Mesocaval Shunt Research Articles

Revascularization techniques for complete portomesenteric venous occlusion in patients undergoing pancreatic resection

IntroductionPancreatic pathologies causing portomesenteric occlusion complicate extirpative pancreatic resection due to portomesenteric hypertension and collateral venous drainage. MethodsPatients with portomesenteric occlusion undergoing pancreatectomy were identified between 2007 and 2020 at Stanford University Hospital. Demographic and clinical data, technique and perioperative factors, and post-operative outcomes were analyzed. ResultsOf twenty-seven (27) patients undergoing venous revascularization during pancreatectomy, most (15) were for pancreatic neuroendocrine tumor. Occlusions occurred mostly at the portosplenic confluence (15). Median occlusion length was 4.0 cm [3.1–5.8]. Regarding revascularization strategy, mesocaval shunting was used in 11 patients, in-line venous revascularization with internal jugular conduit in three patients, traditional venous resection and reconstruction in 9 patients, and thrombectomy in two patients. Median cohort operative time and estimated blood loss were 522 min [433–638] and 1000 mL [700–2500], respectively. Median length of stay was 10 days [8–14.5] with overall readmission rate of 37%. Significant complications occurred in 44% of patients despite only one (4%) perioperative mortality. DiscussionDespite the technical complexity for managing portomesenteric occlusions, early revascularization strategies including mesocaval shunting or in-line venous revascularization are feasible and facilitate a safe pancreatic resection for surgically fit patients.

The use of temporary mesocaval shunt in pancreatic resectional surgery

The use of temporary mesocaval shunt in pancreatic resectional surgery

Use of temporary mesocaval shunt in surgery for locally advanced pancreatic cancer

Use of temporary mesocaval shunt in surgery for locally advanced pancreatic cancer

Outcomes of Portosystemic Shunts in Children with and without Liver Transplantation.

Limited data exist regarding outcome and morbidity associated with portosystemic shunts in the pediatric transplant population. Our study assesses the outcomes of pediatric patients who underwent a portosystemic shunt procedure, both with and without liver transplantation (LT). This study retrospectively reviewed the medical records of pediatric patients aged 0-19 years who underwent shunt placement between 2003 and 2017 at a tertiary care center. The analysis included cases of shunt placement with or without LT. A total of 13 pediatric patients were included in the study with median age of 8.8 years. Among the cases, 11 out of 13 (84.6%) underwent splenorenal shunt, 1 (7.7%) underwent a mesocaval shunt, and another 1 (7.7%) underwent a Modified Rex (mesoportal) shunt. Additionally, 5 out of 13 (38.5%) patients had LT, with 4 out of 5 (80.0%) receiving the transplant before shunt placement, and 1 out of 5 (20.0%) receiving it after shunt placement. Gastrointestinal bleeding resulting from portal hypertension was the indication in all cases. A total of 10 complications were reported in 5 patients; the most common complication was anemia in 3 (23.1%) patients. At the most recent follow-up visit, the shunts were functional without encephalopathy, and no deaths were reported. Shunt placement plays a crucial role in the management of patients with portal hypertension. Our study demonstrates favorable long-term outcomes in pediatric patients who underwent shunt placement. Long term shunt outcomes were similar and unremarkable in patients with LT and without LT.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Extension for Transhepatic Mesocaval Shunt Creation: A Case Series for Treating Refractory Upper Gastrointestinal Bleeding in Patients with Chronic Portal Vein Thrombosis.

Transjugular intrahepatic portosystemic shunt (TIPS) is known to benefit patients with decompensated liver disease by alleviating portal pressure. However, TIPS creation is technically difficult and challenging to perform in patients with chronic portal vein thrombosis (PVT) (4,5). Multiple endovascular techniques for portal vein recanalization with or without creating portosystemic shunt are available to decompress and alleviate portal hypertension in patients with PVT. In this case series, we represent TIPS extension to create an endovascular mesocaval shunt for the treatment of refractory upper gastrointestinal bleeding.

Complex gastrointestinal vascular malformation treated with interpositional mesocaval shunt (Drapanas procedure).

Complex gastrointestinal vascular malformation treated with interpositional mesocaval shunt (Drapanas procedure).

Unconventional shunt surgery for non-cirrhotic portal hypertension in patients not suitable for proximal splenorenal shunt.

Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.

Portosystemic Shunt Surgery for Extrahepatic Portal Venous Obstruction Beyond Endoscopic Variceal Eradication: Two Decades of Pediatric Surgical Experience

This exclusively surgical series on pediatric extrahepatic portal venous obstruction (EHPVO) defines surgical indications beyond endoscopic eradication of esophageal varices (EEEV), the selection of an appropriate surgical procedure, and the long-term post-surgical outcome. EHPVO management protocol at the reporting institute has been endotherapy untilesophageal variceal eradication and surgery for select adverse sequelae manifesting after EEEV. One hundred and thirty-nine EHPVO cases underwent surgery for the following indications in combination: i) massive splenomegaly with severe hypersplenism (n=132, 95%); ii) growth retardation (GR, n=95, 68%); iii) isolated gastric (IGV) and ectopic varices (n=49, 35%); iv) Portal cavernoma cholangiopathy (PCC) (n=07, 5%). A portosystemic shunt (PSS) was performed in 119 (86%) cases. Types of PSS performed were as follows: central end-to-side splenorenal shunt with splenectomy (n=104); side-to-side splenorenal shunt (n=4); mesocaval shunt (n=1); inferior mesenteric vein (IMV) to left renal vein shunt (n=2); IMV to inferior vena cava shunt (n=3); H-graft interposition splenorenal shunt (n=1); spleno-adrenal shunt (n=3); makeshift shunt (n=1). Esophagogastric devascularization (n=20, 14%) was opted for only for non-shuntable anatomy. At a median follow-up (FU) of 41 (range: 6-228) months, PSS block was detected in 13 (11%) cases, with recurrent variceal bleeding in 4 cases. PCC-related cholestasis regressed in 5 of 7 cases. Issues of splenomegaly were resolved, and growth z-scores improved significantly. Endotherapy for secondary prophylaxis untilEEEV has resulted in a shift in surgical indications for EHPVO. Beyond EEEV, surgery was indicated predominantly for non-variceal sequelae, namely massive splenomegaly with severe hypersplenism, GR, and PCC. Varices warranted surgery infrequently butmore often from sites less amenable to endotherapy, i.e., IGV and ectopic varices. The selection of PSS was tailored to anatomy and surgical indications. On long-term FU post surgery, PSS block was detected in 13% of patients. PCC-related cholestasis regressed in 71%, and issues of splenomegaly resolved with significantly improved growth Z scores.

Complex Gastrointestinal Vascular Malformation Treated with Interpositional Mesocaval Shunt (Drapanas Procedure)

This video shows an open superior mesenteric vein to inferior cava vein shunt (Drapanas procedure) to treat severe recalcitrant gastrointestinal bleeding. This patient had previously has extensive inferior vena cava and superior mesenteric vein thrombosis that progressed to a massive complex portal vascular malformation. The patient survived for 10 months free of symptoms and with no recurrent gastrointestinal bleeding after the procedure, before dying from unrelated causes. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4NTFiMjU5M2JkMmMzMzBmZWU3ZWE2ZWE0NDZiOWU3OSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg0ODU2MDA1fQ.CmDw7kksZLkcK06tdS_ZdZfB0hwVA2lcH2YUVHNa_RAx8nuCi3qlJOETRtq25NNDP23Sle_PT2mCGATsWHY570IwqchjhgvKlsrxd2kp8R03ljnSc5iOiTdfWGa7G2nB_7f1t8nojjbbBi7Wk5pKLnXBcvfLvPO7fU4mo_qbEy0aooZgtT2pD4I4JckacwDmJ67K9ktLtvJyMnOiVwNwdN07PeFl-6VBtYy4CHv8oASWbqmMV53LxQDy0Gcz2vewjFu9NZVtwM9b0EbcZzHRbRhWgr5i5n9tXiQsq3StQYyW1xtv0ka2ZjAJ1_fLHrx_XRP4QzcykrSrsXnOyFSdHQ Download .mp4 (79.86 MB) Help with .mp4 files SUBMISSION 1.11.2023.mp4

Endovascular Alternatives to Transhepatic Shunt Creation.

Portomesenteric decompression is often necessary to treat patients with refractory symptoms of portal hypertension. When transjugular or direct intrahepatic portosystemic shunt creation is not feasible or is inadequate, surgical portosystemic shunt creation is considered, which carries significant morbidity and mortality in these high-risk patients. Surgery is further complicated in patients with portomesenteric thrombosis who require concurrent thrombectomy and long-term anticoagulation. In this article, we outline the technique for performing advanced endovascular alternatives to intrahepatic portosystemic shunt creation including mesocaval and splenorenal shunting. We will also discuss some of the clinical considerations for treating these patients with symptomatic portal hypertension and portomesenteric thrombosis.

Diverting portomesenteric hypertension during pancreatic resection with a mesocaval shunt

Background: Portomesenteric occlusions result from tumor compression, invasion or tumor thrombus extending through the portal and/or superior mesenteric vein (PV/SMV), often leading to cavernous transformation and portomesenteric hypertension. Portomesenteric hypertension is associated with an extremely high risk of variceal bleeding that often can preclude surgery. Mesocaval shunting can decompress the portomesenteric varices, necessitating safe pancreatic dissection and resection.

S2572 Bleeding Duodenal Varix Treated With Hemostatic Clips

Introduction: Duodenal varices are a rare etiology of upper gastrointestinal bleeding with a prevalence of 0.4% in patients with portal hypertension undergoing esophagogastroduodenoscopy (EGD). Ectopic varices account for 1–5% of variceal bleeding, of which 17–40% are estimated to occur within the duodenum. Definitive guidelines on the management of duodenal varices, which have an estimated mortality rate of 40%, have not been established. We report the use of hemostatic clips to achieve hemostasis in a case of a bleeding duodenal varix due to portal hypertension in an orthotopic liver transplant patient with a dysfunctional mesocaval shunt. Case Description/Methods: A 42-year-old female with advanced liver cirrhosis (MELD 17) secondary to alcohol use and primary biliary cholangitis status post orthotopic liver transplantation complicated by portal vein thrombosis and biliary stricture for which she underwent mesocaval shunting and biliary reconstruction with recurrent portal hypertension. She presented with one day of bright red blood per rectum. On admission, her vital signs were significant for hypotension (81/61 mmHg) and tachycardia (132 bpm). Her hemoglobin was 7.6 g/dL (baseline 12 g/dL). Computed tomography angiography was remarkable for prominent proximal duodenal mucosal varices, portosystemic shunting with prominent splenorenal and gastric/gastroesophageal varices, and portal vein thrombosis. EGD was significant for a large (>5 mm) actively bleeding varix in the second portion of the duodenum, for which two hemostatic clips were successfully placed with resolution of bleeding. The patient remained hemodynamically stable post-procedure and was transferred to her transplant center for further management with no further bleeding episodes. Discussion: Alcoholic-associated liver disease (ALD) is one of the most common causes of cirrhosis. As the incidence and prevalence of ALD continues to rise, it is important that management of duodenal variceal bleeding becomes more standardized. Only a few cases have reported the use of hemostatic clips in these patients. Treatment options include band ligation, coiling, cyanoacrylate injection, balloon-occluded retrograde transvenous obliteration, and transjugular intrahepatic portosystemic shunt. Standardized treatment modalities for duodenal variceal bleeds have not been well-established and further studies are required to investigate appropriate management strategies. Our case demonstrates that hemostatic clips can be effectively used to achieve hemostasis (Figure 1).Figure 1.: (A) Computed tomography angiography (CTA) revealing prominent proximal duodenal mucosal varices, likely from the superior mesenteric vein. (B) Esophagogastroduodenoscopy (EGD) demonstrating a large (>5 mm) actively bleeding varix in the second portion of the duodenum. (C) EGD demonstrating hemostatic clips placed on the duodenal varix with resolution of bleeding.

Cirrhosis-related Spontaneous Mesocaval Shunt.

Online supplemental material is available for this article.

Small-for-Size Syndrome: Systemic Review in a Porcine Experimental Model

The small-for-size syndrome (SFSS) is characterized by prolonged hyperbilirubinemia, coagulopathy, and/or encephalopathy caused by a small liver graft that cannot sustain the metabolic demands of the recipient after a partial liver transplant (PLT). Models of PLT in pigs are excellent for studying this syndrome. This review aimed to identify the different porcine models of SFSS in the literature and compare their technical aspects and therapeutics methods focused on portal inflow modulation (PIM). We performed a systematic review of the porcine experimental model and SFSS. The MEDLINE-PubMed, EMBASE, Cochrane Library, LILACS, and SciELO databases were electronically searched and updated until June 20, 2021. The MeSH terms used were ''ORGAN SIZE'' AND ''LIVER TRANSPLANTATION". Thirteen SFSS porcine models were reported. Four were performed with portocaval shunt to PIM and 3 with mesocaval shunt to PIM. A few studies focused on clinical therapeutics to PIM; a study described somatostatin infusion to avoid SFSS. Initially, studies on PIM showed its potentially beneficial effects without mentioning the minimum portal flow that permits liver regeneration. However, an excessive portal diversion could be detrimental to this process. The use of porcine models on SFSS resulted in a better understanding of its pathophysiology and led to the establishment of various types of portal modulation, surgical techniques with different complexities, and pharmaceutical strategies such as somatostatin, making clear that without reducing the portal vein pressure the outcomes are poor. With the improvement of these techniques, SFSS can be avoided.

Surgical Indications and Outcomes of Resection for Pancreatic Neuroendocrine Tumors with Vascular Involvement.

Simple SummaryPancreatic neuroendocrine tumors (pNETs) are a heterogenous group of rare epithelial neoplasms. For most patients, surgery remains the only treatment modality to cure pNETs, and is recommended for patients with surgically resectable disease. Many of these tumors are non-functional tumors and do not produce clinical symptoms, so patients may present with locally advanced tumors, which invade surrounding organs or neighboring blood vessels. The presence of vascular involvement had previously been considered a contraindication to surgery, but, in recent years, at centers with considerable experience, aggressive surgery to remove pNETs with vascular reconstruction has been performed safely and with good long-term survival. In this review, we will discuss the considerations for resectability, review novel surgical approaches, and present the available evidence on the immediate and long-term postoperative outcomes.Complete surgical resection of pancreatic neuroendocrine tumors (pNETs) has been suggested as the only potentially curative treatment. A proportion of these tumors will present late during disease progression, and invade or encase surrounding vasculature; therefore, surgical treatment of locally advanced disease remains controversial. The role of surgery with vascular reconstruction in pNETs is not well defined, and there is considerable variability in the use of aggressive surgery for these tumors. Accurate preoperative assessment is critical to evaluate individual considerations, such as anatomical variants, areas and lengths of vessel involvement, proximal and distal targets, and collateralization secondary to the degree of occlusion. Surgical approaches to address pNETs with venous involvement may include thrombectomy, traditional vein reconstruction, a reconstruction-first approach, or mesocaval shunting. Although the amount of literature on pNETs with vascular reconstruction is limited to case reports and small institutional series, the last two decades of studies have demonstrated that aggressive resection of these tumors can be performed safely and with acceptable long-term survival.

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

Introduction and objectivesSpontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT). PatientsWe identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected. ResultsAt presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12). ConclusionsSPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.

Acquired Broncho-Biliary Fistula in Patient with Portal Cavernoma Cholangiopathy Treated with Meso-Caval Shunt Using Cadaveric Allograft: A Case Report

Background: Broncho-biliary fistulas are abnormal communications between the biliary tract and bronchial tree. This is a scarce entity and in most of the cases presented with biliptysis, cough and fever.

Overcoming SMV/PV Occlusions and Portomesenteric Hypertension with Mesocaval Shunt during Pancreatic Resection

Portomesenteric (SMV/PV) occlusions present the surgical challenge of mesenteric hypertension during pancreatic surgery. Creation of an intraoperative mesocaval shunt (MCS) allows for mesenteric diversion and variceal decompression, allowing for safe pancreatic dissection and resection, followed by venous reconstruction. Preoperative imaging is essential to determine proximal and distal targets for venous reconstruction. Selective preoperative splenic artery embolization may be necessary to reduce portal hypertension when access to the splenic artery would be challenging.

Abstract No. 29 Percutaneous mesocaval shunt creation: a retrospective review of 5 patients with midterm outcomes

To evaluate the indication, approach, safety, and outcomes of percutaneous mesocaval shunt placement Institutional review board-approved retrospective review of the electronic medical records of patients with percutaneous mesocaval shunts was performed from January 2001 through March 2020 (n = 5). Indication for mesocaval shunt placement was refractory variceal hemorrhage in all 5 patients. All patients had extensive portal vein thrombosis (PVT) (1 intrahepatic, 4 extrahepatic) precluding transjugular intrahepatic portosystemic shunt placement. The underlying etiologies for PVT were non-alcoholic cirrhosis, primary sclerosing cholangitis, pancreatic cancer, post-surgical, and during pregnancy of indeterminate etiology. Post-procedurally, patients were followed for up to 10 years with clinical and laboratory assessment as well as CT or MRI imaging. Technical success was defined as placement of a stent from the superior mesenteric vein to the inferior vena cava. Clinical success was defined as cessation of refractory bleeding. Patient demographics, technical approach for placement, pre-procedure and post-procedure MELD scores, shunt patency, and complications were recorded. Technical and clinical success was achieved in 100% (5 of 5) of patients. Procedural imaging was available for 4/5 patients. To perform the inferior vena cava to superior mesenteric vein puncture, a combination of fluoroscopy and intravascular ultrasound was used in 25% (1/4), fluoroscopy and transabdominal ultrasonography was used in 25% (1/4), and fluoroscopy and intracardiac echocardiography was used in 50% (2/4). MELD scores (9 – 29) did not significantly deviate from pre-procedure to 30 days post-procedure in any patient. Mesocaval shunt primary unassisted patency was 5/5 (100%) at 6 months, 4/4 (100%) at 12 and 18 months, and 2/3 (67%) at 24 months. After 32 months, one patient underwent intentional mesocaval shunt closure for chronic, refractory hepatic encephalopathy (HE). The final patient maintained mesocaval shunt patency for greater than 10 years. No immediate complications occurred peri-procedurally. Two patients (40%) suffered HE, one of which resolved with medical optimization and the second required eventual shunt closure. Mesocaval shunt placement is an uncommonly performed procedure to treat complications of portal hypertension when a TIPS cannot be placed. In this cohort, outcomes were comparable to TIPS as it was safe, well tolerated, and remained patent in a majority of patients at 24 months.

Mesocaval Shunt to Decompress Cavernous Transformation in Pancreatic Surgery

Cavernous transformation of the portal vein (PV) due to obstruction or severe narrowing of the spleno-porto-mesenteric confluence in pancreatic diseases often renders surgical removal of the pancreatic head impossible. A mesocaval shunt (MCS) allows for decompression of the porta hepatis and peripancreatic varices necessary for safe dissection in patients who would otherwise be considered inoperable. We utilize the left internal jugular (IJ) vein as the vascular conduit as it offers the best size match. An IJ vein-to-inferior vena cava(IVC) end-to-side anastomosis is created caudal to the left renal vein junction with a running 6-0 polypropylene suture. The superior mesenteric vein (SMV) is then divided just cephalad to its bifurcation into the jejunal and ileal branches. An end-to-end SMV-to-IJ vein anastomosis is created with 6-0 polypropylene interrupted suture. When combined with a splenorenal bypass, all mesenteric venous return is temporarily diverted to the systemic circulation. After removal of the pancreatic head, the IVC anastomosis is disconnected and hepatopetal flow in the portal vein is restored with an end-to-end anastomosis of the IJ graft to the PV. Occasionally, we have left a MCS bypass intact as a permanent shunt when the splenoportal confluence can be preserved. A MCS allows for resection of the pancreatic head in the setting of profound porta hepatis varices in patients with cavernous transformation of the PV.