Portopulmonary shunt by splenopneumopexy for portal hypertension in children

Triplex operation for children with extrahepatic portal hypertension

BACKGROUND/PURPOSE

How to deal with the vexatious problem of esophageal and gastric varices secondary to extrahepatic portal hypertension has been discussed extensively among pediatric surgeons around the world. The aim of this study is to evaluate the effect of triplex operation (splenopneumopexy, portal azygous devascularization, and ligation of splenic artery) for children with portal hypertension in the author's hospital.

METHODS

From March 1993 to November 1998, 7 children with extrahepatic portal hypertension were admitted to the author's hospital to undergo triplex operation. The diagnoses of these patients were confirmed by gastroscopy, barium meal, and Doppler ultrasonography. The number of white blood cells and platelets and the hepatic function were checked before and after operation. And the free portal pressures (FPP) were checked before and after the ligation of the splenic artery. All patients underwent follow-up for 1 to 7 years (mean, 4.6 years). The episodes of upper gastrointestinal bleeding were recorded. The degree of varices of distal esophagus and proximal stomach were assessed by barium meal and gastroscopy. The diameters of the spleenic and portal vein were obtained by B ultrasonography. The portopulmonary shunt and portal blood flow were evaluated by color Doppler flow image (CDFI). The indices of hemorheology such as hematocrit, viscosity of whole blood and plasma, and the indexes of deformability and aggregability of red blood cells were obtained through viscometer (R-20 Seerle, Beijing, China).

RESULTS

There was no operative mortality in this group. Postoperatively, hemorrhage from the esophagus and gastric varices was completely controlled. Although the diameter of spleen reduced progressively, no patient's spleen recovered to normal during the follow-up period. The degree of varices was mitigated, and the FPP was decreased significantly to 34.48 +/- 5.71 cm H(2)O from the preoperative 42.62 +/- 6.72 cm H(2)O (P <.05). The rate of portal flow also was decreased. The direction of portal vein was bidirection (one part was away from the liver and the other was toward the liver). The numbers of white blood cells and platelets were increased. The viscosities of whole blood and hematocrit also were increased after operation.

CONCLUSION

The triplex operation is an effective procedure for the control of hemorrhage from varices in children with extrahepatic portal hypertension.

Causes and management of portal hypertension in the pediatric population

Therapeutic options for children with portal hypertension now include a broad range of pharmacologic, endoscopic, and surgical procedures. Thoughtful application of all of these options can improve quality of life by decreasing the complications of portal hypertension and can decrease mortality by preventing the consequences of variceal hemorrhage. The development of portal hypertensive gastropathy following palliative procedures such as endoscopic sclerotherapy and band ligation may limit their long-term success in children. The excellent results now obtained with selective portosystemic shunts and liver transplantation assure that definitive surgical treatments will continue to be important components in the treatment of children with portal hypertensive complications or progressive liver disease. Evolving procedures, such as TIPS, represent excellent short-term life-preserving techniques to stabilize critically ill patients while awaiting liver transplantation. Their role in the future, long-term management of children is yet to be defined.

Diseases of the hepatopulmonary axis

Hepatopulmonary syndrome is the most widely recognized of the processes associated with end-stage liver disease. Chronic liver dysfunction is associated with pulmonary manifestations due to alterations in the production or clearance of circulating cytokines and other mediators. Hepatopulmonary syndrome results in hypoxemia due to pulmonary vasodilatation with significant arteriovenous shunting and ventilation-perfusion mismatch. Hepatic hydrothorax may develop in patients with cirrhosis and ascites. Rarely, pulmonary hypertension occurs in the setting of portal hypertension. A second group of disorders may primarily affect the lungs and liver (the hepatopulmonary axis). Among these are the congenital conditions alpha(1)-antitrypsin deficiency and cystic fibrosis. Autoimmune liver disease may be associated with lymphocytic interstitial pneumonitis, fibrosing alveolitis, intrapulmonary granulomas, and bronchiolitis obliterans with organizing pneumonia. Sarcoidosis affects the lung and liver in up to 70% of patients. Medications such as amiodarone can result in a characteristic radiologic appearance of pulmonary and hepatic toxic effects. Knowledge of these associations will assist the radiologist in forming a meaningful differential diagnosis and may influence treatment decisions.

Selective distal splenorenal shunts for intractable variceal bleeding in pediatric portal hypertension

The treatment of portal hypertension in the pediatric population has undergone an evolution toward less invasive methods of care. With the advent of endoscopic sclerotherapy, surgery is less common in the acute care of these patients. Few reports deal with the role of portosystemic shunting in the emergent management of variceal hemorrhage in children. To address this issue, the authors studied the medical records of all pediatric patients at their institution who underwent placement of a shunt for portal hypertension during the last 10 years. Nine patients underwent a total of 10 emergent or semiurgent shunting procedures. Seven were boys and two were girls. Six patients had portal hypertension as a result of intrahepatic disease. Two had extrahepatic portal vein thrombosis. Five children had abnormal hepatic function. The median age at the time of the procedure was 9 years. The indication for surgical shunting in all cases was gastrointestinal hemorrhage not responsive to sclerotherapy. Eight patients underwent emergent distal splenorenal shunts (DSRS), and two underwent a nonselective mesocaval shunt, with one undergoing both. Postoperatively all patients had cessation of bleeding. Operative mortality was zero. Early complications included ascites (3), small bowel obstruction (1), and hepatorenal syndrome (1). The child who underwent a nonselective shunt procedure had encephalopathy. Two DSRS thrombosed, requiring reexploration; eight shunts remained patent. Three patients eventually had orthotopic liver transplantation (OLT) because of progressive hepatic failure. Two children died; neither death was shunt related.(ABSTRACT TRUNCATED AT 250 WORDS)