Management of Extrahepatic Portal Hypertension in Children

Abstract

Among 69 patients with PVT, 338 variceal bleeding episodes occurred. Only two patients died from bleeding, and both lived in remote communities and were inaccessible to medical care. Fifty-three children underwent 164 operations for the management of PVT. Once operative management was undertaken, subsequent operations frequently were necessary. Nonoperative measures controlled acute variceal hemorrhage in most instances during the past 10 years. Almost all patients who underwent splenectomy alone, variceal ligation, gastric division, splenic transposition, or makeshift shunts subsequently rebled. These operations are rarely indicated in the current management of children with PVT. Portal venography is essential to define the portal venous circulation before a shunt operation is attempted. Cavomesenteric or central splenorenal shunts prevented further bleeding in eight of 15 patients and are the most reliable operations to control bleeding in patients with PVT. Emergency operation is rarely necessary to control bleeding. Sixteen patients (average age 14.6 years) with PVT did not undergo any operations, and are alive. Each of the six patients with PVT who died from complications of portal hypertension did so within nine months of an operation. Four of these patients had previous splenectomy and died with sepsis as one of the major factors. Bleeding episodes became less frequent as the patients increased in age. Patients who underwent shunts under unfavorable circumstances or who received various other operations to treat portal hypertension appeared to have a higher risk of morbidity and mortality than those managed nonoperatively.

Long term outcome after surgery for extrahepatic portal vein thrombosis.

“…3-58 13 15 32 Splenectomy alone was associated with a poor outcome. 34 This proved to be the correct course of action to take in two children, who are currently alive, well, and free from haemorrhage. Predicting who is likely to benefit is fraught with error, as seen in the two other similarly managed children who died, whereas another patient was lost to follow up.…”

The ECK fistula in animals and humans

“…Thrombosis after portacaval shunt in children with portal hypertension has been so high that most pediatric surgeons prefer to use the operation only in patients older than 8 or 10 years and in those whose anastomoses can be made at least 1 cm in diameter. 127,148 Although these minimum conditions did not obtain in the majority of our patients, there were no thromboses and no deaths.…”

“…The observations were consonant with those of previous workers. 127,128 Even more reassuring were the results obtained in the French hepatology unit of Alagille and summarized by Alvarez et al 129 Seventy-six children with portal obstruction had portalsystemic shunts (32 central splenorenal, 32 Marion mesocaval, 6 interposition mesocaval, 3 makeshift, 2 distal splenorenal, 1 portacaval). Seventy of the shunts remained patent.…”

Gastrointestinal bleeding

“…Em crianças portadoras de hipertensão portal, sem disfunção hepatocelular (ex. trombose de veia porta), existe uma tendência de redução do sangramento após a adolescência, como conseqüência da recanalização da veia porta e do desenvolvimento de colaterais portossistêmicos em outros locais 40 .…”

“…Após fixação do balão gástrico, pode-se esperar um período de 4 a 6 horas, apenas com o balão gástrico insuflado, pois apenas esta medida pode ser suficiente para o controle da hemorragia, por diminuir o fluxo para as varizes esofágicas. O uso do balão em crianças requer, em geral, sedação 29,40,44 .…”