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Unconventional Alternative Shunts in Pediatric Extrahepatic Portal Vein Obstruction - Experience With Satisfactory
Tarun Kumar Gupta1, Basant Kumar1, Pujana Kanneganti1
1Department of Pediatric Surgical Super Specialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, UP, India.
Insights
Unconventional shunts offer a viable alternative for pediatric patients with extrahepatic portal vein obstruction when standard procedures are not possible. These alternative surgeries successfully managed variceal bleeding and improved patient outcomes.
Area of Science:
- Pediatric Surgery
- Hepatobiliary Surgery
- Vascular Surgery
Background:
- Extrahepatic portal vein obstruction (EHPVO) is a primary cause of variceal bleeding in children in the Indian subcontinent.
- Portosystemic shunt surgery (PSS) is crucial for managing refractory cases, with proximal splenorenal shunt (PSRS) being common.
- Anatomical variations and technical challenges necessitate exploring unconventional or alternative shunt procedures.
Purpose of the Study:
- To evaluate the efficacy and outcomes of unconventional shunt procedures in pediatric patients with EHPVO.
- To present surgical experience with nonconventional shunts in cases where standard options are not feasible.
Main Methods:
- Retrospective observational cohort study analyzing data from June 2019 to July 2024.
- Inclusion of all pediatric patients who underwent unconventional or alternative shunt procedures.
- Data collected from hospital electronic and operative records.
Main Results:
- Seven pediatric patients (6.3% of 112) underwent unconventional shunts (spleno-adrenal, inferior mesenteric-vena caval, collateral-based).
- Common symptoms included growth retardation, splenomegaly with hypersplenism, and variceal bleeding.
- Significant reduction in omental vein pressure, improved hematological parameters, and variceal regression were observed post-surgery.
Conclusions:
- Unconventional shunts are a feasible and valuable surgical option for select pediatric patients with EHPVO.
- These procedures serve as a critical rescue plan when anatomical constraints limit conventional shunt surgeries.
- Positive outcomes, including improved growth and appetite, were noted in patients following these alternative interventions.
Background:
Major variceal hemorrhages in children of the Indian subcontinent, are caused by extrahepatic portal vein obstruction (EHPVO). Portosystemic shunt surgery (PSS) is the recommended course of action for long-term care in refractory cases, even if endoscopic techniques constitute the initial line of treatment for acute variceal hemorrhage. The most usual surgery, particularly with splenomegaly, is the proximal splenorenal shunt (PSRS). However, in some cases, unusual or alternative nonconventional shunts are required for treatments due to anatomical variances and technical difficulties. We present our experience with pediatric patients underwent unconventional shunt procedures with satisfactory outcome.
Methodology:
Retrospectively between June 2019 and July 2024; all patients underwent unconventional or "alternative shunts were included in the study. The patients' information was collected from hospital electronic and operative records, and all available data was analyzed.
Result:
Seven (7/112; 6.3 %) patients were operated as unconventional shunt for various reasons in total of 112 patients during study period. Five were males and median age was 11 years (ranged 3-17 years). The most common symptoms were splenomegaly with hypersplenism (6/7; 85.7 %) growth retardation (7/7; 100 %) abdominal pain/discomfort (4/7; 57.2 %), hematemesis (5/7; 71.4 %) and melena (4/7; 57.2 %) in the combination with each other. Various unconventional shunts, including spleno-adrenal, inferior mesenteric-vena caval, and collateral-based shunts, were performed. The median shunt diameter was 7 mm [7-8 mm (25th - 75th Percentile)] and post-surgery reduction in median omental vein pressure was significant (p = 0.017). All patients showed improved hematological parameters and variceal regression. One patient experienced shunt thrombosis, successfully managed with interventional radiology. Follow-up ranging from 5 to 56 months showed good outcomes with improved appetite, weight gain.
Conclusion:
Unconventional shunts are a viable alternative in select cases where conventional shunt options are not feasible, providing a valuable surgical rescue plan when anatomical constraints are encountered.
Type Of Study:
Retrospective observational cohort study.
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