren in meso-Rex bypass. 2whether was the left portal branch, especially the left pockeo thrombosised is a decisive factor in bypass, but portal vein angiography is the gold standard.3. Color Doppler ultrasound and MSCT scanning has an important role in the cavernous diagnosis and preoperative assessment, for postoperative follow-up, color Doppler ultrasound is the preferred choice. Purpose:Meso-Rex bypass (MRB) is increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (PVT)or cavernous transformation of the portal vein (PVC), in children. Rather than using the internal jugular vein (the traditional venous graft), we used an great saphenous vein segment graft for the MRB.,as the same time,preoperative and follow-up postoperative assessment.Methods:Eighteen children had Meso-Rex bypass with portal hypertension of unknown etiology.Including Five boys and three girls; mean9.1±2.5years; mean weight34.5±3.6kg.All children had a history of recurrent upper gastrointestinal variceal bleeding and melena despite endoscopic sclerotherapy. Six children had splenectomy.Left portal vein patency was verified with intraoperative direct portography through the umbilical vein in8patients. The great saphenous vein was harvested from the left thigh through a groin incision for use as a conduit for revascularization of the left portal vein. The harvested segments of the great saphenous vein were about10%longer than the estimated graft length. End-to-side anastomosis was performed first between the graft and the junction of the round ligament and left portal vein and then to the SMV using7-0Prolene sutures.All patients were followed for12±48months (mean,26.6±12.7months) and no patients were lost to follow-up.Results:The mean operative time was295minutes (range,255-350minutes), and the average hospital stay was14days (range,11-19days). The median length of the harvested saphenous vein was7.0cm (range,6.0-8.0cm), and the median diameter of the graft vein was0.41cm (range,0.38-0.45cm). The portal pressure gradient was measured intraoperatively and decreased from32±6cm H2O before bypass to19±4cm H2O after bypass (p<0.05). Doppler evaluation of the vessels upon completion of the anastomoses revealed excellent flow. Postoperative recovery was rapid and uneventful in seven patients. GI variceal bleeding recurred in one patient on the seventh postoperative day. Anticoagulant therapy was stopped, and the GI bleeding was successfully treated by endoscopic sclerotherapy. Patients who underwent the Rex shunt procedure were followed for6to36months postoperatively.Twelve months postoperatively, the median blood flow rate through the midgraft was14.3cm/s (mean±standard deviation,15.6±4.2cm/s) by Doppler US evaluation Although the left portal vein and its intrahepatic branches were hypoplastic during the preoperative Doppler evaluation, the mean blood flow velocity of the umbilical part of the left portal vein increased from15.7±3.6to20.7±5.2cm/s(p<0.05). All patients have undergone a postoperative upper gastrointestinal endoscopy.Endoscopic status has significantly improved in all cases after the operation.Residual varices were single,small or medium size,and pressure depressed. There has no recurrence of bleeding in any of the eight patients.Two patients underwent follow-up low dose computed tomography examination, which showed that the graft vein had good flow to the liver after the Rex shunt procedure.During the follow-up period, the mean leukocyte and platelet counts dramatically increased from5.2±1.1to7.8±2.7×109/L (p<0.05) and76.5±13.1to187.2±34.3×109/L (p<0.05), respectively. The hemoglobin increased from70.1±21.3×109/L to106.3±20.5×109/L (P<0.05). All biochemical parameters were within their reference ranges in all patients.(p<0.05).Conclusions: We have shown that construction of a great saphenous vein graft is a feasible and valuable alternative for mesoportal bypass in patients withCTPV. |
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