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Portosystemic shunts for extrahepatic portal hypertension in children
Insights
Portosystemic shunts effectively treat children with prehepatic portal hypertension and bleeding varices. Mesocaval shunts are favored for their patency and spleen preservation, preventing re-bleeding in most pediatric patients.
Area of Science:
- Pediatric Surgery
- Hepatology
- Vascular Surgery
Background:
- Prehepatic portal hypertension in children often leads to severe hemorrhage from esophagogastric varices.
- Ruptured varices pose a significant risk of mortality and morbidity in pediatric patients.
- Portal vein anomalies, such as cavernomatosis and double portal veins, are common in this population.
Purpose of the Study:
- To evaluate the efficacy and safety of portosystemic shunts in managing pediatric prehepatic portal hypertension with variceal hemorrhage.
- To compare outcomes between different types of portosystemic shunts in children.
- To determine the long-term patency and complication rates of these shunts.
Main Methods:
- A cohort of 23 children with prehepatic portal hypertension and variceal bleeding underwent portosystemic shunt surgery.
- The study included patients aged 2.7 to 15 years, with 11 under eight years old.
- Procedures included 21 mesocaval shunts and 2 splenorenal shunts; patient data were analyzed for outcomes.
Main Results:
- No surgical mortality was observed.
- Two shunts occluded in very young infants (2.7 and 3 years old).
- The remaining shunts remained patent, with no further bleeding episodes in 21 patients; only one patient developed neuropsychiatric disorders.
Conclusions:
- Elective portosystemic shunt surgery is recommended for children experiencing major variceal hemorrhage due to prehepatic portal hypertension.
- The mesocaval shunt is favored due to larger vessel anastomosis and spleen preservation, crucial for infection defense.
- Portosystemic shunting demonstrates a favorable risk-benefit profile for preventing recurrent variceal bleeding in pediatric patients.
Abstract:
Twenty-three children with prehepatic portal hypertension and hemorrhage due to ruptured esophagogastric varices had portosystemic shunts. Their ages ranged from two years and seven months to 15 years. Eleven were less than eight years of age. Twenty patients had portal vein cavernomatosis and three patients had double portal veins. In 21 patients, a mesocaval type of shunt was done. A splenorenal shunt was performed in two. There was no surgical mortality. Two shunts occluded, both in rather young infants--two years and seven months and three years of age. In all the others, there was no further bleeding, and the shunts remained patent, as shown by abdominal angiograms. Neuropsychiatric disorders, probably due to hepatic encephalopathy, occurred in only one patient. On the basis of this favorable experience, we believe that an elective portosystemic shunt should, in general, be performed upon children with prehepatic portal hypertension after one major variceal hemorrhage. We favor a mesocaval type of shunt in these children because of the larger diameter of the vessels involved in the anastomosis and because it preserves the spleen, maintaining defense against subsequent infection.