Use of meso-Rex shunt with transposition of the coronary vein for the management of extrahepatic portal vein obstruction
A meso-Rex shunt with transposition of the coronary vein was performed in a 20-year-old man. The patient had a previous clinical history of increased abdominal volume and five episodes of gastrointestinal bleeding, and was diagnosed with idiopathic portal vein obstruction at 5 years of age. Hypercoagulability studies were performed at the time of thediagnosis. Antithrombin III level was 58% of normal, but other parameters were all unremarkable. One month before the shunt operation, an endoscopy identified aggravated esophageal and paraesophageal varices and hypertensive gastropathy. The size and patency of the umbilical portion of the intrahepatic left portal vein were assessed by preoperative Doppler ultrasonography and computed tomography; there was massive splenomegaly and no detectable intrahepatic left portal vein (). A preoperative percutaneous transhepatic liver needle biopsy showed a noncirrhotic liver without fibrosis, and hepatic venous pressure gradient was 28 mmHg (pressure in the inferior vena cava 7 mmHg, wedged hepatic venous pressure 35 mmHg).\nAfter laparotomy, the round ligament was dissected toward the distal part of the left portal vein at the level of the Rex recessus. The left portal vein was then approached, and its ventral and lateral aspects were dissected over a length of 3-4 cm. The intrahepatic left portal vein was evaluated by surgical exploration, and its diameter was approximately 3 mm. Splenectomy was performed because of massive splenomegaly. There was a nest of peripancreatic collaterals with flow toward the gastroesophageal junction through a series of large varices, which included the coronary vein with an adequate diameter and flow in the hepatopetal direction. This vein was fully mobilized, divided, and then transposed across the mesocolon and behind the pylorus to the intrahepatic left portal vein to which it was anastomosed end-to-side using nonabsorbable monofilament interrupted sutures (). Unclamping of the meso-Rex shunt immediately allowed adequate portal flow into the liver, as confirmed by intraoperative portography, and there were no remaining large portosystemic shunts (). Postoperative recovery was rapid and uneventful, with liver function tests within normal ranges and normal portal flow observed by Doppler ultrasonography and computed tomography (). Follow-up was uneventful, with improvement of the signs of portal hypertension, without any new episodes of gastrointestinal bleeding. Six months after surgery, computed tomography showed preserved portal vein flow via the shunt.