The degree of the risk for developing hyperammoniemia after various vascular shunting surgeries in children with portal hypertension

Abstract

BACKGROUND: Hyperammonemia and hepatic encephalopathy (HE) after portosystemic shunt surgeries in children with portal hypertension (PH) is still a pressing problem in modern pediatric surgery.

AIM: To date, there are very few information in the literature on hyperammonemia prevalence after various vascular bypass surgeries in large groups of patients with PH. To study this problem is an important step in making an adequate choice of treatment modality in children with PH regarding the risk of HE development in future.

METHODS: This paper analyzes the results of studies of ammonia content in venous blood in 173 children, of whom 153 had PH (most had undergone vascular bypass surgery).

RESULTS: The analysis performed has shown that the risk of hyperammonemia in non-operated patients with PH is low, but it increases after certain vascular bypass surgeries on the portal system vessels. To the least extent, this applies to the physiological mesoprotal shunt (MPS) and selective distal splenorenal anastomosis (DSRA), and to the greatest extent — to total portosystemic shunts: splenorenal anastomoses (SRA) (side-to-side splenorenal anastomosis, splenosuprarenal anastomoses) and mesocaval shunt (MCS).

CONCLUSION: Our findings have confirm advantages (low risk of hyperammonemia in childhood) of the mesoportal shunt and distal splenorenal anastomosis compared to splenorenal anastomoses and mesocaval H-shunt. At the same time, the study proves the effectiveness of reconstruction of the splenorenal anastomosis into a distal splenorenal anastomosis in reducing the level of ammonia in the blood (this operation was developed at the N.F. Filatov Children's City Clinical Hospital).

Keywords

hyperammonemia / portal hypertension / vascular bypass operations / children / splenorenal anastomoses / anastomotic reconstruction / mesoportal shunt

References

[1] Warren WD, Millikan WJ, Smith RB, et al. Noncirrhotic portal vein thrombosis. Physiology before and after shunts. Ann Surg. 1980;192(3):341–349. doi: 10.1097/00000658-198009000-00009

[2] Zhang HY, Li WB, Ye H, et al. Long-term results of the paraesophagogastric devascularization with or without esophageal transection: Which is more suitable for variceal bleeding? World J Surg. 2014;38(8):2105–2112. EDN: ORQYSP doi: 10.1007/s00268-014-2478-2

[3] Patel N, Grieve A, Hiddema J, et al. Surgery for portal hypertension in children: A 12-year review. South African Med J. 2017;107(10):12132.

[4] Rehman ZU, Nazir Z. Distal Splenorenal Shunt (DSRS) in children with extrahepatic portal hypertension. J College Physicians Surgeons Pakistan. 2019;29(12):1228–1229. doi: 10.29271/jcpsp.2019.12.1228

[5] Mitupov ZB, Razumovsky AY, Rachkov VE, et al. Vascular bypass surgery in the treatment of extrahepatic portal hypertension in children (review). Russ J Pediatric Surg Anesthesia Intensive Care. 2023;13(1):37–52. EDN: NDVVRF doi: 10.17816/

[6] Margaryan SR, Mitupov ZB, Razumovsky AY. Hepatic encephalopathy after portosystemic bypass surgery. N.I. Pirogov J Surg. 2023;(7):57–65. EDN: EILHEF doi: 10.17116/hirurgia202307157

[7] Prakash R, Mullen KD. Mechanisms, diagnosis and management of hepatic encephalopathy. Nature Rev Gastroenterol Hepatol. 2010;7(9):515–525. EDN: XYLFGK doi: 10.1038/nrgastro.2010.116

[8] Liere V, Sandhu G, DeMorrow S. Recent advances in hepatic encephalopathy. F1000Res. 2017;6:1637. doi: 10.12688/f1000research.11938.1

[9] Papavasiliou PS, Miller ST, Cotzias GG. Role of liver in regulating distribution and excretion of manganese. Am J Physiol. 1966;211(1):211–216. doi: 10.1152/ajplegacy.1966.211.1.211

[10] Chiu B, Superina RA. Encephalopathy caused by a splenorenal shunt can be reversed by performing a mesenteric-to-left portal vein bypass. J Pediatr Surg. 2006;41(6):1177–1179. doi: 10.1016/j.jpedsurg.2006.01.075

[11] Van Praet KM, Ceulemans LJ, Monbaliu D, et al. An analysis on the use of Warren’s distal splenorenal shunt surgery for the treatment of portal hypertension at the University Hospitals Leuven. Acta Chir Belg. 2021;121(4):254–260. doi: 10.1080/00015458.2020.1726099

[12] Srivastava A, Yadav SK, Lal R, et al. Effect of surgical portosystemic shunt on prevalence of minimal hepatic encephalopathy in children with extrahepatic portal venous obstruction: Assessment by magnetic resonance imaging and psychometry. J Pediatr Gastroenterol Nutr. 2010;51(6):766–772. doi: 10.1097/MPG.0b013e3181ecaf62

[13] Bambini DA, Superina R, Almond PS, et al. Experience with the rex shunt (mesenterico-left portal bypass) in children with extrahepatic portal hypertension. J Pediatr Surg. 2000;35(1):13–18; discussion 18–19. doi: 10.1016/s0022-3468(00)80005-6

[14] Razumovsky AYu, Dronov AF, Rachkov VE, et al. Portal hypertension in pediatric patients: 28 Years of experience in surgical treatment. Doctor.Ru. 2017;(12):43–49. EDN: ZTQXND

[15] Saad WE. Portosystemic shunt syndrome and endovascular management of hepatic encephalopathy. Semin Intervent Radiol. 2014;31(3):262–265. doi: 10.1055/s-0034-1382795

[16] Mínguez B, García-Pagán JC, Bosch J, et al. Noncirrhotic portal veinthrombosis exhibits neuropsychological and MR changes consistent with minimal hepatic encephalopathy. Hepatology. 2006;43(4):707–714. doi: 10.1002/hep.21126

[17] Margaryan SR, Razumovsky AYu, Mitupov ZB, et al. Reconstruction of total portosystemic shunt into selective portosystemic shunt in a child. N.I. Pirogov J Surg. 2023;(12):140–146. EDN: KQNWAP doi: 10.17116/hirurgia2023121140

[18] Patent RUS № RU 2789284 C1. Byul. № 4. Razumovskiy AYu, Margaryan SR. Method of treatment of complications due to total discharge of blood from the portal system into the inferior vena cava in children who underwent splenorenal bypass ‘side-to-side’ or splenosupprenal bypass for portal hypertension. (In Russ.) EDN: AMHMAV Available from: https://patents.google.com/patent/RU2789284C1/ru. Accessed: 15.10.2024.

[19] Sharma P, Sharma BC, Puri V, Sarin SK. Minimal hepatic encephalopathy inpatients with extrahepatic portal vein obstruction. Am J Gastroenterol. 2008;103(6):1406–1412. doi: 10.1111/j.1572-0241.2008.01830.x

[20] Degtyareva AV, Sokolova EV, Zakharova EYu, et al. Hyperammonemia in neonatologist practice. Russ Bulletin Perinatol Pediatr. 2020;65:(6):98–107. EDN: KUHHHZ doi: 10.21508/1027-4065-2020-65-6-98-107

[21] Ipatova MG, Shumilov PV, Mukhina YG. Interpretation of blood biochemical analysis in liver pathology: A manual for doctors. Moscow: Prima Print; 2017. 136 р. (In Russ.)

[22] Lazebnik LB, Golovanova EV, Alekseenko SA, et al. Russian Consensus ”Hyperammonemia in Adults”. Exp Clin Gastroenterol. 2019;172(12):4–23. EDN: CBRGXX doi: 10.31146/1682-8658-ecg-172-12-4-23

[23] Mitra SK, Rao KL, Narasimhan KL, et al. Side-to-side lienorenal shunt without splenectomy in noncirrhotic portal hypertension in children. J Pediatr Surg. 1993;28(3):398–401; discussion 401-402. doi: 10.1016/0022-3468(93)90239-h

[24] Kirby R, Burke FD, Jones JD. Emergency and elective surgical treatment of portal hypertension. A review of 23 years’ experience. Ann R Coll Surg Engl. 1975;57(3):148–158.

[25] Longmire WP. Personal reflections on the surgical treatment of portal hypertension. JPN J Surg. 1985;15(4):243–248. doi: 10.1007/BF02469912

[26] Voorhees AB, Chaitman E, Schneider S, et al. Portal-systemic encephalopathy in the noncirrhotic patient. Effect of portal-systemic shunting. Arch Surg. 1973;107(5):659–663. EDN: XQRLOI doi: 10.1001/archsurg.1973.01350230017005

[27] Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967;166(3):437–455. doi: 10.1097/00000658-196709000-00011

[28] Superina R, Bambini DA, Lokar J, et al. Correction of extrahepatic portal vein thrombosis by the mesenteric to left portal vein bypass. Ann Surg. 2006;243(4):515–521. doi: 10.1097/01.sla.0000205827.73706.97

Funding

Правительство г. МосквыGovernment of Moscow(2412-37/22)

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