A. R. Cortez1,2, A. Kassam1,2, C. J. Nathan2, T. M. Jenkins2, J. D. Nathan1,2, M. H. Alonso1,2, G. M. Tiao1,2, A. J. Bondoc1,2 1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2Cincinnati Children’s Hospital Medical Center,Division Of Pediatric General And Thoracic Surgery,Cincinnati, OH, USA
Introduction: Creation of a surgical shunt to divert portal blood flow plays a major role in the treatment of medically refractory portal hypertension (pHTN). Similar to the adult population with end-stage liver disease, pediatric patients suffer from intra-hepatic pHTN, but more commonly they experience pre-hepatic pHTN due to extrahepatic portal vein thrombosis (EPVT). Consequently, both portosystemic shunts (PSS) and the meso-Rex bypass (MRB) are potential interventions for these patients. Herein, we set out to evaluate our center’s experience with surgical shunts for the treatment of pediatric pHTN.
Methods: All patients who underwent PSS or MRB at a single institution from 2008-2017 were reviewed. Patient demographics, operative details, and outcomes were collected. Shunt types were compared using Wilcoxon rank-sum test for continuous variables and Fisher's exact test for categorical variables. Intervention-free shunt patency was calculated using Kaplan-Meier survival analysis with differences between groups estimated by a Log-rank test. A p-value <0.05 was considered statistically significant.
Results: 34 patients underwent surgical shunt creation during the 10-year study period. The median age was 7.7 years (IQR 4.3-12.0). 29 patients (85.3%) had pre-hepatic pHTN and 5 patients (14.7%) had intra-hepatic pHTN. The primary manifestations of pHTN among these patients were esophageal varices (97.1%) and gastrointestinal bleeding (76.5%). 18 patients (52.9%) had an MRB, 10 patients (29.4%) had a splenorenal shunt, and 6 patients (17.7%) had a mesocaval shunt. These patients experienced good short- and long-term outcomes including minimal wound complications (3.8%), re-bleeding events (11.8%), and mortality (2.9%). Moreover, there were no differences in postoperative outcomes among the groups (p>0.05 for each). Among all patients, 10 (29.4%) experienced shunt occlusion, 4 of which occurred in the immediate postoperative period and required urgent intervention. Overall, the 1- and 5-year intervention-free shunt patency rates were 75% and 63%, respectively. Although there was no statistically significant difference in shunt patency among the groups (p=0.266), mesocaval shunts appeared to have poorer rates of primary patency (Figure).
Conclusions: Pediatric patients suffer significant morbidity from the sequalae of pHTN. Our experience reinforces the feasibility of surgical shunts as an effective means of treating this disease process with low rates of morbidity and mortality. Moreover, both the PSS and MRB effectively improve patient symptoms with acceptable long-term, intervention-free shunt patency rates.
