Surgical Portosystemic Shunts: History, Evolution, and Current Applications

2020 ◽  
Vol 04 (02) ◽  
pp. 157-167
Author(s):  
Fidel Lopez-Verdugo ◽  
Jorge Sánchez-García ◽  
Andrew Gagnon ◽  
Zachary J. Kastenberg ◽  
Ivan Zendejas ◽  
...  
Keyword(s):  
Pediatric Population ◽  
Recurrent Bleeding ◽  
Extrahepatic Portal Vein Obstruction ◽  
Portal Hemodynamics ◽  
Portosystemic Shunts ◽  
Portal Vein Obstruction ◽  
Intrahepatic Portosystemic Shunt ◽  
Great Relevance ◽  
Clinically Significant ◽  
Small For Size

AbstractMechanical obstruction, thrombus, intrinsic liver disease causing fibrosis or cirrhosis, or an outflow obstruction at the level of the sinusoids or hepatic venous obstruction can cause an increase in pressure or resistance, or both, leading to portal hypertension (PH). Portosystemic shunts (PSS) are usually performed to relieve the congestion that inevitably occurs in the setting of PH. Since their introduction, surgical PSS were often the treatment of choice to prevent recurrent bleeding in patients with clinically significant PH. Development of novel pharmacological therapies, continuous improvement of endoscopic approaches, the introduction of transjugular intrahepatic portosystemic shunt, and advancements in transplantation has provided an evolution in the approach for PH and has precipitated the steady decrease in the proportion of patients needing surgical shunts. Despite this, PSS remain important tools in the surgeon's armamentarium, as they are often employed in the pediatric population with extrahepatic portal vein obstruction and are frequently being used for portal inflow modulation to achieve better portal hemodynamics in resections and transplantation. This has become of great relevance to decrease the risk of small-for-size syndrome and portal hyperperfusion in liver transplantation, and to decrease the risk of posthepatectomy liver dysfunction after major resections in hepatobiliary surgery.

Surgical Mesoportal Bypass and Portosystemic Shunt Interventions

2019 ◽  
Vol 03 (03) ◽  
pp. 227-239
Author(s):  
Arthie Jeyakumar ◽  
Jeffrey Forris Beecham Chick ◽  
Patrick J. Healey ◽  
Eric J. Monroe
Keyword(s):  
Portal Vein ◽  
Surgical Intervention ◽  
Splenic Vein ◽  
Clinical Signs ◽  
Endoscopic Management ◽  
Endovascular Techniques ◽  
Extrahepatic Portal Vein Obstruction ◽  
Portal Vein Obstruction ◽  
Shunt Dysfunction ◽  
Clinically Significant

AbstractExtrahepatic portal vein obstruction is defined by obstruction of the extrahepatic portal vein with or without involvement of the intrahepatic veins and does not include isolated thrombosis of the splenic vein or superior mesenteric vein. The etiology may be congenital versus acquired and acute versus chronic. Historically, surgical intervention has been reserved for patients with symptoms refractory to medical or endoscopic management. Over time, however, advances in surgical technique and research have caused a shift in practice. The interventionalists' role is primarily to address clinically significant shunt dysfunction, including shunt stenosis and thrombosis. In this article, the authors discuss the classification and indications of surgical portosystemic conduits, pre-and postoperative imaging, and clinical signs, and endovascular techniques to address shunt dysfunction.

Pediatric Transjugular Intrahepatic Portosystemic Shunts

2017 ◽  
Vol 01 (04) ◽  
pp. 277-285 ◽  
Author(s):  
David Shin ◽  
Giridhar Shivaram ◽  
Kevin Koo ◽  
Eric Monroe
Keyword(s):  
Portal Hypertension ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Portosystemic Shunt ◽  
Portal Vein Occlusion ◽  
Vein Occlusion ◽  
Portosystemic Shunts ◽  
Portal Decompression ◽  
Life Saving ◽  
Intrahepatic Portosystemic Shunt

AbstractTransjugular intrahepatic portosystemic shunt (TIPS) creation offers potentially life-saving portal decompression regardless of patient age or size, but has been underutilized in pediatric patients to date. Experience has therefore been limited, and the full clinical benefit in this population is yet to be realized. Those wishing to embark on pediatric TIPSs would benefit not only from significant experience in adult TIPSs, but also from an awareness of challenges posed by the unique pediatric population. We herein review the etiologies and manifestations of portal hypertension more common in children, highlight some of the technical nuances of creating TIPSs in smaller anatomy, and summarize the existing literature on the topic. As extrahepatic portal vein occlusion (EHPVO) occurs with greater frequency in pediatric patients, special attention is paid to this condition and its associated challenges.

Non-conventional portosystemic shunts in children with extrahepatic portal vein obstruction

1995 ◽  
Vol 37 (1) ◽  
pp. 17-20 ◽  
Author(s):  
ASHLEY J. D'CRUZ ◽  
PATRICK S. KAMATH ◽  
C. RAMACHANDRA ◽  
ANAND JALIHAL
Keyword(s):  
Portal Vein ◽  
Extrahepatic Portal Vein Obstruction ◽  
Portosystemic Shunts ◽  
Portal Vein Obstruction

Splanchnic vein closures

2019 ◽  
Vol 98 (6) ◽  
pp. 239-244
Keyword(s):  
Portal Vein ◽  
Surgical Approach ◽  
Medical Problem ◽  
Budd Chiari Syndrome ◽  
Extrahepatic Portal Vein Obstruction ◽  
Mesenteric Vein ◽  
Vein Thrombosis ◽  
Portal Vein Obstruction ◽  
Chiari Syndrome ◽  
Outflow System

Closures in the splanchnic venous system (SVS) represent a broad medical problem. Anatomically, individual or even multiple sections of SVS may be affected at the same time. Main sections of SVS include the venous liver outflow system, the portal vein, and the upper mesenteric vein and its basin. Thrombosis is clearly the predominant cause of closure. The closures can present as acute, subacute, chronic occult or chronic manifest. The main pathological and anatomical units are the Budd-Chiari syndrome (BCS), extrahepatic portal vein obstruction (EHPVO) and mesenteric vein thrombosis (MVT). Advanced laboratory, imaging and intervention methods substantially modify the approach to prevention, diagnosis and treatment; surgical approach also plays a role. The problem of SVS closures is interdisciplinary.

The Frequency of Random Findings on Abdominal / Pelvis Computed Tomography in Pediatric Trauma Patients

2020 ◽  
Vol 16 ◽  
Author(s):  
Betül Tiryaki Baştuğ
Keyword(s):  
Computed Tomography ◽  
Incidental Findings ◽  
Pediatric Population ◽  
Pediatric Trauma ◽  
Trauma Patients ◽  
Injured Child ◽  
Level 3 ◽  
Male Patients ◽  
Clinically Significant ◽  
Discharge Summaries

Aims: In this study, we aimed to find the percentage of random pathologies and abdominopelvic region anomalies that are not related to trauma in pediatric patients. Background: An abdominal assessment of an injured child usually involves computed tomography imaging of the abdomen and pelvis (CTAP) to determine the presence and size of injuries. Imaging may accidentally reveal irrelevant findings. Objectives: Although the literature in adults has reviewed the frequency of discovering these random findings, few studies have been identified in the pediatric population. Methods: Data on 142( 38 female, 104 male) patients who underwent CTAP during their trauma evaluation between January 2019 and January 2020 dates were obtained from our level 3 pediatric trauma center trauma records. The records and CTAP images were examined retrospectively for extra traumatic pathologies and anomalies. Results: 67 patients (47%) had 81 incidental findings. There were 17 clinically significant random findings. No potential tumors were found in this population. Conclusion: Pediatric trauma CTAP reveals random findings. For further evaluation, incidental findings should be indicated in the discharge summaries.

scholarly journals Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation

2020 ◽  
Vol 3 (1) ◽  
Author(s):  
Osman Ahmed ◽  
Abhijit L. Salaskar ◽  
Steven Zangan ◽  
Anjana Pillai ◽  
Talia Baker
Keyword(s):  
Liver Transplantation ◽  
Portal Vein ◽  
Splenic Vein ◽  
Portosystemic Shunt ◽  
Refractory Ascites ◽  
Hepatic Veins ◽  
Sonographic Guidance ◽  
Portosystemic Shunts ◽  
Intrahepatic Portosystemic Shunt ◽  
End To End

Abstract Background Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation. Case presentation A 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation. Conclusions In the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis.

scholarly journals Value of preoperative computed tomography for meso-Rex bypass in children with extrahepatic portal vein obstruction

2021 ◽  
Vol 12 (1) ◽  
Author(s):  
Huiying Wu ◽  
Ning Zhou ◽  
Lianwei Lu ◽  
Xiwen Chen ◽  
Tao Liu ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Portal Vein ◽  
Predictive Value ◽  
Extrahepatic Portal Vein Obstruction ◽  
Portal Vein Obstruction ◽  
Left Portal Vein ◽  
History Of ◽  
Associated Malformations ◽  
Sensitivity Specificity

Abstract Background Extrahepatic portal vein obstruction (EHPVO) is the most important cause of hematemesis in children. Intrahepatic left portal vein and superior mesenteric vein anastomosis, also known as meso-Rex bypass (MRB), is becoming the gold standard treatment for EHPVO. We analyzed the value of preoperative computed tomography (CT) in determining whether MRB is feasible in children with EHPVO. Results We retrieved data on 76 children with EHPVO (50 male, 26 female; median age, 5.9 years) who underwent MRB (n = 68) or the Warren procedure (n = 8) from 2013 to 2019 and retrospectively analyzed their clinical and CT characteristics. The Rex recess was categorized into four subtypes (types 1–4) depending on its diameter in CT images. Of all 76 children, 7.9% had a history of umbilical catheterization and 1.3% had leukemia. Sixteen patients (20 lesions) had associated malformations. A total of 72.4% of Rex recesses could be measured by CT, and their mean diameter was 3.5 ± 1.8 mm (range 0.6–10.5 mm). A type 1, 2, 3, and 4 Rex recess was present in 9.2%, 53.9%, 11.8%, and 25.0% of patients, respectively. MRB could be performed in patients with types 1, 2, and 3, but those with type 4 required further evaluation. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of CT were 100%, 83.8%, 42.1%, 100%, and 85.5%, respectively. Conclusions Among the four types of Rex recesses on CT angiography, types 1–3 allow for the performance of MRB.

Sign in / Sign up

Export Citation Format

Share Document