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. 2019:60:230-233.
doi: 10.1016/j.ijscr.2019.05.051. Epub 2019 Jun 4.

Revision of meso-Rex bypass utilizing a collateral vein in a patient with portal steal phenomenon after liver transplant: A case report

Ruben Blachman-Braun  1 , Fidel Lopez-Verdugo  1 , Diane Alonso  1 , Linda Book  2 , G Peter Feola  3 , Manuel I Rodriguez-Davalos  4
Affiliations

Revision of meso-Rex bypass utilizing a collateral vein in a patient with portal steal phenomenon after liver transplant: A case report

Ruben Blachman-Braun et al. Int J Surg Case Rep. 2019.

Abstract

Introduction: In children with extrahepatic portal vein obstruction or those who develop portal vein thrombosis after liver transplant, the use of Meso-Rex Bypass (MRB) creates a more physiological state by redirecting mesenteric blood flow back into the intrahepatic portal system via a venous conduit.

Presentation of case: A 3-year-old female with biliary atresia associated with polysplenia syndrome and a surgical history of Kasai portoenterostomy procedure, and an ABO incompatible whole liver transplant. Within a year after transplant she presented with prehepatic portal hypertension, that was treated with MRB using a deceased donor ABO compatible iliac vein as conduit. Six months later, she was taken to the operating room for bypass revision, during the procedure the MRB showed no flow and no thrombus, and a large splenorenal collateral vein that was causing a portal perfusion steal phenomenon was observed. After dissecting the collateral vein, an 8 cm x8 mm segment of this vessel was used as an autologous conduit to re-do the Rex.

Discussion: Failed of MRB can be attributed to portal steal phenomenon, hypercoagulable disorders, bypass contraction or kinking. In this case we believe the culprit to be the former. When there is a history of longstanding portal hypertension, large collaterals develop; thus, intraoperative portal vein flow measurement is critical and ligation of large collaterals during liver transplantation and MRB should be performed to avoid portal steal phenomenon postprocedure.

Conclusion: Using a collateral vein as an alternative autologous venous conduit is a feasible option that can have durable success.

Keywords: Collateral vein; Meso-Rex bypass; Pediatric liver transplantation; Portal steal phenomenon.

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Figures

Fig. 1
Fig. 1
A) CT scan before the revision of the MRB showing a large splenorenal collateral vein (arrow), and the Rex recess (*). B) 3D reconstruction before the revision of the MRB showing a large splenorenal collateral vein (arrow). C) Intraoperative portogram performed during the revision of the MRB (arrow), showing a normal intrahepatic portal system. D) Image showing the re-do MRB (arrow) that was performed using a splenorenal collateral vein as an autologous venous conduit, Rex recess (*).
Fig. 2
Fig. 2
A) CT scan 1 month after the re-do MRB showing a patent conduit (arrow). B) 3D reconstruction of the re-do MRB 1 month after the operation.
Fig. 3
Fig. 3
Drawing of a MRB in a patient with and biliary atresia associated with polysplenia syndrome and portal vein thrombosis (PVT) after transplant.
See this image and copyright information in PMC

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