Surgical Shunt Procedures in Childhood Portal Hypertension: A Review Article (original) (raw)
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Selective shunts for portal hypertension: Current role of a 21-year experience
Liver Transplantation, 1997
The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child- Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function.
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.
Gut, 1978
The usefulness of selective transplenic decompression of oesophageal varices by distal splenorenal shunt and splenocaval shunt was evaluated in the control of gastrointestinal haemorrhage in patients with portal hypertension of varied aetiology. (Decompression was successful in 69 out of 78 cases.) It was shown that it is superior to total portosystemic shunts, as the incidence of encephalopathy was very low compared with the data from our series of portocaval shunts. The operative mortality has been progressively lowered and has now reached levels comparable with portocaval shunt. Distal splenorenal shunt when performed as an emergency procedure to arrest bleeding has limited usefulness but when performed as an elective or prophylactic procedure its results are comparable with those of portocaval shunt without the untoward complications such as encephalopathy. A modified selective decompression of varices has been described in which the distal end of the splenic vein is anastomosed to the inferior vena cava. Though no long term follow-up studies are available, we believe that this shunt is likely to prove superior to distal sp]enorenal shunt as it has both the advantages of the distal splenoral and the haemodynamic advantage of end-to-side portocaval shunt. We conclude that in patients with portal hypertension of varied aetiology, who have not had a haemorrhagic episode but in whom varices have been demonstrated or who have had one episode of haemorrhage from varices, the splenocaval shunt when feasible or the distal splenorenal shunt offers the optimal method of management at present in India.
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)
Journal of Vascular and Interventional Radiology, 1995
blood flow, bypassing perfusion Michael 5. Webb, MD through the liver. This can lead to Patient 1.-The patient was a 67-Richard A. Haas, MD pathologic venous engorgement, or year-old man with a history of alco-Robert P. Beecham, MD varices, which can hemorrhage, reholic cirrhosis who presented with sulting in up to 36%-53% mortality weakness, melena, and bradycardia. despite endoscopic sclerotherapy or The total bilirubin level was 0.9 Index terms: Hypertension, portal, banding (1,2). Most patients who mg/dL (15.4 pmoVL), serum albumin 957.711 Shunts, portosystemic, 957.453 present with bleeding gastroesophwas 2.4 g/dL (24 g/L), and the pro-* Shunts, splenorenal, 957.4533 * Stomageal varices have supradiaphragach, varices, 72.75,959.711
Effects of altered portal hemodynamics after distal splenorenal shunts
The American Journal of Surgery, 1987
In addition to decompression of esophagogastric varices, the objectives of the distal splenorenal shunt, as stated by Warren et al [I] in 1967, are preservation of hepatic portal perfusion and maintenance of portal venous hypertension. Early postoperative hemodynamic studies of distal splenorenal shunt patients have emphasized the status of hepatic portal perfusion. Severe loss of portal flow to the liver, usually secondary to portal vein thrombosis, has had adverse effects on early morbidity and mortality in most series, but not in all [2-41. In contrast, the consequences of acute changes in portal pressure after the distal splenorenal shunt have not been assessed. In the present investigation, cirrhotic patients who had undergone distal splenorenal shunts were grouped based on preoperative and postoperative changes in hepatic portal perfusion and portal pressure. The aim of the study was to determine the effects of these acute hemodynamic alterations on early and late postoperative morbidity and mortality. Material and Methods From January 1978 through July 1984,91 patients with cirrhosis underwent distal splenorenal shunts for variceal hemorrhage at the University of Utah Medical Center and the Salt Lake City Veterans Administration Medical Center. All operations were performed by a single surgeon (LFR). Sixty-three patients (69 percent) received both preoperative and early postoperative (1 to 3 weeks) visceral angiography and corrected sinusoidal pressure determinations. Angiography revealed shunt occlusion in
Surgery, 1999
Since the advent of liver transplantation and transjugular intrahepatic portosystemic shunts (TIPS), the role of surgical portosystemic shunts in the treatment of portal hypertension has changed. However, we have continued to use portosystemic shunts in patients with noncirrhotic portal hypertension and in patients with Child's A cirrhosis. We performed 48 surgical portosystemic shunt procedures between 1988 and 1998. The outcomes of these patients were evaluated to assess the efficacy of this treatment. Data from 39 of 48 patients were available for analysis. The average follow-up was 42 months. Liver function generally remained stable for the patients; only 2 patients had progressive liver failure and required transplant procedures. Gastrointestinal bleeding (3 patients), encephalopathy (3 patients), and shunt thrombosis (3 patients) were rare. Patient survival was 81% at 4 years, similar to survival with liver transplantation (P = .22). Surgical shunts remain the treatment of choice for prevention of recurrent variceal bleeding in patients with good liver function and portal hypertension.