Skip to main content

Advertisement

SpringerLink
Log in

Surgery for Portal Hypertension in Children

  • Published:
Current Gastroenterology Reports Aims and scope Submit manuscript

Abstract

Management of children with portal hypertension has evolved considerably over the past decades. Development of physiologic shunts (meso-Rex bypass) and successful liver transplant has changed the paradigm of portal hypertension surgery. Children with pre-hepatic portal hypertension are investigated and, if suitable, candidates are offered the mesenteric-to-left portal vein bypass (meso-Rex) preemptively, before development of symptoms of portal hypertension. Aggressive medical management, endoscopic ligation of bleeding varices, and radiologically placed intrahepatic stents have greatly reduced the need for emergent surgical procedures. A larger number of surgical options offer a permanent solution for children with portal hypertension in the setting of well-compensated liver function. Portal hypertension in the setting of decompensated liver disease is managed medically (via endoscopy) or radiologically (via transjugular intrahepatic portosystemic shunt) with the aim to offer liver transplant as a permanent solution.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Whitington P. Portal hypertension in children. Pediatr Ann. 1985;14:494–9.

    PubMed  CAS  Google Scholar 

  2. Bismuth H, Franco D. Portal diversion for portal hypertension in early childhood. Ann Surg. 1976;183:439–46.

    Article  PubMed  CAS  Google Scholar 

  3. Superina RA, Alonso EM. Medical and surgical management of portal hypertension in children. Curr Treat Options Gastroenterol. 2006;9:432–43.

    Article  PubMed  Google Scholar 

  4. Grace ND, Conn HO, Resnick RH, et al. Distal splenorenal vs portal-systemic shunts after hemorrhage from varices: a randomized controlled trial. Hepatology. 1988;8:1475–81.

    Article  PubMed  CAS  Google Scholar 

  5. Botha JF, Campos BD, Grant WJ, et al. Portosystemic shunts in children: a 15-year experience. J Am Coll Surg. 2004;199:179–85.

    Article  PubMed  Google Scholar 

  6. Shilyansky J, Roberts EA, Superina RA. Distal splenorenal shunts for the treatment of severe thrombocytopenia from portal hypertension in children. J Gastrointest Surg. 1999;3:167–72.

    Article  PubMed  CAS  Google Scholar 

  7. Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967;166:437–55.

    Article  PubMed  CAS  Google Scholar 

  8. Maksoud JG, Gonçalves ME. Treatment of portal hypertension in children. World J Surg. 1994;18:251–8.

    Article  PubMed  CAS  Google Scholar 

  9. Brems JJ, Hiatt JR, Klein AS, et al. Effect of a prior portasystemic shunt on subsequent liver transplantation. Ann Surg. 1989;209:51–6.

    Article  PubMed  CAS  Google Scholar 

  10. Hasegawa T, Tamada H, Fukui Y, et al. Distal splenorenal shunt with splenopancreatic disconnection for portal hypertension in biliary atresia. Pediatr Surg Int. 1999;15:92–6.

    Article  PubMed  CAS  Google Scholar 

  11. Spina GP, Santambrogio R, Opocher E, et al. Early hemodynamic changes following selective distal splenorenal shunt for portal hypertension: comparison of surgical techniques. World J Surg. 1990;14:115–21.

    Article  PubMed  CAS  Google Scholar 

  12. Eizaguirre I, Tovar JA, Orcolaga R, et al. Warren's shunt in the treatment of portal hypertension in children. Cir Pediatr. 1991;4:134–9.

    PubMed  CAS  Google Scholar 

  13. Mitra SK, Mukherjee B, Prasad GR, et al. Extrahepatic portal obstruction in children–experience with side-to-side lienorenal shunt without splenectomy. Indian J Pediatr. 1983;50:55–60.

    Article  PubMed  CAS  Google Scholar 

  14. Mitra SK, Rao KL, Narasimhan KL, et al. Side-to-side lienorenal shunt without splenectomy in noncirrhotic portal hypertension in children. J Pediatr Surg. 1993;28:398–401.

    Article  PubMed  CAS  Google Scholar 

  15. Auvert J. Portal hypertension in children. Long-term results of porto-caval interventions for extra-hepatic blockage. Chir Pédiatr. 1982;23:234–6.

    PubMed  CAS  Google Scholar 

  16. Ahn SS, Yellin A, Sheng FC, et al. Selective surgical therapy of the Budd-Chiari syndrome provides superior survivor rates than conservative medical management. J Vasc Surg. 1987;5:28–37.

    Article  PubMed  CAS  Google Scholar 

  17. Descottes B, Lachachi F, Maisonnette F, et al. Long-term results of mesocaval shunts with polytetrafluoroethylene grafts. Int Surg. 2008;93:268–73.

    PubMed  Google Scholar 

  18. Altman RP. Portal decompression by interposition mesocaval shunt in patients with biliary atresia. J Pediatr Surg. 1976;11:809–14.

    Article  PubMed  CAS  Google Scholar 

  19. Gauthier F, De Dreuzy O, Valayer J, et al. H-type shunt with an autologous venous graft for treatment of portal hypertension in children. J Pediatr Surg. 1989;24:1041–3.

    Article  PubMed  CAS  Google Scholar 

  20. Collins JC, Rypins EB, Sarfeh IJ. Narrow-diameter portacaval shunts for management of variceal bleeding. World J Surg. 1994;18:211–5.

    Article  PubMed  CAS  Google Scholar 

  21. Rypins EB, Sarfeh IJ. Partial portal decompression: two approaches to the management of portal hypertension. Hepatology. 1990;12:370–2.

    Article  PubMed  CAS  Google Scholar 

  22. de Ville de Goyet J, Alberti D, Clapuyt P, et al. Direct bypassing of extrahepatic portal venous obstruction in children: a new technique for combined hepatic portal revascularization and treatment of extrahepatic portal hypertension. J Pediatr Surg. 1998;33:597–601.

    Article  PubMed  Google Scholar 

  23. de Ville de Goyet J, Clapuyt P, Otte JB. Extrahilar mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplant. Transplantation. 1992;53:231–2.

    PubMed  Google Scholar 

  24. de Ville de Goyet J, Alberti D, Falchetti D, et al. Treatment of extrahepatic portal hypertension in children with mesenteric-to-left portal vein bypass: a new physiological procedure. Eur J Surg. 1999;165:777–81.

    Article  PubMed  Google Scholar 

  25. de Ville de Goyet J, Gibbs P, Clapuyt P, et al. Original extrahilar approach for hepatic portal revascularization and relief of extrahepatic portal hypertension related to later portal vein thrombosis after pediatric liver transplantation. Long term results. Transplantation. 1996;62:71–5.

    Article  PubMed  Google Scholar 

  26. Dasgupta R, Roberts E, Superina RA, et al. Effectiveness of Rex shunt in the treatment of portal hypertension. J Pediatr Surg. 2006;41:108–12.

    Article  PubMed  Google Scholar 

  27. Krebs-Schmitt D, Briem-Richter A, Grabhorn E, et al. Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension. Pediatr Transplant. 2009;13:540–4.

    Article  PubMed  CAS  Google Scholar 

  28. • Sharif K, McKiernan P, de Ville de Goyet J, et al.: Mesoportal bypass for extrahepatic portal vein obstruction in children: close to a cure for most! J Pediatr Surg. 2010; 45:272–6. This paper reports an experience of meso-portal bypass showing good results. It highlights the fact that meso-rex with jugular vein has the best result, the spleen decrease in size but returns to normal for age in 30% of children. The return of flow in the cavernoma needs further evaluation.

    Article  PubMed  Google Scholar 

  29. • Superina R, Shneider B, Emre S, et al.: Surgical guidelines for the management of extra-hepatic portal vein obstruction. Pediatr Transplant. 2006; 10:908–13. This fine article gives guidelines for the management of portal hypertension in children.

    Article  PubMed  Google Scholar 

  30. Chiu B, Pillai SB, Sandler AD, et al. Experience with alternate sources of venous inflow in the meso-Rex bypass operation: the coronary and splenic veins. J Pediatr Surg. 2007;42:1199–202.

    Article  PubMed  Google Scholar 

  31. Ateş O, Hakgüder 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:E10–1.

    PubMed  Google Scholar 

  32. Chardot C, Darani A, Dubois R, et al. Modified technique of meso-Rex shunt in case of insufficient length of the jugular vein graft. J Pediatr Surg. 2009;44:e9–12.

    Article  PubMed  Google Scholar 

  33. Chin AC, Thow F, Superina RA. Previous portal hypertension surgery negatively affects results of mesenteric to left portal vein bypass. J Pediatr Surg. 2008;43:114–9.

    Article  PubMed  Google Scholar 

  34. Sugiura M, Futagawa S. A new technique for treating esophageal varices. J Thorac Cardiovasc Surg. 1973;66:677–85.

    PubMed  CAS  Google Scholar 

  35. Sharma D, Agrawal S, Saxena A, et al. A modified technique of devascularization for surgical management of portal hypertension in children. Trop Doct. 2001;31:93–5.

    PubMed  CAS  Google Scholar 

  36. Superina RA, Weber JL, Shandling B. A modified Sugiura operation for bleeding varices in children. J Pediatr Surg. 1983;18:794–9.

    Article  PubMed  CAS  Google Scholar 

  37. Uchiyama M, Iwafuchi M, Ohsawa Y, et al. Long-term results after nonshunt operations for esophageal varices in children. J Pediatr Surg. 1994;29:1429–33.

    Article  PubMed  CAS  Google Scholar 

  38. Abouna GM, Baissony H, Al-Nakib BM, et al. The place of Sugiura operation for portal hypertension and bleeding esophageal varices. Surgery. 1987;101:91–8.

    PubMed  CAS  Google Scholar 

  39. Shah R, Mahour GH, Ford EG, et al. Partial splenic embolization: an effective alternative to splenectomy for hypersplenism. Am Surg. 1990;56:774–7.

    PubMed  CAS  Google Scholar 

  40. Kheradpir MH. Late results of a modified new surgical procedure for the treatment of portal hypertension. Eur J Pediatr Surg. 2007;17:17–22.

    Article  PubMed  CAS  Google Scholar 

Download references

Disclosure

Conflicts of interest: S. Scholz—none; K. Sharif—none.

Author information

Authors and Affiliations

  1. Paediatric HPB Surgery and Transplantation, Liver Unit, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK

    Stefan Scholz & Khalid Sharif

Authors
  1. Stefan Scholz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Khalid Sharif
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Khalid Sharif.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Scholz, S., Sharif, K. Surgery for Portal Hypertension in Children. Curr Gastroenterol Rep 13, 279–285 (2011). https://doi.org/10.1007/s11894-011-0186-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11894-011-0186-8

Keywords

Search

Navigation