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Gastroportal shunt for portal hypertension in children
Journal of Pediatric Surgery (2012) 47, 253–257
www.elsevier.com/locate/jpedsurg
Operative techniques
Gastroportal shunt for portal hypertension in children Jin-Shan Zhang a , Long Li a,⁎, Shu-Li Liu a , Wei Cheng b,⁎, Mei Diao a , Wen-Ying Hou a , Jun Zhang a , Sheng-Li Li a , Yao Liu a , Hai-Bin Wang a , An-Xiao Ming a a
Department of Pediatric Surgery, Capital institute of Pediatrics, Beijing 100020, China Department of Paediatric Surgery, Monash Children's, Southern Health, Department of Paediatrics and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria 3168, Australia b
Received 7 May 2011; revised 13 September 2011; accepted 28 September 2011
Key words: Gastroportal shunt; Rex shunt; Extrahepatic portal hypertension; Children
Abstract Purpose: Extrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension. Methods: The mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months). Results: The gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding. Conclusions: The gastroportal shunt is an effective treatment of extrahepatic portal hypertension. © 2012 Elsevier Inc. All rights reserved.
⁎ Corresponding authors. Long Li, is to be contacted at Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing 100020, China. Tel.: +86 10 85695669; fax: +86 10 85628367. Wei Cheng, MD, Department of Paediatric Surgery, Monash Children's, Southern Health, Departments of Paediatrics and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia. Tel.: +61 3 9594 5674; fax: +61 3 9594 6495. E-mail addresses: [email protected] (L. Li), [email protected] (W. Cheng). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.09.058
Extrahepatic portal venous obstruction (EHPVO) is the most common cause of portal hypertension in children. Studies have shown that EHPVO accounts for 66% to 76.5% of all children with portal hypertension [1,2]. Currently, the treatment options for extrahepatic portal hypertension include portal-systemic bypass and mesoportal bypass (Rex shunt). The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension, thereby
254 eliminating the risk of variceal hemorrhage and restoring normal anatomy and physiology of portal system [3]. Conventional Rex shunt uses internal jugular vein as a bypass vein. Inevitably, such a procedure would require neck dissection and lead to impedance of venous drainage. In the current study, we report our result of gastroportal shunt as a viable option of treating children with EHPVO.
1. Materials and methods Between October 2008 and November 2010, 8 patients (6 boys and 2 girls) with extrahepatic portal hypertension were treated in the Department of Pediatric Surgery, Capital Institute of Pediatrics. The mean age was 66.6 months at the time of operation (range, 25-144 months). Of these 8 patients, 7 had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism.
1.1. Operative technique The same surgeon carried out all the surgeries on these children. Selective mesenteric angiography was first performed to map out both extra- and intrahepatic portal vessels (Fig. 1A). The umbilical vein was recanalized. A catheter was inserted for direct portography to evaluate the anatomy of the intrahepatic portal system (Fig. 2). The surgical technique involved dissection of the falciform ligament toward the distal part of the left portal vein, exposure of left-sided branches of the portal vein, and placement of a lateral clamp on this part of the portal vein. The left gastric vein was dissected up to the esophageal hiatus and was ligated at the level of the esophageal hiatus. Then, the vascular anastomosis was performed between the proximal end of the left gastric vein and the left portal vein using 6/0 Prolene suture (Figs. 3A and B and Fig. 4). In 1 patient, the left gastric vein was too short and had to be
J.-S. Zhang et al. lengthened by a venous graft (the inferior mesenteric vein) (Fig. 3C). After anastomosis, the patients underwent intraoperative portal venous angiography to confirm its patency (Fig. 1B), and the pressure of portal vein was then measured.
1.2. Follow-up The patients were followed up for 3 to 20 months (median, 9 months). During the follow-up, spleen size and the shunt patency were assessed by Doppler ultrasound. Routine blood and blood biochemistry tests were carried out.
1.3. Statistical analysis Data (the mean ± SD) were analyzed using pairedsamples t test. Statistical analysis was carried out using the SPSS 13.0 (SPSS Inc, Chicago, IL) software program package. Results were considered statistically significant when P value was less than.05.
2. Results The gastroportal shunt was performed successfully in all patients. The median operative time was 265 minutes (range, 205-360 minutes). The intraoperative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). The diameter of the left gastric vein ranged from 0.5 to 1.4 cm (median, 0.7 cm); the length of the left gastric vein ranged from 2.5 to 6.5 cm (median, 6.0 cm). The portal venous angiography demonstrated the patency of the shunt in all patients. The portal venous pressure in 8 patients decreased from a mean of 36.8 cm H2O preoperatively to a mean of 26.4 cm H2O postoperatively. The left portal venous pressure increased from a mean of 8.3 cm H2O preoperatively to a
Fig. 1 Venous phase of a selective superior mesenteric angiogram in a patient with extrahepatic portal hypertension. Preshunt (A) and postshunt (B).
Gastroportal shunt for portal hypertension in children
255
Fig. 2 A, The portography by inserting a catheter into the recanalized umbilical vein. B, The intrahepatic angiogram before shunting, which showed the stenosis at the origin of left portal vein.
mean of 28.7 cm H2O postoperatively. Postoperatively, routine blood results normalized (Table 1). During follow-up, Doppler ultrasonography was performed regularly to confirm the shunt patency, demonstrate then, blood flow inside the shunt, and measure the spleen size. Postoperatively, the size of spleen reduced significantly. The length of spleen decreased from 12.8 ± 1.2 cm preoperatively to 10.9 ± 0.7 cm postoperatively (P = .027). Similarly, the thickness of the spleen decreased from preoperative 5.0 ± 0.7 cm to postoperative 3.9 ± 0.3 cm (P = .022). During the follow-up, values of biochemical parameter were in the reference range in all patients, and there was no recurrence of variceal bleeding. Postoperative ultrasound and computed tomographic scan confirmed shunt patency and satisfactory blood flow in the shunt in each patient (Fig. 5).
3. Discussion In the early 1990s, de Ville et al [4] reported using mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplantation; he suggested that the bypass was effective in relieving symptoms of
Fig. 3
extrahepatic portal hypertension by restoring a normal hepatic portal venous flow [5]. In due course, the Rex shunt, using inferior mesenteric, splenic, and large pancreaticoduodenal vein as the extrahepatic vessel, evolved [6-8]. All these procedures need a vein graft to establish communication between the extraportal vessel (mesenteric, splenic, and large pancreaticoduodenal vein) and left portal vein. A common autologous graft source for the bypass is the internal jugular vein. Incidences of patients developing symptoms of pseudotumor cerebri after extraction of the right internal jugular vein have been reported [9]. In addition, to harvest the internal jugular vein, surgeons had to carry out neck dissection. We have proposed a new technique for the treatment of extrahepatic portal hypertension, in which the left gastric vein was used as the extrahepatic vessel and was anastomosed to left portal vein directly. This technique is a modification of the conventional Rex shunt, which reduced the number of vascular anastomosis and avoided neck dissection. During operation, the left gastric vein was dissected up to the esophageal hiatus and was ligated at the level of the esophageal hiatus. This further reduces the risk of variceal bleeding. In our series, no further
The procedure of gastroportal shunt. Preshunt (A), postshunt (B), and left gastric vein lengthened by a graft vein (C).
256
Fig. 4
J.-S. Zhang et al.
The left gastric vein was anastomosed to the left portal vein.
esophageal variceal bleeding was encountered postoperatively in any patient. In our study, the portal venous pressure recorded in 8 patients decreased from a mean of 36.8 cm H2O preoperatively to a mean of 26.4 cm H2O postoperatively. This indicated that the symptom of portal hypertension was effectively relieved by the gastroportal shunt. The left portal venous pressure increased from a mean of 8.3 cm H2O preoperatively to a mean of 28.7 cm H2O postoperatively. This finding suggested the patency of the shunt and restoration of intrahepatic portal vein perfusion. Postoperatively, the routine blood tests returned to the reference range in all patients. This further suggests that symptoms of hypersplenism were relieved by the shunt. In addition, the size of spleen after operation was significantly reduced as compared with its preoperative size. This change signifies that splenomegaly was partially reversed. All these findings indicate that the gastroportal shunt can restore intrahepatic portal vein perfusion, relieve extrahepatic portal hypertension, and relieve symptoms of hypersplenism, and therefore,
Table 1
Fig. 5 The 15-month postoperative computed tomographic scan in the same patient as in Fig. 1.
it can be adopted as successful treatment of extrahepatic portal hypertension in children. A precondition for the Rex shunt is that an occlusionfree vein be used as the bypass with the presence of a detectable flow in the left, nonoccluded central portal vein. In our study, all patients underwent preoperative and postoperative portal venous angiography to assess patency of the portal veins. The postoperative angiography and ultrasound confirmed patency of the shunt and the improved intrahepatic portal perfusion in each patient, indicating that the gastroportal shunt was successful as a treatment of extrahepatic portal hypertension. What are the preconditions for a successful operation? Besides the surgical indications for extrahepatic portal hypertension [10], the diameter of the left gastric vein must be adequate in size; otherwise the shunt cannot relieve portal hypertension effectively. Kim et al [11] had used a gonadal vein as a venous graft in a mesogonadal shunt for the treatment of extrahepatic portal hypertension and
Preoperative and postoperative blood cell count of the patients PLT (×10 9/L)
Patients no.
Follow-up (mo)
Pre
1 2 3 4 5 6 7 8 Mean
20 16 13 11 7 5 3 3 9.8
170 61 157 87 171 100 78 175 124.9
RBC (×10 12/L)
WBC (×10 9/L)
HGB (g/L)
Post
Pre
Post
Pre
Post
Pre
Post
255 105 100 145 499 210 142 188 205.5
3.94 4.6 4.19 4.96 3.19 2.73 3.89 4.22 3.97
4.44 5.19 4.93 5.5 4.12 4.63 4.18 5.25 4.78
8.38 5.1 3.95 3.94 8.25 2.53 2.69 7.65 5.31
11.09 4.56 4.42 5.76 11.72 4.3 6.9 6.85 6.95
78 115 102 105 93 69 90 109 95.1
124 128 113 129 110 107 109 121 117.6
PLT indicates platelet; RBC, red blood cell; WBC, white blood cell; HGB, hemoglobin.
Gastroportal shunt for portal hypertension in children suggested that the gonadal vein, which was more than or equal to 5 mm, was sufficient. In our study, we ensured that the diameter of the left gastric vein was no less than 5 mm, which is essential to ensure adequate intrahepatic portal vein perfusion. In the current study, the length of left gastric vein was between 6 and 8 cm, which allowed tension-free anastomosis in most situations. In case of inadequate length, it can be lengthened by venous graft. In 1 patient, the left gastric vein was not long enough to be anastomosed to the left portal vein and had to be lengthened by a venous graft (the inferior mesenteric vein). However, the left gastric vein may meet the requirement of gastroportal shunt in some patients, whereas Rex shunts may be used in others. Further studies are needed to observe the effect of gastroportal shunt because of the small sample size and short follow-up duration in this study.
4. Conclusion The gastroportal shunt is an effective treatment of extrahepatic portal hypertension. Our results suggested that this procedure has the following advantages: (1) restores intrahepatic portal vein perfusion, (2) minimizes upper gastrointestinal bleeding, (3) relieves extrahepatic portal hypertension, (4) relieves symptoms of hypersplenism, and (5) reduces the number of vascular anastomosis and neck dissection.
257
References [1] Arora NK, Lodha R, Gulati S, et al. Portal hypertension in north Indian children. Indian J Pediatr 1998;65(4):85-91. [2] Simon EG, Joseph AJ, George B, et al. Aetiology of paediatric portal hypertension-experience of a tertiary care centre in south India. Trop Doct 2009;39(1):42-4. [3] Razumovskii ALU, Rachkov VE, Feoktistova EV, et al. Portal hypertension at children: current aspects of portal-systemic bypass. Khirurgiia(Mosk) 2007;9:41-5. [4] De Ville de Goyet J, Clapuyt P, Otte JB. Extrahilar mesentericoleft portal shunt to relieve extrahepatic portal hypertension after partial liver transplant. Transplantation 1992;53:231-2. [5] De Ville de Goyet J, Alberti D, Falchetti D, et al. Treatment of extrahepatic portal hypertension in children by mesenteric-to-left portal vein bypass: a new physiological procedure. Eur J Surg 1999; 165:777-81. [6] Ates O, Hakguder G, Olguner M, et al. Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus. J Pediatr Surg 2003;38(10):E10-1. [7] Chen VT, Wei J, Lin VC. A new procedure for management of extrahepatic portal obstruction. Proximal splenic-left intrahepaic portal shunt. Arch Surg 1992;127:1358-60. [8] Gauthier F. Recent concepts regarding extra-hepatic portal hypertension. Semin Pediatr Surg 2005;14:216-25. [9] Fuchs J, Warmann S, Kardorff R, et al. Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach. J Pediatr Gastroenterol Nutr 2003;36: 213-6. [10] Superina R, Shneider B, Emre S, et al. Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant 2006;10(8):908-13. [11] Kim HB, Pomposelli JJ, Lillehei CW, et al. Mesogonadal shunts for extrahepatic portal vein thrombosis and variceal hemorrhage. Liver Transpl 2005;11(11):1389-94.
www.elsevier.com/locate/jpedsurg
Operative techniques
Gastroportal shunt for portal hypertension in children Jin-Shan Zhang a , Long Li a,⁎, Shu-Li Liu a , Wei Cheng b,⁎, Mei Diao a , Wen-Ying Hou a , Jun Zhang a , Sheng-Li Li a , Yao Liu a , Hai-Bin Wang a , An-Xiao Ming a a
Department of Pediatric Surgery, Capital institute of Pediatrics, Beijing 100020, China Department of Paediatric Surgery, Monash Children's, Southern Health, Department of Paediatrics and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria 3168, Australia b
Received 7 May 2011; revised 13 September 2011; accepted 28 September 2011
Key words: Gastroportal shunt; Rex shunt; Extrahepatic portal hypertension; Children
Abstract Purpose: Extrahepatic portal venous obstruction is the most common cause of portal hypertension in children. The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension. In the conventional Rex shunt, the internal jugular vein is used as a venous graft. Inevitably, such a procedure requires neck exploration and sacrifice of internal jugular vein. The authors describe a novel adaptation of gastroportal shunt, successfully carried out in 8 children with extrahepatic portal hypertension. Methods: The mean age of the 8 patients (6 boys and 2 girls) was 66.6 months at the time of operation. All children had portal hypertension. Seven had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism. Gastroportal shunt was performed in all patients. The left gastric vein was mobilized and anastomosed to left portal vein. In 1 patient, the left gastric vein was not of adequate length and required a venous graft (the inferior mesenteric vein). All patients were followed up for 3 to 20 months (median, 9 months). Results: The gastroportal shunt was successfully performed in all patients. The median operative time was 265 minutes (range, 205-360 minutes). Operative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). Intraoperative portal venous angiography demonstrated the patency of the shunt in all patients. Postoperatively, the complete blood count normalized, and the biochemistry tests were within reference range. Postoperative ultrasound confirmed shunt patency and satisfactory flow in the gastroportal shunt in each patient. The size of spleen decreased. There was no recurrence of variceal bleeding. Conclusions: The gastroportal shunt is an effective treatment of extrahepatic portal hypertension. © 2012 Elsevier Inc. All rights reserved.
⁎ Corresponding authors. Long Li, is to be contacted at Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing 100020, China. Tel.: +86 10 85695669; fax: +86 10 85628367. Wei Cheng, MD, Department of Paediatric Surgery, Monash Children's, Southern Health, Departments of Paediatrics and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia. Tel.: +61 3 9594 5674; fax: +61 3 9594 6495. E-mail addresses: [email protected] (L. Li), [email protected] (W. Cheng). 0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.09.058
Extrahepatic portal venous obstruction (EHPVO) is the most common cause of portal hypertension in children. Studies have shown that EHPVO accounts for 66% to 76.5% of all children with portal hypertension [1,2]. Currently, the treatment options for extrahepatic portal hypertension include portal-systemic bypass and mesoportal bypass (Rex shunt). The Rex shunt has been used successfully to treat patients with extrahepatic portal hypertension, thereby
254 eliminating the risk of variceal hemorrhage and restoring normal anatomy and physiology of portal system [3]. Conventional Rex shunt uses internal jugular vein as a bypass vein. Inevitably, such a procedure would require neck dissection and lead to impedance of venous drainage. In the current study, we report our result of gastroportal shunt as a viable option of treating children with EHPVO.
1. Materials and methods Between October 2008 and November 2010, 8 patients (6 boys and 2 girls) with extrahepatic portal hypertension were treated in the Department of Pediatric Surgery, Capital Institute of Pediatrics. The mean age was 66.6 months at the time of operation (range, 25-144 months). Of these 8 patients, 7 had a history of upper gastrointestinal bleeding, and 4 had splenomegaly and hypersplenism.
1.1. Operative technique The same surgeon carried out all the surgeries on these children. Selective mesenteric angiography was first performed to map out both extra- and intrahepatic portal vessels (Fig. 1A). The umbilical vein was recanalized. A catheter was inserted for direct portography to evaluate the anatomy of the intrahepatic portal system (Fig. 2). The surgical technique involved dissection of the falciform ligament toward the distal part of the left portal vein, exposure of left-sided branches of the portal vein, and placement of a lateral clamp on this part of the portal vein. The left gastric vein was dissected up to the esophageal hiatus and was ligated at the level of the esophageal hiatus. Then, the vascular anastomosis was performed between the proximal end of the left gastric vein and the left portal vein using 6/0 Prolene suture (Figs. 3A and B and Fig. 4). In 1 patient, the left gastric vein was too short and had to be
J.-S. Zhang et al. lengthened by a venous graft (the inferior mesenteric vein) (Fig. 3C). After anastomosis, the patients underwent intraoperative portal venous angiography to confirm its patency (Fig. 1B), and the pressure of portal vein was then measured.
1.2. Follow-up The patients were followed up for 3 to 20 months (median, 9 months). During the follow-up, spleen size and the shunt patency were assessed by Doppler ultrasound. Routine blood and blood biochemistry tests were carried out.
1.3. Statistical analysis Data (the mean ± SD) were analyzed using pairedsamples t test. Statistical analysis was carried out using the SPSS 13.0 (SPSS Inc, Chicago, IL) software program package. Results were considered statistically significant when P value was less than.05.
2. Results The gastroportal shunt was performed successfully in all patients. The median operative time was 265 minutes (range, 205-360 minutes). The intraoperative blood loss was 21 ± 7.4 mL, and the length of hospital stay varied from 9 to 19 days (median, 15 days). The diameter of the left gastric vein ranged from 0.5 to 1.4 cm (median, 0.7 cm); the length of the left gastric vein ranged from 2.5 to 6.5 cm (median, 6.0 cm). The portal venous angiography demonstrated the patency of the shunt in all patients. The portal venous pressure in 8 patients decreased from a mean of 36.8 cm H2O preoperatively to a mean of 26.4 cm H2O postoperatively. The left portal venous pressure increased from a mean of 8.3 cm H2O preoperatively to a
Fig. 1 Venous phase of a selective superior mesenteric angiogram in a patient with extrahepatic portal hypertension. Preshunt (A) and postshunt (B).
Gastroportal shunt for portal hypertension in children
255
Fig. 2 A, The portography by inserting a catheter into the recanalized umbilical vein. B, The intrahepatic angiogram before shunting, which showed the stenosis at the origin of left portal vein.
mean of 28.7 cm H2O postoperatively. Postoperatively, routine blood results normalized (Table 1). During follow-up, Doppler ultrasonography was performed regularly to confirm the shunt patency, demonstrate then, blood flow inside the shunt, and measure the spleen size. Postoperatively, the size of spleen reduced significantly. The length of spleen decreased from 12.8 ± 1.2 cm preoperatively to 10.9 ± 0.7 cm postoperatively (P = .027). Similarly, the thickness of the spleen decreased from preoperative 5.0 ± 0.7 cm to postoperative 3.9 ± 0.3 cm (P = .022). During the follow-up, values of biochemical parameter were in the reference range in all patients, and there was no recurrence of variceal bleeding. Postoperative ultrasound and computed tomographic scan confirmed shunt patency and satisfactory blood flow in the shunt in each patient (Fig. 5).
3. Discussion In the early 1990s, de Ville et al [4] reported using mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplantation; he suggested that the bypass was effective in relieving symptoms of
Fig. 3
extrahepatic portal hypertension by restoring a normal hepatic portal venous flow [5]. In due course, the Rex shunt, using inferior mesenteric, splenic, and large pancreaticoduodenal vein as the extrahepatic vessel, evolved [6-8]. All these procedures need a vein graft to establish communication between the extraportal vessel (mesenteric, splenic, and large pancreaticoduodenal vein) and left portal vein. A common autologous graft source for the bypass is the internal jugular vein. Incidences of patients developing symptoms of pseudotumor cerebri after extraction of the right internal jugular vein have been reported [9]. In addition, to harvest the internal jugular vein, surgeons had to carry out neck dissection. We have proposed a new technique for the treatment of extrahepatic portal hypertension, in which the left gastric vein was used as the extrahepatic vessel and was anastomosed to left portal vein directly. This technique is a modification of the conventional Rex shunt, which reduced the number of vascular anastomosis and avoided neck dissection. During operation, the left gastric vein was dissected up to the esophageal hiatus and was ligated at the level of the esophageal hiatus. This further reduces the risk of variceal bleeding. In our series, no further
The procedure of gastroportal shunt. Preshunt (A), postshunt (B), and left gastric vein lengthened by a graft vein (C).
256
Fig. 4
J.-S. Zhang et al.
The left gastric vein was anastomosed to the left portal vein.
esophageal variceal bleeding was encountered postoperatively in any patient. In our study, the portal venous pressure recorded in 8 patients decreased from a mean of 36.8 cm H2O preoperatively to a mean of 26.4 cm H2O postoperatively. This indicated that the symptom of portal hypertension was effectively relieved by the gastroportal shunt. The left portal venous pressure increased from a mean of 8.3 cm H2O preoperatively to a mean of 28.7 cm H2O postoperatively. This finding suggested the patency of the shunt and restoration of intrahepatic portal vein perfusion. Postoperatively, the routine blood tests returned to the reference range in all patients. This further suggests that symptoms of hypersplenism were relieved by the shunt. In addition, the size of spleen after operation was significantly reduced as compared with its preoperative size. This change signifies that splenomegaly was partially reversed. All these findings indicate that the gastroportal shunt can restore intrahepatic portal vein perfusion, relieve extrahepatic portal hypertension, and relieve symptoms of hypersplenism, and therefore,
Table 1
Fig. 5 The 15-month postoperative computed tomographic scan in the same patient as in Fig. 1.
it can be adopted as successful treatment of extrahepatic portal hypertension in children. A precondition for the Rex shunt is that an occlusionfree vein be used as the bypass with the presence of a detectable flow in the left, nonoccluded central portal vein. In our study, all patients underwent preoperative and postoperative portal venous angiography to assess patency of the portal veins. The postoperative angiography and ultrasound confirmed patency of the shunt and the improved intrahepatic portal perfusion in each patient, indicating that the gastroportal shunt was successful as a treatment of extrahepatic portal hypertension. What are the preconditions for a successful operation? Besides the surgical indications for extrahepatic portal hypertension [10], the diameter of the left gastric vein must be adequate in size; otherwise the shunt cannot relieve portal hypertension effectively. Kim et al [11] had used a gonadal vein as a venous graft in a mesogonadal shunt for the treatment of extrahepatic portal hypertension and
Preoperative and postoperative blood cell count of the patients PLT (×10 9/L)
Patients no.
Follow-up (mo)
Pre
1 2 3 4 5 6 7 8 Mean
20 16 13 11 7 5 3 3 9.8
170 61 157 87 171 100 78 175 124.9
RBC (×10 12/L)
WBC (×10 9/L)
HGB (g/L)
Post
Pre
Post
Pre
Post
Pre
Post
255 105 100 145 499 210 142 188 205.5
3.94 4.6 4.19 4.96 3.19 2.73 3.89 4.22 3.97
4.44 5.19 4.93 5.5 4.12 4.63 4.18 5.25 4.78
8.38 5.1 3.95 3.94 8.25 2.53 2.69 7.65 5.31
11.09 4.56 4.42 5.76 11.72 4.3 6.9 6.85 6.95
78 115 102 105 93 69 90 109 95.1
124 128 113 129 110 107 109 121 117.6
PLT indicates platelet; RBC, red blood cell; WBC, white blood cell; HGB, hemoglobin.
Gastroportal shunt for portal hypertension in children suggested that the gonadal vein, which was more than or equal to 5 mm, was sufficient. In our study, we ensured that the diameter of the left gastric vein was no less than 5 mm, which is essential to ensure adequate intrahepatic portal vein perfusion. In the current study, the length of left gastric vein was between 6 and 8 cm, which allowed tension-free anastomosis in most situations. In case of inadequate length, it can be lengthened by venous graft. In 1 patient, the left gastric vein was not long enough to be anastomosed to the left portal vein and had to be lengthened by a venous graft (the inferior mesenteric vein). However, the left gastric vein may meet the requirement of gastroportal shunt in some patients, whereas Rex shunts may be used in others. Further studies are needed to observe the effect of gastroportal shunt because of the small sample size and short follow-up duration in this study.
4. Conclusion The gastroportal shunt is an effective treatment of extrahepatic portal hypertension. Our results suggested that this procedure has the following advantages: (1) restores intrahepatic portal vein perfusion, (2) minimizes upper gastrointestinal bleeding, (3) relieves extrahepatic portal hypertension, (4) relieves symptoms of hypersplenism, and (5) reduces the number of vascular anastomosis and neck dissection.
257
References [1] Arora NK, Lodha R, Gulati S, et al. Portal hypertension in north Indian children. Indian J Pediatr 1998;65(4):85-91. [2] Simon EG, Joseph AJ, George B, et al. Aetiology of paediatric portal hypertension-experience of a tertiary care centre in south India. Trop Doct 2009;39(1):42-4. [3] Razumovskii ALU, Rachkov VE, Feoktistova EV, et al. Portal hypertension at children: current aspects of portal-systemic bypass. Khirurgiia(Mosk) 2007;9:41-5. [4] De Ville de Goyet J, Clapuyt P, Otte JB. Extrahilar mesentericoleft portal shunt to relieve extrahepatic portal hypertension after partial liver transplant. Transplantation 1992;53:231-2. [5] De Ville de Goyet J, Alberti D, Falchetti D, et al. Treatment of extrahepatic portal hypertension in children by mesenteric-to-left portal vein bypass: a new physiological procedure. Eur J Surg 1999; 165:777-81. [6] Ates O, Hakguder G, Olguner M, et al. Extrahepatic portal hypertension treated by anastomosing inferior mesenteric vein to left portal vein at Rex recessus. J Pediatr Surg 2003;38(10):E10-1. [7] Chen VT, Wei J, Lin VC. A new procedure for management of extrahepatic portal obstruction. Proximal splenic-left intrahepaic portal shunt. Arch Surg 1992;127:1358-60. [8] Gauthier F. Recent concepts regarding extra-hepatic portal hypertension. Semin Pediatr Surg 2005;14:216-25. [9] Fuchs J, Warmann S, Kardorff R, et al. Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach. J Pediatr Gastroenterol Nutr 2003;36: 213-6. [10] Superina R, Shneider B, Emre S, et al. Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant 2006;10(8):908-13. [11] Kim HB, Pomposelli JJ, Lillehei CW, et al. Mesogonadal shunts for extrahepatic portal vein thrombosis and variceal hemorrhage. Liver Transpl 2005;11(11):1389-94.