Surgical Management of Extrahepatic Portal Vein Obstruction in Children: Advantages of Meso-Rex Shunt Compared with Distal Spleno-Renal Shunt (original) (raw)
Related papers
Portal obstruction in children. II. Results of surgical portosystemic shunts
Journal of Pediatrics, 1983
Seventy-six children with portal vein obstruction underwent surgical portosystemic shunt, for severe gastrointestinal tract bleeding in 64 and for prophylactic purposes in 12. Endoscopy and angiography or both showed shunt patency in 70 children; thrombosis occurred in the remaining six. The mean age at successful shunt surgery was 6 years 10 months. Early postoperative assessment of shunt patency was judged from regression of splenomegaly and thrombocytopenia when splenectomy was not performed; when done, early postoperative ultrasonography correctly indicated the result. Significant regression of variees on endoscopy was most often delayed postoperatively for up to six months. Children with a proved patent shunt did not have any further episodes of gastrointestinal tract bleeding, displayed no clinical signs of eneephalopathy, and often exhibited a striking increase in growth velocity. These results strongly support the contention that a portosystemie shunt is the best treatment for portal vein obstruction after the first spontaneous bleeding episode, even in young children. (J PEDtATR 103"703, 1983)
Results of a Stepwise Approach to Extrahepatic Portal Vein Obstruction in Children
Journal of Pediatric Gastroenterology and Nutrition, 2013
Background: The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB). Methods: After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective b-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options. Results: Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P ¼ 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit. Conclusions: Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.
Journal of Pediatric Surgery, 2012
Background: The internal jugular vein is routinely used as a graft for the Rex shunt. We analyzed results of mesoportal bypass using an alternative autologous graft. Methods: Twenty-one children with extrahepatic portal vein obstruction were treated with a Rex shunt constructed using both greater saphenous veins. Follow-up included ultrasound and blood count screening at 3, 6, and 12 months and annually thereafter. Results: Median age was 8.7 years (range, 3.6-14 years), and follow-up time, 5.3 years (range, 0.6-7.1 years). Occlusion or narrowing occurred in 6 patients after a median of 20 months (range, 2.6-52 months). In 2 cases, patency was restored, giving an overall success rate of 81%. During follow-up, no variceal bleeding occurred while hemoglobin, platelet count, and leukocyte levels increased (P ≤ .02 for all) and spleen size decreased (P = .001). Patients with occlusive shunt complications weighed less (P = .01), had higher preoperative platelet levels (P = .02), and tended to have a smaller spleen preoperatively (P = .06) than patients without shunt complications. Cumulative graft patency at 6 months, 1 year, 3 years, and 5 years was 100%, 89%, 82%, and 74%, respectively. Conclusions: Rex shunt constructed using the greater saphenous veins is a valuable alternative to the internal jugular vein graft, allowing long-term reversal of portal hypertension, splenomegaly, and hypersplenism. Low patient weight and high platelet count predicted shunt occlusion.
Long term follow-up of 100 patients with portal hypertension treated by a modified splenorenal shunt
British Journal of Surgery, 1986
One hundred consecutive Child's A or B patients with portal hypertension who survived the index episode of variceal bleeding were electively treated by a distal splenorenal shunt modified by a retroperitoneal approach. The operative mortality of the whole series was 11 per cent, but fell from 16per cent in thefirst 50 patients to 6per cent in the second halfof the series.
Tropical Gastroenterology
Background: Patients with extrahepatic portal hypertension may have to undergo splenorenal shunt surgery which requires a patent splenic vein of adequate calibre with a normal renal vein. This study reports a modification of splenorenal shunt for portal hypertension in children obviating the need for complex splenic vein-pancreatic disconnection. Methods: 12 children with extrahepatic portal hypertension receiving the modified procedure were included. Indications for surgery were: recurrent hematemesis after endoscopic ablation of oesophageal varices in eight, hematemesis during sclerotherapy in two, and hematemesis in two patients coming from remote places. All patients had massive splenomegaly with hypersplenism. CT venogram demonstrated a cavernomatous transformation of the extrahepatic portal vein. The cavernoma extended up to the splenic vein and the superior mesenteric vein in six. After control of hematemesis and correction of coagulopathy, splenectomy was done with premeditated preservation of terminal tributaries of splenic vein, long and wide enough for anastomosis with left adrenal or renal vein without the need of tedious splenic vein-pancreatic disconnection. Results: With completion of shunt, a significant reduction in the splenic vein pressure was noted in all patients. Recurrent hematemesis occurred in two patients while another two had ascites. CT venogram after one-year follow-up in eight patients revealed patent shunt in seven. Conclusion: In patients with massive splenomegaly, during splenectomy for splenoadrenal shunt, premeditated preservation of a long terminal tributary of splenic vein and its use for splenoadrenal or splenorenal shunt can obviate the need of complex splenic vein-pancreatic disconnection.