Proximal Splenorenal Shunts for Extrahepatic Portal Venous Obstruction in Children

Abstract

ObjectiveThe results of proximal splenorenal shunts done in children with extrahepatic portal venous obstruction were evaluated. Summary Background DataExtrahepatic portal venous obstruction, a common cause of portal hypertension in children in India, is being treated increasingly by endoscopic sclerotherapy instead of by proximal splenorenal shunt. It is believed that surgery (or the operation) carries high mortality and rebleeding rates and is followed by portosystemic encephalopathy and postsplenectomy sepsis. However, a proximal splenorenal shunt is a definitive procedure that may be more suitable for children, particularly those who have limited access to medical facilities and safe blood transfusion. MethodsBetween 1976 and 1992, the authors performed 160 splenorenal shunts in children. Twenty were emergency procedures for uncontrollable bleeding and 140 were elective procedures -102 for recurrent bleeding and 38 for hypersplenism. ResultsThe overall operative mortality rate was 1 .9%-10% (3/160-2/20) after emergency operations and 0.7% (1/140) after elective operations. Rebleeding occurred in 17 patients (1 1% ConclusionsA proximal splenorenal shunt, a one-time procedure with a low mortality rate and good long-term results, is an effective treatment for children in India with extrahepatic portal venous obstruction.Extrahepatic portal venous obstruction (EHO), the main reasons for this change are that EST is easy to permost common cause of upper gastrointestinal hemor-form, atraumatic, and effective in preventing bleeding, rhage in children,'"2 is being treated increasingly by en-once the esophageal varices are obliterated. Surgery is fadoscopic sclerotherapy (EST) instead of by surgery. The vored less because it is thought to be accompanied by 193

Portal hypertension

“…Moreover, the control of portal hypertensive gastropathy, portal biliopathy and growth retardation in these patients can be addressed only by a portosystemic shunt. 2,8 The average survival of cirrhotic patients after shunt surgery, however, is only 5 years and a liver transplantation is the only definitive mode of treatment in these patients.…”

Current Role of Surgery in Portal Hypertension

“…Preprimary prophylaxis [1] [13,25] ii. Proximal splenorenal shunt (PSRS) with splenectomy [9,26] iii. S-side splenorenal shunt without splenectomy (Mitra et al [27]) c. Selective or partial portosystemic shunts i. Distal splenorenal shunt (DSRS) [28] ii.…”

“…At surgery, a gastrotomy is often required to directly under run the esophagogastric varices with interlocking nonabsorbable sutures to arrest the hemorrhage before constructing the decompressive portosystemic shunt [7,9,26]. In centers where expertise is available, surgical shunt should be considered in patients with Child's A status and patients with noncirrhotic portal hypertension (NCPH) once the other modalities have failed to arrest the variceal bleeding.…”

“…It must be borne in mind that in cirrhotics the major factor determining survival is the status of the liver disease at the time of surgery rather than the type of procedure performed, whereas in the case of NCPH, whenever feasible, surgery should be chosen with regard to its efficacy in immediate control of bleeding. In general, patients with NCPH are better treated with decompressive shunts [7,9,26,43]. If suitable shuntable veins are not available, devascularization may be the only option [21,24].…”

“…Even though endoscopic variceal obliteration has good long-term outcomes there are certain caveats that should be kept in mind: [9,26]. None of these patients developed encephalopathy.…”