Partial splenectomy and use of splenic vein as an autograft for meso-Rex bypass: a clinical observational study.
BACKGROUND
Meso-Rex bypass (MRB) surgery is being increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (EPVT) and cavernous transformation (EPVCT) in children. Rather than using the internal jugular vein (IJV, the traditional venous graft), we used an autogenous splenic vein segment graft for MRB.


METHODS
We examined 25 children with extrahepatic portal hypertension and a history of recurrent upper gastrointestinal (GI) variceal bleeding despite previous endoscopic sclerotherapy. All patients had melena, splenomegaly, hypersplenism, or some combination thereof. Left portal vein (LPV) patency was verified in 22 patients using intraoperative direct portography through the umbilical vein. Partial splenectomy was performed to enable the harvest of the splenic vein trunk, which was anastomosed between the superior mesenteric vein (SMV) and the left portal vein (LPV). All patients were followed for 12-48 months (mean=25.6 months) and no patients were lost to follow-up.


RESULTS
Preoperative Doppler ultrasound (US) imaging indicated that 18/25 patients had adequate intrahepatic portal veins for shunting, with no blood flow in the LPVs of 7 patients. LPV patency in 22/25 patients was verified using intraoperative direct portography, with successful MRB. Shunting was converted into a portosystemic shunt in the remaining 3/25 patients with thrombosed LPVs. A Doppler US evaluation of the vein conduit revealed excellent postoperative flow. The patients' mean hemoglobin, platelet, and white blood cell counts increased significantly, and in all cases the endoscopic status obviously improved after shunting. Occlusion or narrowing occurred in 2/22 patients after discharge. At 12 months (for 1 patient) and 24 months (for 1 patient), the shunt was converted into a portosystemic shunt. The cumulative graft patency rate was 91% (20/22).


CONCLUSIONS
Partial splenectomy and splenic vein autografting in MRB surgery can successfully resolve prehepatic portal hypertension and hypersplenism in children.
Department of Radiology, Second Hospital of Shandong University, Jinan, Shandong, China (mainland).
Zhang
Z
Wei
Department of Radiology, Second Hospital of Shandong University, Jinan, Shandong, China (mainland).
Shao Guang
SG
Rui
Department of Evidence-Based Medicine, Second Hospital of Shandong University, Jinan, Shandong, China (mainland).
Zhang
Z
Yuan
Department of Pediatric Surgery, Second Hospital of Shandong University, Jinan, Shandong, China (mainland).
Li Dian
LD
Guo
Department of Pediatric Surgery, Second Hospital of Shandong University, Jinan, Shandong, China (mainland).
Liu
L
Qian
Department of Anatomy, Medical College of Shandong University, Jinan, Shandong, China (mainland).
Liu Shu
LS
Wei
D000293:Adolescent; D000792:Angiography; D064592:Autografts / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D004724:Endoscopy; D004932:Esophageal and Gastric Varices / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008642:Mesenteric Veins / Q000000981:diagnostic imaging / Q000601:surgery; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000601:surgery; D011170:Portasystemic Shunt, Surgical; D012039:Regional Blood Flow; D013156:Splenectomy; D013162:Splenic Vein / Q000000981:diagnostic imaging / Q000601:surgery* / Q000637:transplantation*; D018608:Ultrasonography, Doppler; D014656:Vascular Surgical Procedures / Q000379:methods*