Portal venous decompression with H-type mesocaval shunt using autologous vein graft: a North American experience.
OBJECTIVE
Portal hypertension in children often is caused by prehepatic venous obstruction or intrahepatic fibrosis without cirrhosis. This situation is uniquely amenable to shunting; this report details the experience of 3 North American centers with an H-type mesocaval shunt using autologous vein, which has been widely used in European centers.


METHODS
Retrospective chart review was conducted of records from 1980 through 1999 at 3 North American institutions. Charts were reviewed for etiology of portal hypertension, diagnostic workup, preoperative management, operative results and complications, postoperative shunt patency, patient well-being, and eventual need for liver transplantation.


RESULTS
Twenty patients were identified with prehepatic causes of venous obstruction undergoing shunt therapy. Eleven had portal venous thrombosis or cavernous transformation. Of these, 3 had umbilical catheters placed in the neonatal period. Five children had American-Indian cirrhosis, 1 had congenital hepatic fibrosis, and 3 had hepatic fibrosis associated with polycystic kidney disease. Patients presented at a median age of 3.7 years and underwent follow-up for an average of 4.3 years after surgery. These patients had an average of 3.6 bleeding episodes, (with 3.9 attempts at sclerotherapy) and received 3 units of blood preoperatively. Average age at operation was 8 years, average weight was 30 kg, and perioperative blood requirement was 200 mL. In general, patients did well postoperatively; 2 patients required reoperation for lymphatic leaks, and there was 1 death caused by a leaking G-tube, unrelated to shunt functioning. Two patients had transient encephalopathy postoperatively, and 1 patient had severe pancreatitis. All shunts remain patent, with good function and no further bleeding.


CONCLUSIONS
These results are encouraging, and we would suggest that the H-type mesocaval shunt utilizing autologous vein be considered for wider use in pediatric patients with prehepatic cause of portal hypertension. An algorithm for the work-up of pediatric patients with variceal bleeding is presented, with the recommendation that shunt surgery be considered early in patients with a prehepatic or fibrotic causes of portal hypertension.
Sigalet
D L
DL
Alberta Children's Hospital, Calgary, Alberta, and Hopital Sainte-Justine, Montreal, Quebec.
Mayer
S
S
Blanchard
H
H
D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006975:Hypertension, Portal / Q000601:surgery*; D007223:Infant; D007601:Jugular Veins / Q000637:transplantation; D008297:Male; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D012189:Retrospective Studies; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D014654:Vascular Patency