title: Spleno-adrenal shunt: a novel alternative for portosystemic decompression in children with portal vein cavernous transformation.
abstract: OBJECTIVE
  Children with portal vein cavernous transformation (PVCT) can develop life-threatening variceal hemorrhage from progressive portal hypertension. While spleno-renal shunt ± splenectomy is the most common portosystemic decompression surgery performed in children, we have adopted a modified spleno-adrenal (SA) shunt for complicated PVCT. We describe our 10 year experience focusing on technique evolution and treatment efficacy.
  
  
  METHODS
  Between 2001 and 2011, 15 children (9 girls and 6 boys, ages 3-11 years, median: 6 years) with PVCT, portal hypertension, and hypersplenism were treated with SA shunt with splenectomy in Shanghai Children's Medical Center. All children in the study had endoscopy proven active esophageal variceal bleeding requiring multiple transfusions (mean: 4.2 units) with failed sclerotherapy (mean: 2.6 times). Greater omental vein pressure (GVP) approximating portal venous pressure was measured pre- and post-SA shunt. Pre- and post-operative ammonia levels were obtained. Follow-up ranged from 6 months to 10 years (mean: 4.2 ± 2 years).
  
  
  RESULTS
  Intra-operative adrenal vein diameter and length ranged from 0.7 to 1.8 cm and 2 to 3 cm, respectively. Intra-operative GVPs pre-and post-SA shunt were (30 ± 11) and (22 ± 7) mmHg, respectively (p<0.01). On follow-up, there have been no recurrences of GI bleeding. Liver function tests remained normal in all children with the exception of elevated post-operative mean blood ammonia levels [Pre (18 ± 7) mmol/L, post (60 ± 17) mmol/L (p<0.05)] in all children. Ammonia levels normalized in all cases on outpatient follow-up. There have been no cases of hepatic encephalopathy, and all have normal age appropriate neurodevelopment (Bayley's assessment). Barium swallow and/or upper endoscopy showed interval resolution of esophageal varices in all children, and vascular ultrasound showed patent shunt anastomosis without stricture in 14 (93%).
  
  
  CONCLUSIONS
  The left adrenal vein is a viable conduit for effective selective portosystemic decompression. Similar to the more traditional spleno-renal shunt, SA appears also to have the advantage of preventing hepatic encephalopathy preserving neurodevelopment, although the rise in post-operative ammonia levels was unexpected. Longer follow-up is needed to look for late signs of encephalopathy assessing neurodevelopment long term.
authors.affiliation: Shanghai Children's Medical Center, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. gusong@shsmu.edu.cn
authors.forename: Song
authors.initials: S
authors.lastname: Gu
authors.forename: Shirong
authors.initials: S
authors.lastname: Chang
authors.forename: Jun
authors.initials: J
authors.lastname: Chu
authors.forename: Min
authors.initials: M
authors.lastname: Xu
authors.forename: Zhilong
authors.initials: Z
authors.lastname: Yan
authors.forename: Donald C
authors.initials: DC
authors.lastname: Liu
authors.forename: Qimin
authors.initials: Q
authors.lastname: Chen
mesh_terms: D000311:Adrenal Glands / Q000098:blood supply / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D019299:Decompression, Surgical; D004932:Esophageal and Gastric Varices / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006971:Hypersplenism / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006975:Hypertension, Portal / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D008297:Male; D011169:Portal Vein / Q000002:abnormalities* / Q000000981:diagnostic imaging / Q000601:surgery*; D011170:Portasystemic Shunt, Surgical / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D013154:Spleen / Q000601:surgery; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler