Aim of the study: In extrahepatic portal vein obstruction (EHPVO) a successful mesoportal bypass restores physiological portal inflow. We aimed to analyze our national follow-up results of mesoportal bypass extending into adulthood.
Methods: After ethical approval charts of 29 consecutive patients (median age 7.7 years, range 2.3-27.4) with EHPVO who received Rex shunt using grafts constructed of greater saphenous veins (n=22) or internal jugular vein (n=7) between 2002 and 2017 were reviewed. All patients had hypersplenism and 15 suffered from variceal bleeding. Follow-up included abdominal ultrasound and blood count screening at 3, 6, 12 months and annually thereafter.
Main results: After median follow-up of 8.5 (range 0.02-15.2) years 21 patients (72%) had patent rex shunt without variceal bleeding and with resolution of hypersplenism. Three patients (10%) developed rex-anastomosis stenosis 0.7 (0.2-1.9) years postoperatively which was corrected by surgery (n=2) or stenting (n=1). Eight patients (28%) developed permanent shunt occlusion 0.7 years (1 day-4.3 years) after surgery. Two of them had undergone previous surgery for portal hypertension. Attempts to restore shunt patency by surgery (n=3) were unsuccessful and four patients have subsequently received splenorenal shunt. Previous surgery for portal hypertension (2/8 vs 6/27, p=0.07), smaller preoperative spleen size (10.4 (8.0-12.5) vs 14.0 (7.3-20) cm, p=0.06) and higher preoperative platelet levels (119 (50-358) vs 91 (36-162) E9/L, p=0.09) tended to associate with shunt occlusion. Patency of the IJV and saphenous vein grafts was similar (71% vs 73%). Cumulative graft patency at 6 months, 1 year, 3 years, 5 years, and 10 years was 86%, 82%, 75%, 70%, and 70%, respectively (Fig.1).
Conclusion: A successful mesoportal bypass cures portal hypertension in EHPVO and the benefits are long-lasting in the majority of patients. Revision of shunt thrombosis is challenging and often necessitates alternative shunt surgery.