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Image of Vascular Surgery

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Image of Vascular Surgery

Vasc Specialist Int (2022) 38:27

Published online September 30, 2022 https://doi.org/10.5758/vsi.220044

Copyright © The Korean Society for Vascular Surgery.

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

Ara Cho and Seung-Kee Min

Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

Correspondence to:Seung-Kee Min, Division of Vascular Surgery, Rm 5313, Biomedical Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
Tel: 82-2-2072-0297, Fax: 82-2-766-3975, E-mail: skminmd@snuh.org, http://orcid.org/0000-0002-1433-2562

Received: September 27, 2022; Accepted: September 30, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Extrahepatic portal vein obstruction (EHPVO) can cause portal hypertension and life-threatening variceal bleeding (VB) [1]. 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. Herein, we report an adult case of uncontrolled VB due to EHPVO after PD treated with modified MRS using great saphenous vein (GSV) graft shunting between the coronary vein and LPV.

A 52-year-old male presented with hematemesis, melena, and drowsiness. He had undergone total pancreatectomy for pancreatic cancer 2 years earlier. Despite a four-time endoscopic gastroesophageal variceal ligation, VB recurred from the HJ site. Computed tomography (CT) revealed EHPVO (Fig. 1), hilar cavernous transformation, and gastroesophageal HJ varices (Fig. 2). A MRS was planned to control the VB by reducing portal hypertension and maintaining hepatopetal venous flow. Ultrasonography (USG) revealed patent LPV. However, the peak systolic velocity (PSV) was reduced of the LPV was reduced to 11.1 cm/s with a reversed flow (Fig. 3A). Modified MRS was performed through a midline incision using the left proximal GSV (coronary vein to LPV). USG showed improved PSV to 34.3 cm/s (Fig. 3B). CT at 2 years revealed patent MRS (Fig. 4), and the liver function test results were normal.

Figure 1. Computed tomography performed two weeks after total pancreatectomy showed thrombosis (arrow) in the extrahepatic portal vein.

Figure 2. Preoperative computed tomography scan revealed the obliteration of portal vein (thin arrows in coronal view [A] and axial view [B]). Gastric and hepaticojejunostomy varices (thick arrows in A) due to portal hypertension were observed.

Figure 3. (A) Preoperative abdominal ultrasonography (USG) showed patent left portal vein (LPV) near the Rex recess; however, the peak systolic velocity (PSV) was reduced to 11.1 cm/s, and the flow direction was reversed. (B) Postoperative USG showed patent LPV and the PSV improved to 34.3 cm/s.

Figure 4. Follow-up computed tomography after two years showed complete patency of the great saphenous vein graft (thick arrows) and coronary vein (thin arrows).

Oncovascular surgery and neoadjuvant chemoradiotherapy can achieve curative resection of locally advanced pancreatic cancers invading the portomesenteric vein/hepatic artery [3], resulting in long-term survival of these patients. However, some patients develop EHPVO after undergoing PD. 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.

Fig 1.

Figure 1.Computed tomography performed two weeks after total pancreatectomy showed thrombosis (arrow) in the extrahepatic portal vein.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220044

Fig 2.

Figure 2.Preoperative computed tomography scan revealed the obliteration of portal vein (thin arrows in coronal view [A] and axial view [B]). Gastric and hepaticojejunostomy varices (thick arrows in A) due to portal hypertension were observed.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220044

Fig 3.

Figure 3.(A) Preoperative abdominal ultrasonography (USG) showed patent left portal vein (LPV) near the Rex recess; however, the peak systolic velocity (PSV) was reduced to 11.1 cm/s, and the flow direction was reversed. (B) Postoperative USG showed patent LPV and the PSV improved to 34.3 cm/s.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220044

Fig 4.

Figure 4.Follow-up computed tomography after two years showed complete patency of the great saphenous vein graft (thick arrows) and coronary vein (thin arrows).
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220044

References

  1. Flores-Calderón J, Morán-Villota S, Rouassant SH, Nares-Cisneros J, Zárate-Mondragón F, González-Ortiz B, et al. Guidelines for the diagnosis and treatment of extrahepatic portal vein obstruction (EHPVO) in children. Ann Hepatol 2013;12 Suppl 1:S3-S24.
    Pubmed CrossRef
  2. Oh MY, Kim HK, Han A, Yi NJ, Min SK. Standard or variant Meso-Rex shunts for children with variceal bleeding due to extrahepatic portal vein obstruction: a report of two cases. Vasc Specialist Int 2020;36:186-192.
    Pubmed KoreaMed CrossRef
  3. Nagakawa Y, Jang JY, Kawai M, Kim SC, Inoue Y, Yabushita Y, et al. Surgical outcomes of pancreatectomy with resection of the portal vein and/or superior mesenteric vein and jejunal vein for pancreatic head cancer: a multicenter study. Ann Surg 2021; doi: 10.1097/SLA.0000000000005330. [Epub ahead of print].
    Pubmed CrossRef