Perioperative Strategies and Thrombophilia in Children with Extrahepatic Portal Vein Obstruction Undergoing the Meso-Rex Bypass
Tóm tắt
Extrahepatic portal vein obstruction (EHPVO) is an important cause of chronic portal hypertension in children. Although usually idiopathic in etiology, genetic and acquired thrombophilia have been implicated in EHPVO. Meso-Rex bypass is increasingly used to treat EHPVO in children. The objective of this study is to assess the relationship of postoperative anticoagulation strategies and thrombophilic risk factors to the development of bypass thrombosis following the meso-Rex bypass. Records of children who underwent meso-Rex bypass for EHPVO at a single institution from 1999 to 2009 were reviewed, and preoperative thrombophilia testing, perioperative anticoagulation strategies, and postoperative bypass patency based on imaging at last follow-up were examined. Sixty-five children with EHPVO underwent a first time meso-Rex bypass during the study period, and 9 of 65 (14 %) developed bypass thrombosis. The use of warfarin in the postoperative period was more common among children with thrombosed shunts than among those with open shunts [63 % vs. 20 %; OR, 6.5 (95 % CI, 1.3–31.5), p = 0.022]. The contribution of genetic or acquired thrombophilia to shunt thrombosis was inconclusive given variability in testing. Choice of anticoagulation following meso-Rex bypass may affect postoperative incidence of bypass thrombosis. Role of thrombophilic risk factors in the development of shunt thrombosis remains unclear.
Tài liệu tham khảo
Alvarez F, Bernard O, Brunelle F, et al. Portal obstruction in children. I. Clinical investigation and hemorrhage risk. The Journal of Pediatrics. 1983 Nov;103(5):696–702.
Schettino GC, Fagundes ED, Roquete ML, et al. Portal vein thrombosis in children and adolescents. J Pediatr (Rio J). [Review]. 2006 May–Jun;82(3):171–8.
Dubuisson C, Boyer-Neumann C, Wolf M, et al. Protein C, protein S and antithrombin III in children with portal vein obstruction. J Hepatol. 1997 Jul;27(1):132–5.
El-Karaksy H, El-Koofy N, El-Hawary M, et al. Prevalence of factor V Leiden mutation and other hereditary thrombophilic factors in Egyptian children with portal vein thrombosis: results of a single-center case–control study. Ann Hematol. 2004 Nov;83(11):712–5.
Pinto RB, Silveira TR, Rosling L, et al. Thrombophilic disorders in children and adolescents with portal vein thrombosis. J Pediatr (Rio J). 2003 Mar–Apr;79(2):165–72.
Primignani M, Martinelli I, Bucciarelli P, et al. Risk factors for thrombophilia in extrahepatic portal vein obstruction. Hepatology. 2005 Mar;41(3):603–8.
Mack CL, Superina RA, Whitington PF. Surgical restoration of portal flow corrects procoagulant and anticoagulant deficiencies associated with extrahepatic portal vein thrombosis. The Journal of Pediatrics. 2003 Feb;142(2):197–9.
Superina RA, Alonso EM. Medical and surgical management of portal hypertension in children. Curr Treat Options Gastroenterol. 2006 Sep;9(5):432–43.
Shneider B, Emre S, Groszmann R, et al. Expert pediatric opinion on the Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. Pediatr Transplant. [Research Support, Non-U.S. Gov’t]. 2006 Dec;10(8):893–907.
Superina R, Shneider B, Emre S, et al. Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant. 2006 Dec;10(8):908–13.
Mack CL, Zelko FA, Lokar J, et al. Surgically restoring portal blood flow to the liver in children with primary extrahepatic portal vein thrombosis improves fluid neurocognitive ability. Pediatrics. 2006 Mar;117(3):e405–12.
Superina R, Bambini DA, Lokar J, et al. Correction of extrahepatic portal vein thrombosis by the mesenteric to left portal vein bypass. Ann Surg. 2006 Apr;243(4):515–21.
Ates O, Hakguder G, Olguner M, et al. Mesenterico left portal bypass for variceal bleeding owing to extrahepatic portal hypertension caused by portal vein thrombosis. J Pediatr Surg. 2006 Jul;41(7):1259–63.
Bambini DA, Superina R, Almond PS, et al. Experience with the Rex bypass (mesenterico-left portal bypass) in children with extrahepatic portal hypertension. J Pediatr Surg. 2000 Jan;35(1):13–8; discussion 8–9.
Dasgupta R, Roberts E, Superina RA, et al. Effectiveness of Rex bypass in the treatment of portal hypertension. J Pediatr Surg. 2006 Jan;41(1):108–12; discussion 12.
Gibelli NE, Tannuri AC, Pinho-Apezzato ML, et al. Extrahepatic portal vein thrombosis after umbilical catheterization: is it a good choice for Rex bypass? J Pediatr Surg. Jan;46(1):214–6.
Ates O, Hakguder G, Olguner M, et al. Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus. J Pediatr Surg. 2003 Oct;38(10):E10–1.
de Ville de Goyet J, Alberti D, Clapuyt P, et al. Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension. Journal of Pediatric Surgery. 1998 Apr;33(4):597–601.
Emre S, Dugan C, Frankenberg T, et al. Surgical portosystemic bypasss and the Rex bypass in children: a single-centre experience. HPB (Oxford). 2009 May;11(3):252–7.
Fuchs J, Warmann S, Kardorff R, et al. Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach. J Pediatr Gastroenterol Nutr. 2003 Feb;36(2):213–6.
Query JA, Sandler AD, Sharp WJ. Use of autogenous saphenous vein as a conduit for mesenterico-left portal vein bypass. J Pediatr Surg. 2007 Jun;42(6):1137–40.
Siegerstetter V, Huber M, Ochs A, et al. Platelet aggregation and platelet-derived growth factor inhibition for prevention of insufficiency of the transjugular intrahepatic portosystemic bypass: a randomized study comparing trapidil plus ticlopidine with heparin treatment. Hepatology. [Clinical Trial Comparative Study Randomized Controlled Trial]. 1999 Jan;29(1):33–8.