Mesocaval Shunt Research Articles

Abstract No. 498 - Mesocaval shunt creation by interventional radiology: percutaneous and endovascular approaches in an illustrated case-based review

Abstract No. 498 - Mesocaval shunt creation by interventional radiology: percutaneous and endovascular approaches in an illustrated case-based review

Surviving Sengstaken

Aim of the StudyTo report the outcomes of children who underwent Sengstaken–Blakemore tube (SBT) insertion for life-threatening haemetemesis. MethodsSingle institution retrospective review (1997–2012) of children managed with SBT insertion. Patient demographics, diagnosis and outcomes were noted. Data are expressed as median (range). Main Results19 children [10 male, age 1 (0.4–16) yr] were identified; 18 had gastro-oesophageal varices and 1 aorto-oesophageal fistula. Varices were secondary to: biliary atresia (n=8), portal vein thrombosis (n=5), alpha-1-anti-trypsin deficiency (n=1), cystic fibrosis (n=1), intrahepatic cholestasis (n=1), sclerosing cholangitis (n=1) and nodular hyperplasia with arterio-portal shunt (n=1). Three children deteriorated rapidly and did not survive to have post-SBT endoscopy. The child with an aortooesophageal fistula underwent aortic stent insertion and subsequently oesophageal replacement. Complications included gastric mucosal ulceration (n=3, 16%), pressure necrosis at lips and cheeks (n=6, 31%) and SBT dislodgment (n=1, 6%). Six (31%) children died. The remaining 13 have been followed up for 62 (2–165) months; five required liver transplantation, two underwent a mesocaval shunt procedure and 6 have completed endoscopic variceal obliteration and are under surveillance. ConclusionsSBT can be an effective, albeit temporary, life-saving manoeuvre in children with catastrophic haematemesis.

Mesocaval Shunt to Facilitate Complex Venous Resection during Pancreaticoduodenectomy

Mesocaval Shunt to Facilitate Complex Venous Resection during Pancreaticoduodenectomy

A Unique Case of Noncirrhotic Portal Hypertension Secondary to Extrahepatic Sarcoidosis

Introduction: Sarcoidosis is a multisystem disease of unknown etiology characterized by the presence of non-caseating granulomas. Portal hypertension is a rare manifestation of sarcoidosis, first reported in 1949. Here we report the first case of extrahepatic sarcoidosis with granulomatous lymph node involvement at the porta hepatis, compression of portal vein leading to portal hypertension and recurrent episodes of gastrointestinal bleeding due to jejunal varices. A 57-year-old black female presented with pruritus, jaundice, elevated liver enzymes, and thrombocytopenia. Diagnosed with ophthalmic and pulmonary sarcoidosis in 1998, a mass at the porta hepatis causing intrahepatic dilation was now seen on CT abdomen. ERCP revealed a stricture at the proximal hepatic duct below the bifurcation, relieved by placing a biliary stent. Diagnostic exploratory laparotomy showed unresectable massive lymphadenopathy, extending from porta hepatis to the inferior aspect of liver, encroaching the vessels and bile ducts. Intrahepatic right bile duct choledoco-Roux-en-Y-jejunostomy was completed. Biopsy showed marked fibrosis and noncaseating granulomas of lymph nodes. Liver biopsy was free of sarcoidosis. Repeat episodes of pruritis and jaundice were treated with high-dose steroids and mycophenolate mofetil. Patient was readmitted with melena and severe anemia. Imaging showed slight decrease in size of the mass but effacement of extrahepatic portal vein, non-visualization of the left portal vein, and severe narrowing of right portal vein. Double balloon enteroscopy revealed large, bleeding perianastomotic jejunal varices. Endoscopic therapy failed and varices were surgically oversawn. Mycophenalate mofetil was restarted along with steroids. A year later recurrent episodes of severe bleeding developed. High-dose pulse steroid therapy was initiated and mycophenalte was increased. Mesocaval shunting was completed with temporary control of bleeding before occlusion. Patient was kept on high-dose steroids, mycophenalate, octreotide and nadolol. Later, CT abdomen revealed reduction in size of mass with partial visualization of the right branch of the portal vein. TIPS was completed via cannulation of the right portal vein, leading to resolution of portal hypertension and further episodes of GI bleed. Extrahepatic portal hypertension in the setting of porta hepatis sarcoidosis can be life threatening and very challenging to treat. Here we described how a combination immunosuppressant and radiologically placed shunt can be used successfully to treat recurrent episodes of GI bleed in such a patient.

Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011.

Prehepatic portal hypertension in children can be asymptomatic for many years. Once diagnosed, the therapeutic measures (pharmacologic, endoscopic, and surgical) are conditioned by the specific characteristics of each patient. In Mexico, there are no recorded data on the incidence of the disease and patient characteristics. To determine the main clinical, radiologic, and endoscopic characteristics upon diagnosis of these patients at the Instituto Nacional de Pediatría within the time frame of January 2001 and December 2011. A cross-sectional, retrolective, descriptive, and observational study was conducted in which all the medical records of the patients with portal hypertension diagnosis were reviewed. There was a greater prevalence of prehepatic etiology (32/52) (61.5%) in the portal hypertension cases reviewed. Males (62.5%) predominated and 11 of the 32 patients were under 4 years of age. The primary reason for medical consultation was upper digestive tract bleeding with anemia (71.9%) and the main pathology was cavernomatous degeneration of the portal vein (65.6%). Splenoportography was carried out on 17 of the 32 patients. A total of 65.5% of the patients received the combination therapy of propranolol and a proton pump inhibitor. Initial endoscopy revealed esophageal varices in 96.9% of the patients, 12 of whom presented with gastroesophageal varices. Congestive gastropathy was found in 75% of the patients. The varices were ligated in 8 cases, sclerotherapy for esophageal varices was carried out in 5 cases (15.6%), and sclerotherapy for gastric varices was performed in 2 patients. Seventeen patients (53.1%) underwent portosystemic diversion: 10 of the procedures employed a mesocaval shunt and 7 a splenorenal shunt. Nine patients (28.1%) underwent total splenectomy. The primary cause of the disease was cavernomatous degeneration of the portal vein; it was predominant in males and the first symptom was variceal bleeding.

Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011

BackgroundPrehepatic portal hypertension in children can be asymptomatic for many years. Once diagnosed, the therapeutic measures (pharmacologic, endoscopic, and surgical) are conditioned by the specific characteristics of each patient. In Mexico, there are no recorded data on the incidence of the disease and patient characteristics. AimsTo determine the main clinical, radiologic, and endoscopic characteristics upon diagnosis of these patients at the Instituto Nacional de Pediatría within the time frame of January 2001 and December 2011. MethodsA cross-sectional, retrolective, descriptive, and observational study was conducted in which all the medical records of the patients with portal hypertension diagnosis were reviewed. ResultsThere was a greater prevalence of prehepatic etiology (32/52) (61.5%) in the portal hypertension cases reviewed. Males (62.5%) predominated and 11 of the 32 patients were under 4years of age. The primary reason for medical consultation was upper digestive tract bleeding with anemia (71.9%) and the main pathology was cavernomatous degeneration of the portal vein (65.6%). Splenoportography was carried out on 17 of the 32 patients. A total of 65.5% of the patients received the combination therapy of propranolol and a proton pump inhibitor. Initial endoscopy revealed esophageal varices in 96.9% of the patients, 12 of whom presented with gastroesophageal varices. Congestive gastropathy was found in 75% of the patients. The varices were ligated in 8 cases, sclerotherapy for esophageal varices was carried out in 5 cases (15.6%), and sclerotherapy for gastric varices was performed in 2 patients. Seventeen patients (53.1%) underwent portosystemic diversion: 10 of the procedures employed a mesocaval shunt and 7 a splenorenal shunt. Nine patients (28.1%) underwent total splenectomy. ConclusionsThe primary cause of the disease was cavernomatous degeneration of the portal vein; it was predominant in males and the first symptom was variceal bleeding.

Percutaneous Portosystemic Shunts: TIPS and Beyond.

Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.

Reply

Caldow Pilgrim, Charles Henry MD, PhD, FRACS1; Evans, Douglas B. MD2; Christians, Kathleen K. MD, FACS2 Author Information

Mesocaval Shunting

Mesocaval Shunting

Portal inflow preservation during portal diversion in small-for-size syndrome

To investigate the impact of portal inflow on liver remnants in a stable pig model of small-for-size syndrome. Twenty pigs underwent mesocaval shunt (MCS) surgery followed by 85%-90% hepatectomy. The control group had no shunt placement; the S1 group had portal flow maintained at an average of 2.0 times the baseline values; and the S2 group had portal flow maintained at an average of 3.2 times the baseline flow. The effect of portal functional competition on the liver remnant was investigated for 48 h postoperatively. Data were presented as mean ± SD. Statistical significance was determined using Student's t test (SPSS, Chicago, IL, United States). Values of P < 0.05 were considered statistically significant. At 24 h after hepatectomy, biochemical and histological changes were not significantly different between the S1 and S2 groups, but changes in both sets of variables were significantly less than in the control group. At 48 h, biochemical and histological changes were significantly less in the S2 group than in the S1 or control group. The regeneration index was significantly higher in the S2 group than in the S1 group, and was similar to that in the control group. Apoptosis index, serum lipopolysaccharide, and bacterial DNA levels were significantly lower in the S2 group than in the other two groups. Diversion of portal inflow using MCS reduces portal overflow injury. Excessive diversion of portal inflow inhibits liver regeneration following major hepatectomy. Maintaining portal inflow at an average of 3.2 times above baseline helps promote hypertrophy of the liver remnant and reduce apoptosis.

Results of a Stepwise Approach to Extrahepatic Portal Vein Obstruction in Children

The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB). After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective β-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options. Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P = 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit. Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.

Extrahepatic Sarcoidosis Causing Obstructive Jaundice and Recurrent Gastrointestinal Bleeding Due to Portal Hypertension

Purpose: Extrahepatic sarcoidosis with granulomatous lymphnode involvement in porta hepatis is an extremely rare manifestation of sarcoidosis. So far no single case has been reported causing recurrent gastrointestinal bleeding secondary to extrahepatic sarcoidosis. This case report presents a 57-year-old woman who was diagnosed with sarcoidosis in 1998 when she was found to have uveitis and pulmonary nodules, subsequently treated with oral steroid. Eleven years later she presented to our clinic with nonspecific abdominal pain. CT abdomen showed pancreatic head mass which was thought to be malignant. She underwent exploratory laprotomy which showed soft tissue mass in porta hepatis encrouching portal vein. Biospy showed noncaseating granulomatous lymphnode confirming sarcoidosis. Patient declined steroid therapy. One year later, she developed pruritis and obstructive jaundice. Repeat CT abdomen showed growth of porta hepatic mass. She subsequently underwent ERCP for biliary decompression, but ultimately required biliary bypass surgery. One year later, abdominal CT scan revealed that the mass had progressed and was now causing extrinsic obstruction of both portal vein and hepatic artery. Patient had subsequnetly developed portal hypertension which lead to recurrent gastrointesital bleeding due to formation of jejunal varices at the site of biliary anstomosis. Initially, patient was treated conservatively with pulse dose steroid followed by maintenance high-dose steroid and mycophenolate mofetil which showed significant reduction in size of porta hepatic mass. However, she continued to have recurrent gastrointestinal bleeding and thus eventually required mesocaval shunt procedure to alleviate portal hypertension and to prevent recurrent gastrointestinal bleeding.

Mesocaval Shunting: A Novel Technique to Facilitate Venous Resection and Reconstruction and Enhance Exposure of the Superior Mesenteric and Celiac Arteries during Pancreaticoduodenectomy

Adequate exposure of the superior mesenteric artery (SMA) is necessary to facilitate a negative SMA margin, which represents the most critical oncologic step during pancreaticoduodenectomy for pancreatic cancer. For tumors inseparable from the superior mesenteric vein (SMV), or the SMV-portal vein (PV) confluence, which clearly require venous resection and reconstruction, SMA exposure and dissection is traditionally accomplished by 1 of 2 techniques. First, the SMA can be exposed medial to the SMV if the SMV-PV confluence is encased at the splenic vein (SV) confluence, and the SV can be divided, which widely exposes the SMA, as originally described by Fortner. However, if the inferior mesenteric vein (IMV) enters the SMV (rather than the SV), SV ligation may predispose to sinistral portal hypertension and gastrointestinal hemorrhage because retrograde decompression via the IMV is not possible. We have described the use of distal splenorenal shunting in such situations to allow SV decompression. If the SMV segment to be resected is distal to the splenic-portal junction, the SV does not need to be divided; however, this prevents easy access to the proximal SMA from this anterior approach and also prevents the PV from achieving increased length (for a primary anastomosis to the SMV). For these 2 reasons, some surgeons routinely divide the SV when performing segmental venous resection and reconstruction. However, preservation of the splenic-portal junction, if possible, is important because it essentially eliminates the risk of PV thrombosis or stenosis, which can occur after SMV-PV resection or reconstruction when the SV is divided. Alternatively, when resecting

Emergent nonconventional mesosystemic shunt for diffuse portomesenteric thrombosis: Sparing patients from liver/multivisceral transplantation

Emergent nonconventional mesosystemic shunt for diffuse portomesenteric thrombosis: Sparing patients from liver/multivisceral transplantation

Obstructing Spontaneous Major Shunt Vessels is Mandatory to Keep Adequate Portal Inflow in Living-Donor Liver Transplantation

It has not been addressed whether the major spontaneous portosystemic shunt vessels should be ligated in living-donor liver transplantation (LDLT). We performed a retrospective analysis of 324 cases of adult-to-adult LDLT. Factors associated with the presence of major (>10 mm) shunt vessels (n=130) included portal vein (PV) thrombosis (27.7%), lower PV pressure at laparotomy, Child-Pugh class C, and transplantation of right-side grafts. The types of major portosystemic shunt vessels included splenorenal shunts (46.2%), gastroesophageal shunts (26.9%), mesocaval shunts (13.8%), and others (13.1%). Ligation of the major shunt vessels increased PV pressure (mean [SD], from 16.8 [3.9] mm Hg to 18.6 [4.3] mm Hg; P<0.001) and PV flow (mean [SD], from 1.35 [0.67] L/min to 1.67 [0.67] L/min; P<0.001) into the grafts. Post-LDLT computed tomography showed patent major shunts in 14 patients. Nine of such patients (64.3%) with unligated major shunt vessels (undetected shunt vessels, n=5; incomplete ligation, n=2; and the shunt was newly created or left open to maintain high PV pressure after reperfusion, n=3) required secondary interventions. Two of these patients died because of graft dysfunction. PV flow was significantly lower in the nine patients who underwent secondary ligation of the major shunt vessels compared with patients with successful primary ligation (mean [SD], 0.96 [0.34] L/min vs. 1.65 [0.63] L/min; P=0.001). It is an appropriate option to obstruct the major portosystemic shunt vessels to ensure adequate graft inflow in LDLT.

Cavoportal hemitransposition for unrecognized spontaneous mesocaval shunt after liver transplantation: a case report

Spontaneous portosystemic shunts can steal the blood away from the portal system. This may result in graft dysfunction or even loss following liver transplantation and can be sorted by shunt occlusion based on intraoperative flow measurements. Herein, we present an alternative technique with cavoportal hemitransposition performed for unrecognized spontaneous mesocaval shunt with 'portal steal' syndrome and primary graft nonfunction diagnosed first day following the transplant. This was chosen as a rescue strategy because an attempt to locate the shunt during relaparotomy was unsuccessful. As there was no improvement, emergency liver retransplantation with preservation of the cavoportal hemitransposition was performed on the fourth day after the primary transplant with good long-term outcome. We conclude that cavoportal hemitransposition during or after liver transplantation can be used to provide an adequate inflow into the donor portal vein if the shunting vessels responsible for the steal cannot be located and dealt with at surgery.

Surgical and Endovascular Treatment of Severe Complications Secondary to Noncirrhotic Portal Hypertension: Experience of 56 Cases

Major complications of noncirrhotic portal hypertension (NCPH) include bleeding esophagogastric varices, hypersplenism, ascites, and bowel ischemia under acute circumstances. The aim of this article is to determine the outcomes of surgical and endovascular treatments for severe complications from NCPH. From January 2000 to June 2011, 56 patients with symptomatic NCPH underwent open surgery or endovascular thrombolysis. The medical records were retrospectively reviewed. Of the 56 patients, there were 39 males and 17 females. The mean age was 21 years, ranging from 2 to 54 years. Forty-one of them were diagnosed to have prehepatic portal vein obstruction (PHPVO), 9 had Budd-Chiari syndrome (BCS), and 6 had noncirrhotic portal fibrosis (NCPF). All patients were symptomatic from 5 days to 14 years (mean 25 months). Portosystemic shunt (PSS) was primarily performed in 49 patients. Shunts were as follows: 35 mesocaval; 7 splenorenal; 4 portocaval; 2 paraumbilical-jugular; and 1 portal to right atrial. Esophagogastric devascularization was performed in 3 patients, but was converted to mesocaval shunt later in 2. The remaining 4 patients with acute superior mesenteric vein (SMV) and portal vein thrombosis were treated with endovascular catheter-directed thrombolysis. Warfarin was prescribed to all the patients for at least 6 months. Mean follow-up was 57 months, ranging from 2 to 125 months. The outcomes, focusing on 30-day mortality, recurrent bleeding, and hypersplenism, were recorded. In the 49 patients undergoing primary PSS, the shunts remained patent and there was no recurrent variceal bleeding during the follow-up. All 3 patients with esophagogastric devascularization had recurrent variceal bleeding at 8, 13, and 24 months postoperatively. Two of them were converted to mesocaval shunt, and 1 died before redo operation. Thrombolysis in all 4 patients with acute SMV and portal thrombosis was technically successful. Three of the 4 survived without complications and 1 died from small bowel infarction due to recurrent thrombosis 40 days later. In the 47 patients with hypersplenism, mean platelet counts increased from 43×10(9)/L to 239×10(9)/L 2 weeks after surgery. Ascites in 30 of the 31 patients disappeared within 2 months after PSS. There was no postoperative encephalopathy, and perioperative 30-day mortality was 0%. PSS can be employed to treat bleeding esophagogastric varices and severe hypersplenism secondary to NCPH. Post-PSS encephalopathy is less of a concern in NCPH patients with normal liver function. Endovascular catheter-directed thrombolysis via superior mesenteric artery is a useful alternative treatment for acute portal and/or mesenteric venous thrombosis.

Creation of a percutaneous mesocaval shunt to control variceal bleeding in a child

Although transjugular intrahepatic portosystemic shunt (TIPS) placement is the standard procedure for the treatment of portal hypertension, it is often impossible to perform in patients with extrahepatic portal vein occlusion. In these patients, options for decompressing the liver are few. In this report, we present a novel solution for managing gastro-esophageal hemorrhage in a child with portal hypertension and extrahepatic portal vein occlusion, through the creation of a percutaneous mesocaval shunt.

Chronic idiopathic non-cirrhotic portal vein thrombosis treated with a mesocaval shunt procedure and anticoagulation.

Portal vein thrombosis (PVT) was first reported in 1868 by Balfour and Stewart and is a medical condition in which the lumen of the portal vein is completely or partially obstructed due to the presence of a thrombus [1]. Inherited (Factor V Leiden and Prothrombin gene mutation G201210A, Protein C, S and Anti thrombin III deficiency) and acquired thrombophilias (Lupus Anticoagulant, myeloproliferative diseases, malignancy, surgery and trauma) account for majority of the cases of PVT.

Distal splenorenal and temporary mesocaval shunting at the time of pancreatectomy for cancer: Initial experience from the Medical College of Wisconsin

Vascular resection/reconstruction at the time of pancreatectomy is performed when limited vascular involvement is the only barrier to complete resection. Splenic vein (SV) ligation facilitates resection/reconstruction of the superior mesenteric vein (SMV)-portal vein (PV) confluence and widely exposes the superior mesenteric artery and celiac origin. If the inferior mesenteric vein does not provide for retrograde decompression, SV ligation may result in sinistral portal hypertension; creation of a distal splenorenal shunt (DSRS) can prevent this complication. Additional complexity occurs in the setting of cavernous transformation of the PV. A mesocaval shunt (MCS) can be utilized to temporarily divert portal flow allowing for a safe portal dissection. Herein we report our initial experience utilizing DSRS and MCS at the time of pancreatectomy for cancer. We reviewed all patients who underwent pancreatic resection for cancer and had either a DSRS and/or MCS performed between January 1, 2009 and February 1,2012. Of 11 patients identified, 10 had adenocarcinoma, 9 underwent standard or extended pancreaticoduodenectomy, and 2 underwent total pancreatectomy. Median operative time was 9.5 hours, median blood loss was 1,000 mL and median duration of stay was 10 days. There were no mortalities. There was 1 Clavien grade III complication during the index admission and 3 others were readmitted. No patient required reoperation. We provide proof of concept that extended pancreatic resection in the setting of limited vascular involvement can be safely performed. This is the first report utilizing MCS and DSRS to facilitate resection of the SMV-PV confluence in the setting of cavernous transformation of the PV.