A technique for reconstruction of total portosystemic shunts into a selective shunt in children

Abstract

BACKGROUND: Currently, the most effective technique for treating children with portal hypertension is vascular bypass surgery and, for a number of reasons, splenorenal anastomoses (SRA) — which are total portosystemic shunts (PSS) — are predominantly used in practice. However, these shunts can promote the development of some complications: total discharge of the portal blood into the inferior vena cava can also cause some complications such as minimal manifestations of pulmonary arterial hypertension, decreased portal perfusion of the liver (PPP), hyperammonemia, and latent hepatic encephalopathy. An alternative to SRA is distal splenorenal anastomosis (DSRA), which is a selective PSS and which maintains PPL, thus reducing a risk of developing the listed complications. However, in practice, its use is limited due to high frequency of anastomotic thrombosis and ascites/chyloperitoneum at the early postoperative period.

AIM: Prevention of all the above-mentioned complications of artificial PSS continues to be a pressing issue in modern paediatric surgery. However, we have proposed a new curative option — reconstruction of the SRA into a DSRA, which reduced the risk of all mentioned complications, thereby improving the quality of patients’ life.

METHODS: From February 2020 to May 2024, 54 children were operated on with this type of surgery. The goal was to change the direction of the mesenteric venous blood flow (in SRA it is directed towards the anastomosis) towards the liver by clipping/ligating the splenic vein to the right of the anastomosis. All children, before and after the anastomosis reconstruction, underwent a comprehensive examination in full or in part, including a biochemical blood test, magnetic resonance imaging of the brain, echocardiography, ultrasound of the abdominal organs, angiography, esophagogastroduodenoscopy, neuropsychological examination (36 patients were followed-up at late stages after the surgery).

RESULTS: On a comparative findings, improvement of cognitive functions was seen in 60% of children, relief of hyperammonemia — in 71%, relief of signs of manganese salts accumulation of in the central nervous system — in 43%, improvement of hemodynamic parameters according to echocardiography — in 75%, improvement of PPL — in 78%. No patients had anastomotic thrombosis. Ascites/chyloperitoneum was registered only in 5% of cases.

CONCLUSION: The developed surgical technique is a promising one for it prevents/treats complications of artificial PSS, such as pulmonary arterial hypertension, decreased PPL, hepatic encephalopathy, anastomotic thrombosis and ascites.

Keywords

children / portal hypertension / splenorenal anastomoses / anastomotic reconstruction / portal liver perfusion / hyperammonemia / hepatic encephalopathy

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Funding

Российское общество симуляционного обучения в медицинеRussian Society for Simulation Education in Medicine(2412–37/22)

RIGHTS & PERMISSIONS

Margaryan S.R., Razumovsky A.Y., Mitupov Z.B., Chumakova G.Y., Shagina E.D., Baturina A.A., Shkurov F.V., Dudinova A.S., Gincu G.S., Nurik V.I.