Portosystemic shunts in children: a 15-year experience.
BACKGROUND
The role of portosystemic shunt (PSS) in children with portal hypertension has changed because of acceptance of liver transplantation and endoscopic hemostasis. We report our experience with PSS, mainly the distal splenorenal shunt, to define its role in the management of variceal bleeding.


METHODS
From 1987 to 2002, 20 children with variceal bleeding after endoscopic therapy underwent PSS. Patient and database records were reviewed.


RESULTS
There were 14 boys and 6 girls; mean age was 11 years (range 3 to 18 years). Seventeen distal splenorenal and three mesocaval venous interposition shunts were performed. There was no operative mortality, 19 patients were alive at a median followup of 31 months (range 4 to 168 months) without evidence of recurrent gastrointestinal bleeding. One patient underwent transplantation 2 years after PSS and 1 patient died of hepatic failure while awaiting transplantation. The cause of portal hypertension was portal vein thrombosis (n = 13), biliary atresia (n = 3), congenital hepatic fibrosis (n = 2), hepatitis C cirrhosis (n = 1), and Budd-Chiari syndrome (n = 1). Eighteen children were Child-Turcotte-Pugh class A and the remaining two were class B. One patient had two episodes of hematemesis after PSS. Two patients had worsening ascites. One patient had mild encephalopathy and one patient had shunt stenosis requiring angioplasty.


CONCLUSIONS
PSS is a safe and durable therapy for pediatric patients with portal hypertension. Liver transplantation should be reserved for children with poor synthetic function associated with variceal bleeding. PSS may also serve as a bridge to transplantation in patients with preserved hepatic function. PSS, in particular the distal splenorenal shunt, has produced excellent results. This experience challenges the need for alternative forms of portal decompression.
Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA.
Jean F
JF
Botha
B Daniel
BD
Campos
Wendy J
WJ
Grant
Simon P
SP
Horslen
Debra L
DL
Sudan
Byers W
BW
Shaw
Alan N
AN
Langnas
D000293:Adolescent; D001656:Biliary Atresia / Q000150:complications; D006502:Budd-Chiari Syndrome / Q000150:complications; D002648:Child; D004932:Esophageal and Gastric Varices / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000601:surgery*; D019698:Hepatitis C, Chronic / Q000150:complications; D006801:Humans; D006975:Hypertension, Portal / Q000209:etiology / Q000601:surgery*; D008103:Liver Cirrhosis / Q000150:complications; D016031:Liver Transplantation; D008297:Male; D011169:Portal Vein; D011170:Portasystemic Shunt, Surgical / Q000379:methods; D011183:Postoperative Complications; D013164:Splenorenal Shunt, Surgical; D013927:Thrombosis / Q000150:complications