Standard or Variant Meso-Rex Shunts for Children with Variceal Bleeding due to Extrahepatic Portal Vein Obstruction: A Report of Two Cases

Abstract

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of pediatric portal hypertension and can cause life-threatening variceal bleeding. Meso-Rex shunt (MRS) is a surgical procedure that restores physiological portal venous blood flow to the liver by using a graft to connect the superior mesenteric vein and the left portal vein within the Rex recess, and can relieve variceal bleeding and other complications associated with EHPVO. Although the MRS is regarded as an optimal and potentially curative treatment with good long-term patency, graft thrombosis or failure due to unknown causes is not rare, prompting the need for further research on the risk factors of graft failure or poor patency. Herein, we report two cases of EHPVO in patients with recurrent or uncontrolled variceal bleeding, one treated with the classic Rex shunt and the other with the modified Rex shunt, which resulted in a failure and success, respectively.

Location and extent of cavernous transformation of the portal vein dictates different visceral side revascularization in Meso-Rex bypass

“…The pullout route, on the other hand, required dissection of the confluence of the SMV and SV behind the pancreas. The bypass vessel in the conventional pullout route was located behind the pancreas (R2) but was most difficult to be dissected in PVCT [ 21 ]. But in some patients, the retrogastric route (R1) could be used instead of dissecting the retropancreatic tunnel.…”

When Encountering a Rare Vascular Disease, Report and Share your Experience: Six Reasons to Publish a Case Report in VSI

“…Oh et al [ 5 ] reported 2 cases of meso-Rex shunt in children with extrahepatic portal vein occlusion. One case was successful, and the other failed; the reason for the different outcomes was obscure.…”

Modified Meso-Rex Shunt for Extrahepatic Portal Vein Obstruction and Variceal Bleeding after Pancreatoduodenectomy in an Adult

“…Modified Meso-Rex Shunt for Extrahepatic Portal Vein Obstruction and Variceal Bleeding after Pancreatoduodenectomy in an Adult www.vsijournal.org LPV, suitable mesenteric venous inflow, and an adequate autologous conduit [2]. Therefore, preoperative imaging evaluation and meticulous operative techniques determine the success of surgery.…”

“…Meso-Rex shunt (MRS) is an attractive treatment for EHPVO, which involves shunting the mesenteric vein to the intrahepatic left portal vein (LPV) within the Rex recess using an autologous vein graft. MRS is the best option for children because it can perfuse the liver to allow for growth [ 2 ]. EHPVO may develop after pancreatoduodenectomy (PD) and cause VB at the hepaticojejunostomy (HJ) site.…”

“…Therefore, ironically, more patients with VB from the HJ site return to the hospital. The essential conditions for MRS include no intrinsic liver parenchymal disease, patent LPV, suitable mesenteric venous inflow, and an adequate autologous conduit [ 2 ]. Therefore, preoperative imaging evaluation and meticulous operative techniques determine the success of surgery.…”