Reassessment of operative procedures for portal hypertension in infants and children

Treatment of variceal hemorrhage in children

The etiology and management of portal hypertension in infants and children differ from those in adults. Both the plan of management and the prognosis of portal hypertension vary considerably depending upon the nature of the underlying pathologic process. It is essential to determine the type of obstruction as accurately as possible before definitive treatment is initiated. This article considers the management of extrahepatic, intrahepatic, and suprahepatic portal venous obstruction; treatment of the unshuntable patient; portosystemic shunts; and liver transplantation.

Oesophageal varices as a late complication to neonatal umbilical vein catheterization

Three recent cases are presented. Haematemesis in children with splenomegalia and a history of neonatal umbilical vein catheterization should involve careful examination for oesophageal varices due to portal hypertension.

Immediate and long-term results of superior mesenteric vein-inferior vena cava shunt for portal hypertension in children

Experience with 46 superior mesenteric vein-inferior vena cava shunts in children is reported, with postoperative follow-up of from 2 to 15 yr. The first procedure used as an end-to-side implantation of the vena cava into the right side of the superior mesenteric vein or portal vein after ligating the cava above the iliac vessels (16 cases). In the next 30 children, the vena cava was lengthened using the left or right common iliac vein, thus obtaining better anastomosis and reversed portal flow. Patency may be definitely assumed when the esophageal varices have disappeared within 3 mo; this was observed in 33 children. Results are nearly the same with superior mesenteric vein-inferior vena cava shunt, splenorenal shunt and portacaval shunt when the respective veins of the portal system are more than 1 cm in diameter. When it is less, the superior mesenteric vein-inferior vena cava shunt is more successful than others; this is the case in children under 7 yr of age. No serious trouble was observed after the interruption of the venous circulation of the limbs and pelvis when a superior mesenteric vein-inferior vena cava shunt was performed when the patients were less than 15 yr of age.

Management of extrahepatic portal hypertension in children

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 results of surgical treatment for bleeding oesophageal varices in children with portal hypertension

The long-term results of surgical treatment for bleeding oesophageal varices in children with portal hypertension are reviewed. Twenty-four children below the age of 13 years who presented with gastrointestinal bleeding over a 20-year period form the basis of this study. The importance of the aetiology of portal hypertension on the long-term follow-up has been studied. The results of surgical treatment in controlling haemorrhage are assessed.

Though extrahepatic obstruction is considered to be associated with a better long-term prognosis than intrahepatic disease the results of treatment in both groups were similar, with a 7-year survival rate of 75 per cent. Shunt surgery as a definitive procedure is advised in both groups, though the type of shunt used will depend on the age of the child and the site of obstruction.

Portal hypertension in childhood

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