One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients.

The transjugular approach is a safe and effective alternative for performing portal vein embolization

“…[14,15] All of the above techniques have certain advantages and disadvantages, such as portal ligation require general anesthesia and obtain the risk of postoperative adhesions. Based on our high level of experience with transjugular intrahepatic portosystemic shunts (TIPS), [16] we aimed to achieve PVE through the right internal jugular vein (TPVE) to investigate the methodology of this procedure.…”

Percutaneous Direct Puncture of Retropancreatic Splenic Vein and Portal Thrombectomy in a Patient With Liver Transplantation and Simultaneous Splenectomy

“…However, they have several limitations‚ such as graft injury and the requirement for laparotomy. [2][3][4][5] Percutaneous trans-splenic venous access is an alternative approach to accessing the portal vein that can be applied in patients with massive ascites without injuring the graft. However, in Asian countries where LDLT has been developed, left lobe graft is often the first choice for donor safety‚ and splenectomy is performed if necessary.…”

“…Percutaneous Direct Puncture of Retropancreatic Splenic Vein and Portal Thrombectomy in a Patient With Liver Transplantation and Simultaneous Splenectomy Takanobu Hara, MD, PhD, 1 Akihiko Soyama, MD, PhD, 1 Hideki Ishimaru, MD, PhD, 2 Hajime Matsushima, MD, PhD, 1 Hajime Imamura, MD, PhD, 1 Shuto Miyamura, MD, 2 Takashi Hamada, MD, PhD, 1 Kunihito Matsuguma, MD, 1 Masayuki Fukumoto, MD, 1 Takayuki Tanaka, MD, PhD, 1 Tomohiko Adachi, MD, PhD, 1 Masaaki Hidaka, MD, PhD, 1 and Susumu Eguchi, MD, PhD 1 P ortal vein thrombosis (PVT) following living donor liver transplantation (LDLT) reportedly occurs at an incidence of 3.5% and is more common in the early posttransplant period. 1 Conventional methods of portal venous access, including percutaneous transhepatic approaches and transmesenteric antegrade access, are widely selected for radiological interventions.…”