Portal hypertension (PH) is infrequent in children as compared to adults. Currently, repetitive endoscopic ablation of varices is standard treatment. However, endoscopic facilities are not readily available in resource-limited settings. We reviewed the indications, operative morbidity, mortality, shunt patency and re-bleeding episodes in nine patients (age range 6-16 years, M:F 6:3) who had DSRS for recurrent GI bleeding not responding to endoscopic treatment and hypersplenism. DSRS is a safe and effective treatment alternative in resource limiting setting for preventing bleeding and improving hypersplenism in children with extrahepatic portal hypertension

Nazir, Zafar

Rehman, Zia Ur

English

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eCommons@AKU Department of Surgery Department of Surgery 12-2019 Distal splenorenal shunt (DSRS) in children with extrahepatic portal hypertension Zia Ur Rehman Aga Khan University, ziaur.rehman@aku.edu Zafar Nazir Aga Khan University, zafar.nazir@aku.edu Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg  Part of the Pediatrics Commons, and the Surgery Commons Recommended Citation Rehman, Z., Nazir, Z. (2019). Distal splenorenal shunt (DSRS) in children with extrahepatic portal hypertension. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, 29(12), 1228-1229. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/830 1228 Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (12): 1228-1229Extra-hepatic portal vein obstruction (EHPVO) is thecause in majority of cases of portal hypertension (PH) inchildren. It is usually idiopathic and is also reportedfollowing umbilical vessel catheterisation in infancy orbiliary atresia surgery. Currently, medical and repetitivesclerotherapy is the recommended management ofportal hypertension. However, up to 15% of children mayrequire shunt surgery. Shunt surgery offers one-timesolution to recurrent GI bleeding and hypersplenism.1However, in pediatric age the procedure is technicallydemanding due to small calibre veins. This studyevaluates indications, morbidity and patency of DSRS inchildren with portal hypertension.After ERC (ethical review committee) approval (2019-0749-2321), medical records of pediatric patients(<18 years) who had DSRS from January 1995 toDecember 2018 at The Aga Khan University Hospital,Karachi (Pakistan) were reviewed for patient demo-graphics, indication of procedure, imaging, laboratoryinvestigations, operative time, morbidity, hospital stay,shunt patency and episodes of recurrent bleeding.Outcomes measures were prevention from repeatbleeding episodes and improvement in platelet counts.Data was analysed in SPSS version 22. Quantitativevariables were reported as means and/or medians.Frequency was reported for categorical variables.Difference in outcome variables were assessed throughpaired t-test.Median age of nine patients was 11 (6-16) years. Mostwere males (6:3). All patients had history of uppergastrointestinal bleeding including 4 (44.4%) patientshaving multiple episodes. Median sclerotherapy sessionsbefore shunt procedures were 2 (0-4). All patients hadnormal liver function tests. The procedures wereperformed under general anaesthesia through trans-verse upper abdominal incision. The splenic vein wasmobilised from its junction with superior mesenteric veinto a length which can easily be brought to the left renalvein to create a tension-free and supple end-to-sideanastomosis. The mean operative time was 263 ±22.2minutes. Routine postoperative monitoring and carewas provided. There were no operative complicationsincluding bleeding, injury to the surrounding structures,wound infection, or encephalopathy. The mean hospitalstay was 8.8 ±1.26 days. Patients were followed threemonthly during first postoperative year and thenannually, both clinically and with ultrasound doppler.Graft was considered patent if it showed flow from portalvenous system to renal vein.Median follow-up was 3 (1-10) years. Mean preoperativeplatelets improved from 57.3 ±22.2 to 94.3 ±34.4 X 109/l(p=0.005) and splenic size decreased from 15.6 ±2.39 to15.03 ±2.46 cm (p=0.692, Table I). Most patients (88.8%)had no GI bleeding episode. One patient had bleeding 6months after the surgery which required a session ofsclerotherapy. Shunts were patent on last follow-upexcept in one patient whose shunt was noted to beSHORT COMMUNICATIONDistal Splenorenal Shunt (DSRS) in Children with Extrahepatic Portal HypertensionZia Ur Rehman1 and Zafar Nazir2Section of Vascular Surgery1 / Pediatric Surgery2, Department of Surgery, The Aga Khan University Hospital (AKUH), Karachi, PakistanABSTRACTPortal hypertension (PH) is infrequent in children as compared to adults. Currently, repetitive endoscopic ablation ofvarices is standard treatment. However, endoscopic facilities are not readily available in resource-limited settings. Wereviewed the indications, operative morbidity, mortality, shunt patency and re-bleeding episodes in nine patients (agerange 6-16 years, M:F 6:3) who had DSRS for recurrent GI bleeding not responding to endoscopic treatment andhypersplenism. DSRS is a safe and effective treatment alternative in resource limiting setting for preventing bleeding andimproving hypersplenism in children with extrahepatic portal hypertension.Key Words: Children, Portal hypertension, Esophageal varices, GI bleeding, Distal splenorenal shunt (DSRS).How to cite this article: Rehman ZU, Nazir Z. Distal splenorenal shunt (DSRS) in children with extrahepatic portal hypertension. J CollPhysicians Surg Pak 2019; 29(12):1228-1229.Correspondence to: Dr. Zia Ur Rehman, Section of VascularSurgery, Department of Surgery, The Aga Khan UniversityHospital, Stadium Road, Karachi-74800, PakistanE-mail: ziaur.rehman@aku.eduReceived: February 28, 2019;   Revised: April 29, 2019;Accepted: May 20, 2019Table I: Comparison of pre- and post-outcome parameters.Variables Preoperative Postoperative p-valueMean ± (SD) Mean ± (SD)Bleeding episodes 9 (100%) 1 (11.1%) <0.001Platelets count (x 109 / l) 57.4 ±22.2 94.4 ±34.4 0.005Spleen size (cm) 15.6 ±2.4 15.1 ±2.5 0.692Distal splenorenal shunt (DSRS) in children with extrahepatic portal hypertensionblocked at 6-month follow-up. She had protein C and Sdeficiency and had small calibre vein (4 mm) anddissection was difficult due to the previous episode ofpancreatitis. Another patient required splenectomy, twoyears after the procedure for persistent hypersplenism(low platelets and increasing transfusion requirements tomaintain hemoglobin levels).EHPVO (extra-hepatic portal vein obstruction) is usuallythe cause of portal hypertension in children and itmanifests with hematemesis and hypersplenism. Mostpatients are treated with repeated sclerotherapy andpharmacotherapy such as propranolol. In cases, whichare refractory to endoscopic treatment, DSRS is apreferable alternative as it provides efficient and long-lasting decompression of the portal venous system. Thereported cases of children managed with DSRS illustratethat it is effective in preventing recurrent bleeding andresolution of hypersplenism; and can safely be offered ina developing country where access to medical care issuboptimal. However, we observed that shunt surgeryshould not be offered in children with previous history ofsevere pancreatitis or hypercoagulable state.There are several misconceptions about shunt surgeryin pediatric age group, e.g. high failure rates in childrenunder 10 years, particularly those whose veins are lessthan 10 mm in diameter. The other is that bleedingepisodes in such children should be managedconservatively until they grow out of the disease bydevelopment of collateral circulation. There is no long-term data to support these impressions.2Many studies have demonstrated that shunts cansuccessfully be offered to children of any age withminimal morbidity as success rate around 90%, as isreported in different series.3 Orloff et al. have reported97% patency and thrombosis in less than 5% ofpatients.4 Similarly, Laurtz et al. reported remarkableoutcome in terms of prevention of recurrent GIbleeding.5 Recently, Paloma et al. and Patel et al. haveshown effectiveness of DSRS in children.1,6 Moreover,shunts are cost-effective, psychologically less traumaticthan the repeated endoscopic procedures, and favournormal physical growth in children.In conclusion, though this is a retrospective study from asingle centre with a small number of patients, itdemonstrates that shunt surgery is safe and reliablealternative to repeated endoscopic procedures; forprevention of bleeding and to improve hypersplenism inchildren with extrahepatic portal hypertension.AUTHORS’ CONTRIBUTION:ZUR: Study concept, data collection, writing, critical reviewand revision; final approval of the article and account-ability of all aspects of the article.ZN: Study concept, critical review and revision; finalapproval of the article and accountability of all aspects ofthe article. CONFLICT OF INTEREST:Authors declared no conflict of interest.REFERENCES1. Triana Junco P, Alvarez A, Dore M, Jimenez Gomez J,Sánchez Galán A, Vilanova-Sánchez A, et al. Long-termresults after diversion surgery in extrahepatic portal veinobstruction. Eur J Pediatr Surg 2019; 29:23-7.2. Sharma N, Bajpal M, Kumar A, Paul S, Jana M. Portalhypertension: A critical appraisal of shunt procedures withemphasis on distal splenorenal shunt in children. J IndianAssoc Pediatr Surg 2014; 19:80-4.3. Shneider BL, de Ville de Goyet J, Leung DH, Srivastava A,Ling SC, Duché M, et al. Primary prophylaxis of varicealbleeding in children and the role of MesoRex Bypass:summary of the Baveno VI Pediatric stalellite symposium.Hepatology 2016; 63:1368-80.4. Orloff MJ, Orloff MS, Rambotti M. Treatment of bleedingesophagogastric varices due to extrahepatic portal hyper-tension: Results of portal-systemic shunts during 35 years.J Pediatr Surg 1994; 29:142-51.5. Lautz TB, Keys LA, Melvin JC, Ito J, Superina RA. Advantagesof the meso-Rex bypass compared with portosystemic shuntsin the management of extrahepatic portal vein obstruction inchildren. J Am Coll Surg 2013; 21:83-9.6. Patel N, Grieve A, Hiddema J, Botha J, Loveland J. Surgery forportal hypertension in children: A 12-year review. S Afr Med J2017; 107:S12-5.Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (12): 1228-1229 1229

Distal splenorenal shunt (DSRS) in children with extrahepatic portal hypertension

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Distal splenorenal shunt (DSRS) in children with extrahepatic portal hypertension

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