Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children

Timothy B Lautz, Lisa A. Keys, Joseph C. Melvin, Joy Ito, Riccardo A Superina*

*Corresponding author for this work

Research output: Contribution to journalArticle

46 Citations (Scopus)

Abstract

Background: Consequences of extrahepatic portal vein obstruction (EHPVO) include variceal bleeding and hypersplenism due to portal hypertension, as well as metabolic abnormalities secondary to impaired portal venous circulation. The purpose of this study was to compare the effectiveness of meso-Rex bypass and portosystemic shunt (PSS) for reversing these symptoms in children with EHPVO. Study Design: All children with idiopathic EHPVO evaluated for potential meso-Rex bypass at a single institution between 1997 and 2010 were reviewed. Portosystemic shunt was performed in patients with refractory portal hypertension when meso-Rex bypass was not technically feasible. Outcomes of meso-Rex bypass and PSS were compared, including resolution of portal hypertensive bleeding and hypersplenism, as well as changes in liver synthetic function, ammonia levels, and somatic growth. Results: Sixty-five children with EHPVO underwent successful meso-Rex bypass, while 16 required PSS. Nearly all patients experienced complete relief of variceal bleeding after meso-Rex (96%) bypass and PSS (100%). The improvements in platelet count (+82.1 ± 60.0 vs +32.4 ± 56.3 thousand/μL; p = 0.004), internal normalized ratio (-0.22 ± 0.27 vs 0.01 ± 0.14; p = 0.022), and serum ammonia level (-26.8 ± 36.8 vs +19.4 ± 33.1 μM/L; p = 0.002) were greater after meso-Rex bypass than PSS. Among patients with below average (standard deviation z-score <0) preoperative weight for age, the improvement in weight-for-age z-score was greater after meso-Rex bypass (+0.84 ± 0.98) than PSS (+0.17 ± 0.79, p = 0.044). Median duration of follow-up was 4.45 years after meso-Rex bypass and 1.8 years after PSS. Conclusions: Both meso-Rex bypass and PSS effectively relieve symptoms of portal hypertensive bleeding in children with EHPVO, although the meso-Rex better relieves hypersplenism. By restoring normal portal venous circulation, the meso-Rex bypass has additional metabolic benefits.

Original languageEnglish (US)
Pages (from-to)83-89
Number of pages7
JournalJournal of the American College of Surgeons
Volume216
Issue number1
DOIs
StatePublished - Jan 1 2013

Fingerprint

Surgical Portasystemic Shunt
Portal Vein
Hypersplenism
Hemorrhage
Portal Hypertension
Ammonia
Weights and Measures
Platelet Count

Keywords

  • DSRS
  • EHPVO
  • INR
  • IQR
  • LPV
  • PSS
  • SMV
  • distal splenorenal shunt
  • extrahepatic portal vein obstruction
  • international normalized ratio
  • interquartile range
  • left portal vein
  • portosystemic shunt
  • superior mesenteric vein

ASJC Scopus subject areas

  • Surgery

Cite this

@article{096f6df522f247839ad9a5d52103dd48,
title = "Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children",
abstract = "Background: Consequences of extrahepatic portal vein obstruction (EHPVO) include variceal bleeding and hypersplenism due to portal hypertension, as well as metabolic abnormalities secondary to impaired portal venous circulation. The purpose of this study was to compare the effectiveness of meso-Rex bypass and portosystemic shunt (PSS) for reversing these symptoms in children with EHPVO. Study Design: All children with idiopathic EHPVO evaluated for potential meso-Rex bypass at a single institution between 1997 and 2010 were reviewed. Portosystemic shunt was performed in patients with refractory portal hypertension when meso-Rex bypass was not technically feasible. Outcomes of meso-Rex bypass and PSS were compared, including resolution of portal hypertensive bleeding and hypersplenism, as well as changes in liver synthetic function, ammonia levels, and somatic growth. Results: Sixty-five children with EHPVO underwent successful meso-Rex bypass, while 16 required PSS. Nearly all patients experienced complete relief of variceal bleeding after meso-Rex (96{\%}) bypass and PSS (100{\%}). The improvements in platelet count (+82.1 ± 60.0 vs +32.4 ± 56.3 thousand/μL; p = 0.004), internal normalized ratio (-0.22 ± 0.27 vs 0.01 ± 0.14; p = 0.022), and serum ammonia level (-26.8 ± 36.8 vs +19.4 ± 33.1 μM/L; p = 0.002) were greater after meso-Rex bypass than PSS. Among patients with below average (standard deviation z-score <0) preoperative weight for age, the improvement in weight-for-age z-score was greater after meso-Rex bypass (+0.84 ± 0.98) than PSS (+0.17 ± 0.79, p = 0.044). Median duration of follow-up was 4.45 years after meso-Rex bypass and 1.8 years after PSS. Conclusions: Both meso-Rex bypass and PSS effectively relieve symptoms of portal hypertensive bleeding in children with EHPVO, although the meso-Rex better relieves hypersplenism. By restoring normal portal venous circulation, the meso-Rex bypass has additional metabolic benefits.",
keywords = "DSRS, EHPVO, INR, IQR, LPV, PSS, SMV, distal splenorenal shunt, extrahepatic portal vein obstruction, international normalized ratio, interquartile range, left portal vein, portosystemic shunt, superior mesenteric vein",
author = "Lautz, {Timothy B} and Keys, {Lisa A.} and Melvin, {Joseph C.} and Joy Ito and Superina, {Riccardo A}",
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TY - JOUR

T1 - Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children

AU - Lautz, Timothy B

AU - Keys, Lisa A.

AU - Melvin, Joseph C.

AU - Ito, Joy

AU - Superina, Riccardo A

PY - 2013/1/1

Y1 - 2013/1/1

N2 - Background: Consequences of extrahepatic portal vein obstruction (EHPVO) include variceal bleeding and hypersplenism due to portal hypertension, as well as metabolic abnormalities secondary to impaired portal venous circulation. The purpose of this study was to compare the effectiveness of meso-Rex bypass and portosystemic shunt (PSS) for reversing these symptoms in children with EHPVO. Study Design: All children with idiopathic EHPVO evaluated for potential meso-Rex bypass at a single institution between 1997 and 2010 were reviewed. Portosystemic shunt was performed in patients with refractory portal hypertension when meso-Rex bypass was not technically feasible. Outcomes of meso-Rex bypass and PSS were compared, including resolution of portal hypertensive bleeding and hypersplenism, as well as changes in liver synthetic function, ammonia levels, and somatic growth. Results: Sixty-five children with EHPVO underwent successful meso-Rex bypass, while 16 required PSS. Nearly all patients experienced complete relief of variceal bleeding after meso-Rex (96%) bypass and PSS (100%). The improvements in platelet count (+82.1 ± 60.0 vs +32.4 ± 56.3 thousand/μL; p = 0.004), internal normalized ratio (-0.22 ± 0.27 vs 0.01 ± 0.14; p = 0.022), and serum ammonia level (-26.8 ± 36.8 vs +19.4 ± 33.1 μM/L; p = 0.002) were greater after meso-Rex bypass than PSS. Among patients with below average (standard deviation z-score <0) preoperative weight for age, the improvement in weight-for-age z-score was greater after meso-Rex bypass (+0.84 ± 0.98) than PSS (+0.17 ± 0.79, p = 0.044). Median duration of follow-up was 4.45 years after meso-Rex bypass and 1.8 years after PSS. Conclusions: Both meso-Rex bypass and PSS effectively relieve symptoms of portal hypertensive bleeding in children with EHPVO, although the meso-Rex better relieves hypersplenism. By restoring normal portal venous circulation, the meso-Rex bypass has additional metabolic benefits.

AB - Background: Consequences of extrahepatic portal vein obstruction (EHPVO) include variceal bleeding and hypersplenism due to portal hypertension, as well as metabolic abnormalities secondary to impaired portal venous circulation. The purpose of this study was to compare the effectiveness of meso-Rex bypass and portosystemic shunt (PSS) for reversing these symptoms in children with EHPVO. Study Design: All children with idiopathic EHPVO evaluated for potential meso-Rex bypass at a single institution between 1997 and 2010 were reviewed. Portosystemic shunt was performed in patients with refractory portal hypertension when meso-Rex bypass was not technically feasible. Outcomes of meso-Rex bypass and PSS were compared, including resolution of portal hypertensive bleeding and hypersplenism, as well as changes in liver synthetic function, ammonia levels, and somatic growth. Results: Sixty-five children with EHPVO underwent successful meso-Rex bypass, while 16 required PSS. Nearly all patients experienced complete relief of variceal bleeding after meso-Rex (96%) bypass and PSS (100%). The improvements in platelet count (+82.1 ± 60.0 vs +32.4 ± 56.3 thousand/μL; p = 0.004), internal normalized ratio (-0.22 ± 0.27 vs 0.01 ± 0.14; p = 0.022), and serum ammonia level (-26.8 ± 36.8 vs +19.4 ± 33.1 μM/L; p = 0.002) were greater after meso-Rex bypass than PSS. Among patients with below average (standard deviation z-score <0) preoperative weight for age, the improvement in weight-for-age z-score was greater after meso-Rex bypass (+0.84 ± 0.98) than PSS (+0.17 ± 0.79, p = 0.044). Median duration of follow-up was 4.45 years after meso-Rex bypass and 1.8 years after PSS. Conclusions: Both meso-Rex bypass and PSS effectively relieve symptoms of portal hypertensive bleeding in children with EHPVO, although the meso-Rex better relieves hypersplenism. By restoring normal portal venous circulation, the meso-Rex bypass has additional metabolic benefits.

KW - DSRS

KW - EHPVO

KW - INR

KW - IQR

KW - LPV

KW - PSS

KW - SMV

KW - distal splenorenal shunt

KW - extrahepatic portal vein obstruction

KW - international normalized ratio

KW - interquartile range

KW - left portal vein

KW - portosystemic shunt

KW - superior mesenteric vein

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U2 - 10.1016/j.jamcollsurg.2012.09.013

DO - 10.1016/j.jamcollsurg.2012.09.013

M3 - Article

VL - 216

SP - 83

EP - 89

JO - Journal of the American College of Surgeons

JF - Journal of the American College of Surgeons

SN - 1072-7515

IS - 1

ER -