Portal-right portal vein bypassing: a novel technique for extrahepatic portal vein obstruction

Abstract

Objective Original Rex shunt (mesenteric-to-left portal vein bypass) has been employed successfully for treating patients with extrahepatic portal vein obstruction.However, about 14% of children with extrahepatic portal vein obstruction suffered left portal vein agenesis and 4% to 28% patient had failed Rex shunt.Rex shunt became impossible for them.This study reports a novel approach of using portal-right portal vein bypass for treating extrahepatic portal vein obstruction after failed Rex shunt. Methods Four patients with failed Rex shunt underwent portal-right portal vein bypass.Their mean age was 6.1 (3.5-8.9) years.Primary Rex shunt was performed 1.1 to 2.5 years ago.Postoperatively, they developed recurrent gastrointestinal bleeding and hypersplenia not responding to conservative measures.After confirmation of blocked original shunt by dissection, cavernoma was bypassed by interposing a venous inferior mesenteric vein autograft between main portal vein in hepatoduodenal ligament and right portal vein. Results In 3/4 patients, right portal vein was well-developed with a diameter of 5 to 6 mm and another right portal vein became agenesic.Portal-right portal vein bypass was successfully conducted in 3 patients.Operative duration was 2.3(1.9-3.5) hours and bleeding volume was 50(30-80) ml without blood transfusion.After shunting, portal vein pressure decreased from 33 (26-45) to 18.7 (14-24) cmH2O.During a median follow-up period of 0.9 (0.5-1.5) years, there was no recurrence of gastrointestinal bleeding or hypersplenia after bypass.Postoperative Doppler and computed tomographic angiography confirmed shunt patency and satisfactory blood flow in shunts. Conclusions Direct bypass of portal cavemomata by right portal vein is efficacious for portal hypertension in children with failed Rex shunt.Patients with left portal vein agenesis or failed Rex shunt may benefit from this procedure.To our knowledge, this is the first report of treating extrahepatic portal vein obstruction via right portal vein bypass. Key words: Hypertension portal; Rex shunt