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• W2883676184 abstract "See Article on Page 881 Potential conflict of interest: Nothing to report. Abbreviation DSRS distal splenorenal shunt The article in this current issue of Liver Transplantation by Elnaggar et al. is noteworthy for 2 main reasons. First, it draws attention to the benefits of the mesoportal bypass as a means of ameliorating the symptoms of portal hypertension in patients with portal vein thrombosis. Second, it includes adult patients in an area that has been almost exclusively the domain of pediatric surgery and hepatology. The report describes 64 patients over a 13‐year period who had undergone 1 of 4 types of operations to manage complications of portal hypertension. These include what the authors term “portal preserving” operations and “portal diverting” operations. The term portal preserving is applied to both the mesoportal operation as well as the distal splenorenal shunt (DSRS; implying that the 2 operations are similar in their effects on the portal circulation). The mesoportal operation, or the meso‐Rex bypass, was described1 as a means to restore portal blood flow to the liver after portal vein thrombosis after liver transplant. The technique was later applied to children with idiopathic portal vein thrombosis.2 It is therefore a restorative operation in which the mesenteric venous blood is redirected into a liver that has suffered from a relative deprivation of portal blood flow. The DSRS mitigates complications of portal hypertension by shunting blood from gastroesophageal varices and the enlarged spleen typical in patients with portal vein thrombosis into the left renal vein, but it does not increase or restore portal blood flow to the liver. This article also elaborates on how many children or adults make up this cohort of patients. Although there were 64 patients in the study, Table 2 includes the data from only 39 patients for the cross‐sectional volume analysis comparing the patients with the standard liver volume for adults and children. Therefore, the impact of the authors' findings is diminished by the fact that only 56% of patients had both presurgical and at least 1 postsurgical cross‐sectional imaging study available for comparison. More disappointing is that in the patient population of greatest interest, those having had the mesoportal bypass, only 11 patients (7 children and 4 adults) had preoperative and postoperative cross‐sectional imaging allowing for volume comparison. In the 4 adults, there was no significant change in either liver or spleen volume, but in the total of 11 patients, liver volume did increase significantly. There was no change reported in the volume of the spleen. Undoubtedly, the statistical significance of the results was affected by the relatively small number of patients in this subgroup. The authors do not examine the group of distal splenorenal shunts separately from the mesoportal group. It would have been interesting to see if there was a difference between these 2 groups that make up the portal preserving category. Although one can understand why the mesoportal patients would experience an increase in the size of the liver after the restoration of mesenteric blood flow, it is not clear at all why patients in the DSRS group should change in a similar fashion. It is highly likely that the small number of patients in that group would not permit statistical analysis. In Table 4, only 14 patients of the total of 40 in the portal preserving group are included for the statistical demonstration that the liver increases in size after these 2 operations. It is possible that the failure to demonstrate a decrease in spleen size after the portal preserving operations is simply a function of the small number of patients included in the analysis. Others have demonstrated that the mesoportal operation in children does indeed surpass the DSRS in the relief of hypersplenism.3 The authors' observation, despite the lack of statistical significance, that the results in children may be better than those seen in adults is consistent with the findings in previous studies that support the conclusion that the mesoportal operation has better results in younger patients because the intrahepatic portal vein may atrophy with increasing age. It would be interesting to know if the 4 adults with the successful mesoportal operations were younger than those for whom it was not. The timing of the cross‐sectional imaging studies after the surgery is not reported. Did all the shunts stay patent after the operation? The development of an anastomotic stricture could contribute to both the lack of increase in liver size and in improvement of splenomegaly. Strictures can develop at the hepatic end of the mesoportal shunts4 in 15% of patients. Did the authors exclude strictures as a possible cause of the failure of resolution of the hypersplenism in the portal preserving and mesoportal patients? Also, the follow‐up period is relatively short: 5.7 months in the portal preserving group and 11 months in the other. Follow‐up in the DSRS group is important because it is known that even selective shunts may lose their selectivity over time.5 Nevertheless, despite the shortcomings of the study, the authors are to be congratulated for advocating surgical intervention for the treatment of portal hypertension. This area has increasingly been the domain of the interventional radiologist. The authors do not support insertion of transjugular intrahepatic portosystemic shunt for the treatment of portal vein thrombosis because this is often unsuccessful and may jeopardize later attempts at surgical correction. Importantly, the reporting of the success of the mesoportal operation in 4 adults raises the hope that this technique may expand into the realm of adult hepatobiliary surgery and that adults suffering from the consequences of portal vein thrombosis may also enjoy benefits previously reported in children." @default.
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• W2883676184 date "2018-07-01" @default.
• W2883676184 modified "2023-09-26" @default.
• W2883676184 title "Shunts and bypasses for portal hypertension: Making the right choice" @default.
• W2883676184 cites W1966330229 @default.
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• W2883676184 doi "https://doi.org/10.1002/lt.25210" @default.
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