Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video)

Martin Brichard; Samuele Iesari; Jan Lerut; Raymond Reding; Pierre Goffette; Laurent Coubeau

doi:10.1016/j.hbpd.2021.08.003

Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video)

Hepatobiliary Pancreat Dis Int. 2022 Feb;21(1):25-32. doi: 10.1016/j.hbpd.2021.08.003. Epub 2021 Aug 14.

Authors

Martin Brichard¹, Samuele Iesari², Jan Lerut³, Raymond Reding⁴, Pierre Goffette⁵, Laurent Coubeau⁶

Affiliations

¹ Service de Chirurgie et Transplantation Abdominale, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, Brussels 1200, Belgium.
² Service de Chirurgie et Transplantation Abdominale, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, Brussels 1200, Belgium; Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Department of Clinical Sciences and Applied Biotechnology, University of L'Aquila, L'Aquila, Italy; Department of General Surgery and Kidney Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
³ Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
⁴ Service de Chirurgie et Transplantation Abdominale, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, Brussels 1200, Belgium; Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
⁵ Service de Radiologie et Imagerie médicale, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
⁶ Service de Chirurgie et Transplantation Abdominale, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 Avenue Hippocrate, Brussels 1200, Belgium; Pôle de Chirurgie Expérimentale et Transplantation, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium. Electronic address: laurent.coubeau@uclouvain.be.

PMID: 34426078
DOI: 10.1016/j.hbpd.2021.08.003

Abstract

Background: Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management is unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children.

Methods: From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein.

Results: Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB.

Conclusions: Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.

Keywords: Extrahepatic portal hypertension; Extrahepatic portal vein obstruction; Meso-Rex bypass; Portal vein thrombosis; Surgical procedure.

Publication types

Video-Audio Media

MeSH terms

Adult
Aged
Budd-Chiari Syndrome
Female
Humans
Hypertension, Portal* / diagnosis
Hypertension, Portal* / etiology
Hypertension, Portal* / surgery
Male
Mesenteric Veins / diagnostic imaging
Mesenteric Veins / surgery*
Middle Aged
Portal Vein / diagnostic imaging
Portal Vein / surgery*
Quality of Life
Transplants
Vascular Diseases* / diagnostic imaging
Vascular Diseases* / surgery