Variant meso-Rex bypass with transposition of abdominal autogenous vein for the management of idiopathic extrahepatic portal vein obstruction: a retrospective observational study
BACKGROUND Meso-Rex bypass (MRB) and portosystemic surgical shunt (PSS) are both used to treat extrahepatic portal vein obstruction (EHPVO) in children. The aim of this study was to analyse the outcome of MRB and PSS to select patients who could benefit from a prophylactic MRB. METHODS This single-centre retrospective study of children who underwent either MRB or PSS for EHPVO was conducted between 1996 and 2010. Details of patient demographics and preoperative evaluation were collected. Success rates, defined as shunt patency after a minimum of 6 months and clearance of varices or symptoms, were compared. Determinants of outcomes were explored. RESULTS Sixty-nine patients underwent a MRB or PSS. Median (interquartile range, i.q.r.) age at surgery was 6.6 (4.0-10.6) years. Twenty-four patients (35 per cent) had had a neonatal umbilical catheter (NUC) placed previously and 47 (68 per cent) had experienced an upper gastrointestinal bleed. Imaging assessment of the intrahepatic left portal vein was considered favourable in 40 patients. Of 43 MRBs attempted, 11 failed during surgery and four patients had persistent thrombosis after a median of 55 (i.q.r. 18-107) months. The success rate of MRB was 60 per cent (26 of 43) compared with 100 per cent (26 of 26) for PSS (P < 0.001). It was lower among patients in whom a NUC had been used (2 of 10 versus 24 of 33; P = 0.004), for procedures undertaken early in the series (6 of 16 versus 20 of 27; P = 0.020) and when the imaging pattern was unfavourable (0 of 5 versus 26 of 38; P = 0.006). On multivariable analysis, only a previous history of NUC predicted failure (P = 0.016). CONCLUSION Prophylactic MRB seems a good treatment option for EHPVO in children, but should be done only by an experienced team in patients with favourable imaging and without a previous history of NUC.