Modified technique of meso-Rex shunt in case of insufficient length of the jugular vein graft

Abstract

Meso-Rex shunt (MRS) can relieve portal hypertension and restore a physiological portal flow in patients with portal vein thrombosis. We describe a technical variant where the autologous internal jugular vein (IJV) was too short to bridge the superior mesenteric vein (SMV) and the Rex recessus. Patient A 15-year-old boy with portal cavernoma had several episodes of gastrointestinal bleeding despite repeated sclerotherapy. Preoperative assessment, including retrograde transjugular portography, showed persistent esophageal and gastric varices, severe hypertensive gastropathy, obstructed portal vein, patent SMV and splenomesenteric confluence, patent intrahepatic portal branches, and normal transhepatic pressure gradient. An MRS was planned. The left IJV was retrieved from its infracranial part to its confluence with subclavian vein. After performing the Rex recessus to IJV graft anastomosis, the IJV graft proved to be too short for classical end-to-side anastomosis onto the SMV. After clamp testing showing good tolerance of the small bowel, the proximal jejunal branches of the SMV were tied, the proximal SMV was mobilized and transsected 4 cm below the pancreas, and an end-to-end anastomosis between SMV and IJV was performed. Portal pressure decreased from 23 to 13 mm Hg, and intraoperative Ultra Sound Doppler (US Doppler) showed good flows in the shunt. Postoperative course was uneventful, and 1 year after surgery, the child is clinically well, off medication, with a patent shunt, and no portal hypertension. Conclusion This modified MRS technique may be useful when the autologous IJV graft is too short, avoiding the need for prosthetic conduits and prolonged postoperative anticoagulation.