Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 21, 2017; 23(15): 2811-2818
Published online Apr 21, 2017. doi: 10.3748/wjg.v23.i15.2811
One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics
Gloria Pelizzo, Pietro Quaretti, Lorenzo Paolo Moramarco, Riccardo Corti, Marcello Maestri, Giulio Iacob, Valeria Calcaterra
Gloria Pelizzo, Giulio Iacob, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
Gloria Pelizzo, Pediatric Surgery Unit, Ospedale dei Bambini “G. di Cristina”, Istituto Mediterraneo di Eccellenza Pediatrica, 90134 Palermo, Italy
Pietro Quaretti, Lorenzo Paolo Moramarco, Unit of Interventional Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
Riccardo Corti, Radiology Department, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy
Marcello Maestri, Department of Surgery, IRCCS Policlinico San Matteo Foundation, 27100 Pavia, Italy
Valeria Calcaterra, Pediatric Unit, Department of Maternal and Children’s Health, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
Valeria Calcaterra, Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
Author contributions: Pelizzo G performed the pediatric surgical intervention and post-op management; Quaretti P and Moramarco LP performed the vascular intervention; Corti R provided radiological support; Maestri M provided surgical support; Iacob G performed the data collection; Pelizzo G and Calcaterra V designed and wrote the report; all authors contributed to revision of this manuscript.
Institutional review board statement: This case report was exempt from the Institutional Review Board standards at Fondazione IRCCS Policlinico San Matteo.
Informed consent statement: The patient’s parents involved in this study gave their written informed consent authorizing use and disclosure of their protected health information.
Conflict-of-interest statement: All the authors have no conflicts of interests to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Gloria Pelizzo, Professor, Pediatric Surgery Unit, Ospedale dei Bambini “G. di Cristina”, Istituto Mediterraneo di Eccellenza Pediatrica, Via dei Benedettini, 1, 90134 Palermo, Italy. gloriapelizzo@gmail.com
Telephone: +39-91-6666007 Fax: +39-91-6666006
Received: September 22, 2016
Peer-review started: September 23, 2016
First decision: December 2, 2016
Revised: December 14, 2016
Accepted: January 17, 2017
Article in press: January 17, 2017
Published online: April 21, 2017
Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients.

Keywords: Portal cavernoma, Pediatrics, Transjugular intrahepatic portosystemic shunt, Minilaparotomy-assisted transmesenteric

Core tip: We present the first successful hybrid intervention used to treat a portal cavernoma causing recurrent bleeding in a young girl: one step minilaparotomy-assisted transmesenteric anterograde portal recanalization and transjugular intrahepatic portosystemic shunt (TIPS). The combined approach allows direct varices embolization, restores hepatopetal portal flow, in turn preserving the portal stent graft patency by means of the TIPS placement. It is a minimally invasive procedure that can be utilized to avoid or delay surgical treatment or transplantation.