Surgical intervention in children with portal hypertension

Abstract

Over a 5-year period 252 children with bleeding oesophageal varices secondary to portal hypertension were treated by endoscopic injection scletherapy. Surgical treatment was restricted to patients with bleeding complications following sclerotherapy and the occasional problem of symptomatic splenomegaly (2 children). Sclerotherapy failure was due to the development of varices not accessible to sclerotherapy (gastric fundus 7, duodenum 1, jejunum 1, unidentified site in small bowel 1) and to continued bleeding from oesophageal ulcers in 2 children. There were 5 children with Child's grade A cirrhosis. Fifteen children (4.4 % of the total; median age 8.7 years, range 1.5 – 18 years) underwent 16 operations during this period, which included 13 porto-systemic shunts (8 lieno-renal and 5 meso-caval) and 3 oesophageal transections/devascularisations. Sclerotherapy was not attempted in 1 of the 2 children treated for continued bleeding from oesophageal varices. Two lieno-renal shunts thrombosed and 1 of these patients underwent a meso-caval shunt. There were no deaths in this group of patients during a median follow-up of 40 months. One child with biliary atresia has developed a mild intermittent encephalopathy. The use of injection sclerotherapy for bleeding oesophageal varices with surgical intervention limited to patients failing treatment resulted in low morbidity and no mortality in a large group of children with portal hypertension.