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Zhang YQ, Wang Q, Wu M, Li Y, Wei XL, Zhang FX, Li Y, Shao GR, Xiao J.Sonographic functions of umbilical vein recanalization for a Rex shunt on cavernous revolution of portal vein in youngsters .

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World J Clin Cases2020;8(22): 5555-5563
Mei Wu, MD, PhD, combine Professor, room of Ultrasound, The second Hospital, Cheeloo university of Medicine, Shandong University, No. 247 Beiyuan Street, Jinan 250033, Shandong Province, China. a_may0212
This short article is an open-access write-up which to be selected by one in-house editor and fully peer-reviewed by external reviewers. It is dispersed in accordance through the creative Commons Attribution Non advertisement (CC BY-NC 4.0) license, i beg your pardon permits rather to distribute, remix, adapt, build upon this job-related non-commercially, and license their derivative works on various terms, noted the original work-related is properly cited and also the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
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human being J Clin Cases.Nov 26, 2020;8(22): 5555-5563 released online Nov 26, 2020.doi: 10.12998/wjcc.v8.i22.5555
Sonographic features of umbilical vein recanalization because that a Rex shunt on cavernous change of portal vein in children
Yu-Qing Zhang, Qing Wang, Mei Wu, Ya Li, Xiu-Liang Wei, Fei-Xue Zhang, Yan Li, Guang-Rui Shao, Juan Xiao
Yu-Qing Zhang, Mei Wu, Ya Li, Xiu-Liang Wei, Fei-Xue Zhang,
Department the Ultrasound, The second Hospital, Cheeloo college of Medicine, Shandong University, Jinan 250033, Shandong Province, China
Qing Wang, Department of Radiology, Qilu Hospital, Cheeloo college of Medicine, Shandong University, Jinan 250012, Shandong Province, China
Yan Li, Department of atom Medicine, The second Hospital, Cheeloo college of Medicine, Shandong University, Jinan 250033, Shandong Province, China
Guang-Rui Shao, Department the Radiology, The 2nd Hospital, Cheeloo university of Medicine, Shandong University, Jinan 250033, Shandong Province, China
Juan Xiao, Center the Evidence-Based Medicine, academy of medical Sciences, The 2nd Hospital, Cheeloo university of Medicine, Shandong University, Jinan 250033, Shandong Province, China
ORCID number: Yu-Qing Zhang (0000-0002-9878-0222); Qing Wang (0000-0003-1679-0169); Mei Wu (0000-0003-4121-0904); Ya Li (0000-0002-3198-1193); Xiu-Liang Wei (0000-0002-4008-9455); Fei-Xue Zhang (0000-0002-3249-9032); Yan Li (0000-0003-1643-1959); Guang-Rui Shao (0000-0003-4869-6118); Juan Xiao (0000-0002-3340-6627).
Author contributions: Zhang YQ composed the manuscript, performed procedures and analyzed the data; Wang Q created the manuscript, drafted conception and helped design the research; Wu M design the research, performed examinations and also revised the manuscript; Li Y, Wei XL, Zhang FX, Li Y and also Shao GR gathered and interpreted data; Xiao J analyzed the data; every authors participated in performing the research.
Institutional review board statement: The study was reviewed and also approved through the Institutional evaluation Board that The 2nd Hospital, Cheeloo college of Medicine, Shandong University, No. KYLL-2020(LW)-050.
Informed consent statement: The legit guardians that all study participants noted informed written consent before study enrollment.
Open-Access: This article is one open-access article that was selected by an in-house editor and completely peer-reviewed by external reviewers. That is spread in accordance v the an innovative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits rather to distribute, remix, adapt, build upon this work-related non-commercially, and also license your derivative functions on various terms, listed the original occupational is properly cited and the usage is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mei Wu, MD, PhD, combine Professor, department of Ultrasound, The second Hospital, Cheeloo college of Medicine, Shandong University, No. 247 Beiyuan Street, Jinan 250033, Shandong Province, China. A_may0212
Received: august 20, 2020Peer-review started: respectable 20, 2020First decision: September 13, 2020Revised: September 16, 2020Accepted: October 1, 2020Article in press: October 1, 2020Published online: November 26, 2020

The Rex shunt was widely offered as the wanted surgical method for cavernous revolution of the portal vein (CTPV) in kids that create a bypass in between the exceptional mesenteric vein and the intrahepatic left portal vein (LPV). This procedure deserve to relieve portal hypertension and restore physiological hepatopetal flow. However, the modification procedure is technically demanding because it is complicated to make an end-to-end anastomosis the a bypass come a hypoplastic LPV. Plenty of studies reported making use of a recanalized umbilical vein as a conduit to solve this problem. However, the feasibility that umbilical vein recanalization because that a Rex shunt has actually not been totally investigated.


To investigate the efficacy the a recanalized umbilical vein together a conduit for a Rex shunt on CTPV in children by ultrasonography.


A total of 47 children who were diagnosed v CTPV with prehepatic portal hypertension in the 2nd Hospital, Cheeloo university of Medicine, Shandong University, were enrolled in this study. Fifteen youngsters received a recanalized umbilical vein as a conduit for a Rex shunt surgery and also were enrolled in group I. Thirty-two kids received the classic Rex shunt surgery and also were enrolled in team II. The sonographic attributes of the two groups related to intraoperative and postoperative sport in regards to bypass vessel and also the LPV were compared.


The patency rate of team I (60.0%, 9/15) was significantly lower 보다 that of team II (87.5%, 28/32) 7 d after (on the 8 hours d) operation (P p > 0.05). Moreover, 3 mo after (at the beginning of the fourth mo) surgery, the within diameter significantly widened and flow velocity notably boosted for the bypass vessels and also the sagittal component of the LPV compared to intraoperative values in both shunt teams (P ns > 0.05).


For youngsters with hypoplastic LPV in the Rex recessus, utilizing a recanalized umbilical vein together a conduit because that a Rex shunt may be an reliable procedure because that CTPV treatment.


vital Words:
Cavernous change of the portal vein, Rex shunt, Recanalization, Umbilical vein, Ultrasonography

Core Tip: Recanalized umbilical vein as a conduit because that a Rex shunt was newly used come treat cavernous change of the portal vein. Fifteen youngsters who obtained a recanalized umbilical vein as a conduit because that a Rex shunt were consisted of in group I, and the staying 32 children who got a classic Rex shunt were had in group II. There was no difference in patency rate in between the two groups after 3 mo that treatments. Diameter and flow velocity that bypass vessels in both two groups increased, and blood flow into the liver the both groups increased 3 mo after ~ surgery.


Citation: Zhang YQ, Wang Q, Wu M, Li Y, Wei XL, Zhang FX, Li Y, Shao GR, Xiao J.Sonographic attributes of umbilical vein recanalization for a Rex shunt on cavernous transformation of portal vein in kids .World J Clin Cases2020;8(22): 5555-5563

Cavernous revolution of the portal vein (CTPV) refers to the formation of collateral vessels about the portal vein and is a sequelae of congenital dysplasia in the portal vein that consequently reasons portal vein occlusion and portal hypertension<1>. Patients with CTPV often tend to suffer from various complications, such together recurrent top gastrointestinal hemorrhage and hypersplenism<2>. CTPV is the main reason of prehepatic portal hypertension in children<3,4>. That is estimated that roughly 10% the deaths in children with CTPV are because of shock native recurrent upper gastrointestinal bleeding<5>.

Surgical intervention for CTPV treatment is daunting because the its irregular courses and also the nature of vessels to bleed easily<6>. Classic treatments because that CTPV in youngsters include paraesophagogastric devascularization and portosystemic shunt; however, paraesophagogastric devascularization has a high recurrence rate, and also portosystemic shunt gift a high hazard of liver damage. Contrasted to classic methods, the Rex shunt procedure is a relatively brand-new and reliable surgical treatment for CTPV the creates a bypass to carry blood native the premium mesenteric vein come the intrahepatic left portal vein (LPV)<7,8>. The procedure can get rid of prehepatic block, relax portal hypertension and restore hepatopetal flow<5,9-11>. The Rex shunt was also confirmed to be an efficient procedure to enhance the prognosis of children with CTPV<12,13>. However, the classic Rex shunt is limited to kids for whom the sagittal portion of LPV can not be conveniently exposed. For children with hypoplastic LPV in the Rex recessus, the shunt procedure is technically demanding because it is complicated to do an end-to-end anastomosis of a bypass graft to a hypoplastic LPV<14>. Therefore, many studies have reported cases using a recanalized umbilical vein together a conduit for a Rex shunt to avoid this challenge<14,15>. However, the feasibility the a recanalized umbilical vein together a conduit because that a Rex shunt in kids with CTPV has not been completely investigated yet.

In the current study, us retrospectively evaluated the efficacy that a recanalized umbilical vein together a conduit because that a Rex shunt in kids with CTPV by ultrasonography after operation treatment. Ultrasonography has been demonstrated to be a reliable tool because that CTPV evaluation<16,17>. Our examine aimed come find meaningful data of surgical therapies for CTPV.


Between march 2010 and also March 2019, 47 youngsters who were diagnosed v CTPV through portal hypertension through preoperative ultrasonography or computed tomography and also received a Rex shunt in the second Hospital, Cheeloo university of Medicine, Shandong University, were enrolled. Among them, 15 youngsters who received a recanalized umbilical vein together a conduit for a Rex shunt were enrolled in group I, including 10 boys and also 5 girls aged 6 to 18 year (median age was 9.7 years). The bypass vessels had eight splenic veins, five gastric coronal veins and also two internal jugular veins. The continuing to be 32 kids who got a classic Rex shunt were enrolled in team II, including 18 boys and also 14 girls age 3 to 18 years (median age: 7.3 years). The bypass vessels included 18 splenic veins, 10 gastric coronary veins, 2 inner jugular veins and also 2 good saphenous veins. Consist of criteria were that the bypass vessels and the sagittal component of LPV were clearly observed by ultrasound after surgery; otherwise, they were excluded. This research was approved by the principles committee the the second Hospital, Cheeloo university of Medicine, Shandong University. Informed consent was derived from every patient’s guardian.


Color Doppler ultrasonography to be performed using a GE LOGIQ E9 ultrasound system and also convex selection probe (C1-5, 2-5 MHz, general Electric, joined States). The within diameter of the bypass vessel was detected ~ above the longitudinal section. When measuring flow velocity, the angle between the lengthy axis of vessels and also the Doppler beams was 2>. Therefore, the detection indexes the two teams were compared 3 mo after the operation. The detection indexes were as follows: The inner diameter of bypass vessels and also the sagittal part of LPV measured by standard grayscale ultrasound; the circulation filling and direction of blood in the sagittal component of the LPV, and also the bypass vessels to be observed by color Doppler circulation imaging (CDFI); the spectral form was observed by pulse Doppler; and also the flow velocities to be measured at the sagittal component of LPV and the middle segment of the bypass vessels.


SPSS software program (version 22.0) was applied for statistics analysis. Consistent variables were presented as the mean ± conventional deviation, and their normal circulation was analyzed utilizing the Shapiro-Wilk test. According to the results of the normal circulation test, t test (normally distributed data) was provided to compare the distinctions of the data during and after procedure in team I and also group II. Categorical data were presented as the number (percentage), and their difference was analyzed making use of the Chi-square (χ2) test or Fisher’s precise test. A p 1 mirrors the patency the the bypass vessels. Seven days after ~ (on the 8 hours d) surgery, CDFI verified intermittent (Figure 1) or stellate blood circulation signals (Figure 2) in the bypass ship of four children in group I and also one boy in group II. Moreover, CDFI that two children in group I and three kids in group II confirmed no blood flow signals (Figure 3) in the bypass vessels. These data said poor patency that the bypass vessels. The patency price of team I (60.0%, 9/15) was significantly lower 보다 that of group II (87.5%, 28/32) (P = 0.032).


Figure 1Color Doppler ultrasonography that a 9-year-old boy after recanalized umbilical vein as a conduit for Rex shunt (gastric coronary vein-umbilical vein shunt). A: color Doppler circulation imaging (CDFI)showed intermittent blood circulation signal in the bypass ship (gastric coronary vein) 7 d after ~ operation; B: CDFI showed that the bypass vessel to be well filled through blood circulation signals after ~ clinical anticoagulation treatment for 3 mo. Long arrowhead indicates umbilical vein and also short arrowhead indicates gastric coronary vein.


Table 1Patency of the bypass vessels.



Table 3Intraoperative and also postoperative measure of the within diameter and flow velocity of the sagittal component of the left portal vein.


OutcomeGroup IGroup IIP value
Incidence of within diameter widening that bypass vessels80.0 (12/15)84.3 (27/32)1.000
Incidence of circulation velocity rise of bypass vessels66.7 (10/15)71.9 (23/32)0.983
Incidence of within diameter widening that left portal vein80.0 (12/15)87.5 (28/32)0.664
Incidence of flow velocity rise of left portal vein73.3 (11/15)78.1 (25/32)1.000



DISCUSSION

CTPV is a relatively rare vascular deformity that is an ext commonly discovered in children. Complete or partial portal vein obstruction is a major cause the prehepatic portal hypertension in CTPV children<18>. The Rex bypass shunt is thought about the gold-standard strategy<19>, and also it restores splanchnic venous blood circulation by producing a bypass ship to direct blood flow from the LPV right into the liver, thereby effectively reducing portal hypertension<20>. However, for children whose LPV is buried deep in the liver or youngsters with LPV dysplasia, the liver organization wound in ~ the Rex recess could be larger and also the anastomosis effect will be quite negative after operation.

During fetal development, the umbilical vein is offered to shunt oxygenated umbilical cord blood come the LPV. Using the currently connected umbilical vein for a meso-Rex bypass with a solitary anastomosis deserve to restore hepatopetal perfusion and also inflow that hepatotrophic substances therefore reducing extrahepatic portal hypertension and also its sequelae. The umbilical vein can be anastomosed come the premium mesenteric vein after mechanically dilatation hence maintaining its natural extension with the LPV<21>. Facciuto et al<21> offered a recanalized umbilical vein as a conduit for meso-Rex bypass and accomplished decompression the the splanchnic venous device in three kids with extrahepatic portal vein obstruction. Shinkai et al<14> reported the use of a recanalized umbilical vein together a conduit because that bypass construction in 2 patients with extrahepatic portal vein obstruction and also demonstrated that this method could restore intrahepatic portal vein perfusion. Additionally, a previous study confirmed that the Rex shunt has a 91% success rate and can remarkably enhance gastrointestinal bleeding<2>. Chaves et al<22> carried out pre- and also postoperative imaging of the meso-Rex bypass in children and young adults and demonstrated that bypass thrombosis was ribboned top top computed tomography and also typically hypoechoic ~ above ultrasound. Chen et al<23> carry out duplex sonographic review of the meso-Rex bypass and detected acute thrombosis of the graft (no blood flow) in 2 patients on postoperative work 1 and 40. However, at present there room no reports the ultrasound application in postoperative monitoring of a recanalized umbilical vein together a conduit for the Rex shunt.

Postoperative bypass occlusion as result of thrombosis is the most typical complication that the Rex operation and the key complication resulting in surgical failure<22>. The patency that bypass blood ship is an essential indicator because that the prognosis the Rex surgery. The patency that bypass blood ship is continuous with platelet count and changes in esophageal and also gastric varices under gastroscopy<24>. In this study, a little proportion of kids whose postoperative bypass vessels might not be clearly visualized were not had in this study. Therefore, the is extremely recommended to usage computed tomography angiography for diagnosis in the clinic. Moreover, we found that thrombosis was more likely to happen in group I (recanalized umbilical vein together a conduit for the Rex shunt) 보다 in team II on postoperative work 8 (7 d ~ surgery), however there was no far-ranging difference in the complete bypass ship patency rate in between the two groups 3 mo after surgery. The reason may be the although the liver ring ligament might undergo repair after birth, the layered framework of the medial membrane in the vascular wall surface remains intact histologically and also no significant intimal hyperplasia was observed. ~ above postoperative work 8, thrombosis development may be regarded the tendency of early on umbilical cord blood vessels to spasm. After ~ clinical treatment, the vasospasm was relieved, and also the bypass ship were quickly recanalized. Thus, it has been recommended that a stent was regularly implanted v the midpoint at the anastomotic site, such that its proximal finish was located in the umbilical part of the LPV<25>. In this study, the safe size of the umbilical vein recommended by Yamanaka et al<26> to be 3 centimeter for operation recanalization together a conduit for the Rex shunt. This length might effectively stop thrombosis because of the overlength umbilical vein.

Furthermore, Pokrovsky et al<27> reported that the bypass blood ship dilate end time. In our study, the inside diameter that bypass ship widened, and also the blood circulation velocity of the bypass vessels boosted 3 mo after operation contrasted to those data during operation, i beg your pardon is continuous with the vault study. Additionally, there were no far-reaching differences in the widened within diameter and increased circulation velocity of bypass vessels in between the two teams indicating that the efficacy of using a recanalized umbilical vein together a conduit for a Rex shunt surgical procedure is continuous with the of standard Rex surgery. On the various other hand, Superina et al<28> confirmed that the restore of portal vein blood circulation into the liver not just reversed the symptoms of portal hypertension but also enhanced liver growth and synthesis function. Ours results proved that the within diameter substantially widened and also the circulation velocity enhanced 3 mo after operation in the sagittal part of the LPV contrasted to those throughout operation, and also no far-ranging difference existed between the 2 groups. These data suggested that both two species of Rex surgery had actually favorable prognosis.

The current study offered ultrasonography after surgical procedure to evaluate the efficacy that a recanalized umbilical vein as a conduit because that a Rex shunt come treat CTPV in children, offering an reliable reference because that surgery. Although all dimensions were taken by experienced physicians, measurement bias still can not be entirely avoided. Moreover, the small an easy size in the team with a recanalized umbilical vein could interfere with analysis of the in its entirety data, leading to statistical deviation. Last, the applications of ultrasound was just a preliminary exploration, and also it is still important to summarize and also improve ultrasonic detection methods and also conduct much longer follow-up research studies to educate postoperative evaluation of the efficacy of a recanalized umbilical vein together a conduit for a Rex shunt.

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The Rex shunt have the right to restore hepatopetal flow and also relieve portal hypertension by creating a bypass native the superior mesenteric vein come the intrahepatic left portal vein (LPV) in kids with cavernous change of the portal vein (CTPV). Contrasted to traditional surgery, the trouble of high dangers of recurrence and liver damage can be much better resolved. However, the improved shunt with an alternate conduit is technically demanding because of its an obstacle in end-to-end anastomosis between a bypass graft and a hypoplastic LPV in the Rex recessus. Nevertheless, the feasibility the a recanalized umbilical vein as a replaceable conduit for a Rex shunt in pediatric patients v a hypoplastic LPV has not been completely explored.