r Case report 189
Portal Vein Thrombosis of the Adolescent: Indications for Autologous Internal Jugular Vein Interposition Meso-Caval Shunt F. Mosimann J, D. Berger2, P.-F. Cuenoud J, R. Mosimann l
Summary Endoscopic sclerotherapy is now the treatment of first choice for oesophageal varices. However, in spite of its efficiency and safety, recurrent bleeding remains possible and oesophageal selerosis does not eure other potentially incapaeitating symptoms related to portal hypertension. This report describes four adoleseents with prehepatic hypertension for whom selerotherapy was inadequate. They were treated successfully by an autologous interna! jugular vein interposition mesocaval shunt. This operation is safe, decompresses the whole splanchnic territory and obviates the need for long term endoscopic surveillance. Key words Portal hypertension - Autologous internal jugular vein interposition in meso-caval shunt Prähepatische portale Venenthrombose bei Jugendlichen: Indikationen zur autologen Interposition der Vena jugularis interna bei meso-kavalem Shunt Die endoskopische Sklerosierung ist zur Zeit die Therapie der Wahl bei der Behandlung von Ösophagusvarizen. Rezidivierende Blutungen sind jedoch nicht auszu· schließen, und die Sklerotherapie heilt nicht das Grundleiden. Dieser Bericht beschreibt vier Jugendliche mit prähepatischen portalen Venenthrombosen für die die Sklerotherapie nicht angemessen war. Sie wurden erfolgreich durch ein autologes Jugularisinterponat bei einem meso-kavalem Shunt behandelt. Diese Operation ist sicher, dekomprimiert das Pfortadersystem und macht eine langzeitige endoskopische Überwachung überflüssig. Schlüsselwörter Portale Hypertension bei Jugendlichen - Indikation zur Interposition der Vena jugularis interna bei meso-kavalem Shunt
Prehepatic portal hypertension is one of the most important causes of upper gastrointestinal bleeding in children, and endoseopic sclerotherapy has become the most popular treatment for oesophageal varices (14, 17). This method is very rational in cirrhotics awaiting liver transplantation, because a porto-systemic shunt would increase the technical difficulties at the graft operation. This conservative approach may be less logical in young individuals with a thrombosed portal vein and a healthy liver. After a childhood often plagued by bleeding and recurrent hospitalizations, these patients tend to consider reluctantly the prospect of lifelong endoscopic surveillance (16). Moreover, sclerotherapy offers no answer to other problems caused by portal hypertension such as non-oeso· phageal varieeal bleeding, chronic stasis in the splanchnic territory or hypersplenism. This report describes 4 adolescents with portal thrombosis who requested radical therapy and received an internal jugular vein interposition mesocaval shunt (2, 15). Operative technique An incision is made along the anterior border of the sternocleidomastoid museie from the base of the skull to the suprasternal noteh. The internal jugular vein is dissected from the vagus nerve and the common carotid artery. It is then ligated and haxvested. For mesocaval interposition, a midline or transverse laparotomy is performed. The superior mesenteric vein is prepared at the root of the mesentery. A Kocher's duodeno-pancreatie mobilization facilitates identification of the suprarenal inferior vena cava. The autograft is anastomosed to the posterolateral side of the superior mesenteric vein using a continuous 5-0 or 6-0 monofilament. The jugular vein is then occluded so that the mesenteric clamp can be released. At this stage, the length of the interposition must be determined accurately: if it is too long, a kink will result; if it is too short, the graft will be compressed by the duodenum (Fig. 1). A Satinsky clamp is finally applied 10 the vena cava, a small ellipse of caval wall is removed and the jugular vein is anastomosed to the cava with a continuous 5-0 or 6-0 vascular suture. Case reports
Received May 30, 1989 Z Kinderchir 45 (1990) 189-191
C Hippokrates Verlag Stuttgart
1. A male patient underwent neonatal resuscitation for prematurity. The umbilical vein was probably catheterized, leading to portal vein thrombosis. At 3 years of age, splenomegaly was obvious and a barium meal evidenced oesophageal and fundie varices. The patient's condition remained stable until he was 9 years old when he started suffering of recurrent melaena. Four years later the diagnosis of portal vein thrombosis was confirmed: he had a splenectomy for hypersplenism and the oesophageal varices were interrupted by ligation on a Vossschulte prothesis. Two years postoperatively endoscopic
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Departments of tSurgel}' Band 2Paediatric Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
Z KimJ/,/'../zir ·1. (19.90)
F \Ja imalln el ul
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fig. 1 Aulologous In ernal JugUlar vem mterposed b tween lhe superror mesellleric In and he Inle'lor venil cava. lust aoove he renal eins
scJerolherapy \\ a needed for rccu tTelll ocsophageal \'arices These \1 cre p orh mnl roll 'r1 an ('01 'rgcnt'y Inlernal jugul
Portal Vein Thrombosis of the Adolescent: Indications for Autologous Internal Jugular Vein Interposition Meso-Caval Shunt F. Mosimann J, D. Berger2, P.-F. Cuenoud J, R. Mosimann l
Summary Endoscopic sclerotherapy is now the treatment of first choice for oesophageal varices. However, in spite of its efficiency and safety, recurrent bleeding remains possible and oesophageal selerosis does not eure other potentially incapaeitating symptoms related to portal hypertension. This report describes four adoleseents with prehepatic hypertension for whom selerotherapy was inadequate. They were treated successfully by an autologous interna! jugular vein interposition mesocaval shunt. This operation is safe, decompresses the whole splanchnic territory and obviates the need for long term endoscopic surveillance. Key words Portal hypertension - Autologous internal jugular vein interposition in meso-caval shunt Prähepatische portale Venenthrombose bei Jugendlichen: Indikationen zur autologen Interposition der Vena jugularis interna bei meso-kavalem Shunt Die endoskopische Sklerosierung ist zur Zeit die Therapie der Wahl bei der Behandlung von Ösophagusvarizen. Rezidivierende Blutungen sind jedoch nicht auszu· schließen, und die Sklerotherapie heilt nicht das Grundleiden. Dieser Bericht beschreibt vier Jugendliche mit prähepatischen portalen Venenthrombosen für die die Sklerotherapie nicht angemessen war. Sie wurden erfolgreich durch ein autologes Jugularisinterponat bei einem meso-kavalem Shunt behandelt. Diese Operation ist sicher, dekomprimiert das Pfortadersystem und macht eine langzeitige endoskopische Überwachung überflüssig. Schlüsselwörter Portale Hypertension bei Jugendlichen - Indikation zur Interposition der Vena jugularis interna bei meso-kavalem Shunt
Prehepatic portal hypertension is one of the most important causes of upper gastrointestinal bleeding in children, and endoseopic sclerotherapy has become the most popular treatment for oesophageal varices (14, 17). This method is very rational in cirrhotics awaiting liver transplantation, because a porto-systemic shunt would increase the technical difficulties at the graft operation. This conservative approach may be less logical in young individuals with a thrombosed portal vein and a healthy liver. After a childhood often plagued by bleeding and recurrent hospitalizations, these patients tend to consider reluctantly the prospect of lifelong endoscopic surveillance (16). Moreover, sclerotherapy offers no answer to other problems caused by portal hypertension such as non-oeso· phageal varieeal bleeding, chronic stasis in the splanchnic territory or hypersplenism. This report describes 4 adolescents with portal thrombosis who requested radical therapy and received an internal jugular vein interposition mesocaval shunt (2, 15). Operative technique An incision is made along the anterior border of the sternocleidomastoid museie from the base of the skull to the suprasternal noteh. The internal jugular vein is dissected from the vagus nerve and the common carotid artery. It is then ligated and haxvested. For mesocaval interposition, a midline or transverse laparotomy is performed. The superior mesenteric vein is prepared at the root of the mesentery. A Kocher's duodeno-pancreatie mobilization facilitates identification of the suprarenal inferior vena cava. The autograft is anastomosed to the posterolateral side of the superior mesenteric vein using a continuous 5-0 or 6-0 monofilament. The jugular vein is then occluded so that the mesenteric clamp can be released. At this stage, the length of the interposition must be determined accurately: if it is too long, a kink will result; if it is too short, the graft will be compressed by the duodenum (Fig. 1). A Satinsky clamp is finally applied 10 the vena cava, a small ellipse of caval wall is removed and the jugular vein is anastomosed to the cava with a continuous 5-0 or 6-0 vascular suture. Case reports
Received May 30, 1989 Z Kinderchir 45 (1990) 189-191
C Hippokrates Verlag Stuttgart
1. A male patient underwent neonatal resuscitation for prematurity. The umbilical vein was probably catheterized, leading to portal vein thrombosis. At 3 years of age, splenomegaly was obvious and a barium meal evidenced oesophageal and fundie varices. The patient's condition remained stable until he was 9 years old when he started suffering of recurrent melaena. Four years later the diagnosis of portal vein thrombosis was confirmed: he had a splenectomy for hypersplenism and the oesophageal varices were interrupted by ligation on a Vossschulte prothesis. Two years postoperatively endoscopic
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Departments of tSurgel}' Band 2Paediatric Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
Z KimJ/,/'../zir ·1. (19.90)
F \Ja imalln el ul
-c=:=--=----=~
fig. 1 Aulologous In ernal JugUlar vem mterposed b tween lhe superror mesellleric In and he Inle'lor venil cava. lust aoove he renal eins
scJerolherapy \\ a needed for rccu tTelll ocsophageal \'arices These \1 cre p orh mnl roll 'r1 an ('01 'rgcnt'y Inlernal jugul
