A 47-year-old man was referred for evaluation and treatment of gastroi
ntestinal variceal bleeding and possible transjugular intrahepatic por
tal-systemic shunting. Intrahepatic manometry disclosed a normal porta
l pressure, but selective mesenteric arteriography revealed occlusion
of the superior mesenteric, splenic, and inferior mesenteric veins. Du
odenal and gastric varices were noted, but no esophageal varices were
seen. The portal vein was clearly patent. At surgery, a 2 cm mass was
found at the superior mesenteric vein-splenic vein juncture, and subse
quent pathologic examination confirmed the presence of suture material
within dense fibrous tissue as the probable cause for this rare condi
tion. The surgical procedure performed was a superior mesenteric vein-
to-portal vein bypass, employing ringed expanded polytetrafluoroethyle
ne. Graft patency and function have been confirmed postoperatively by
means of both venous-phase mesenteric arteriography and duplex imaging
. The surgical procedure was novel, in that it was possible to decompr
ess the hypertensive mesenteric circulation from the distal superior m
esenteric vein directly into the portal vein with a prosthetic bypass.
The physiologic benefit of this operation is clear: the avoidance of
the encephalopathic syndrome and the facilitation of hepatopetal blood
flow.