Unconventional Alternative Shunts in Pediatric Extrahepatic Portal Vein Obstruction - Experience with satisfactory outcome.

Abstract

Background: Major variceal hemorrhages in children of the Indian subcontinent, are caused by extrahepatic portal vein obstruction (EHPVO). Portosystemic shunt surgery (PSS) is the recommended course of action for long-term care in refractory cases, even if endoscopic techniques constitute the initial line of treatment for acute variceal hemorrhage. The most usual surgery, particularly with splenomegaly, is the proximal splenorenal shunt (PSRS). However, in some cases, unusual or alternative nonconventional shunts are required for treatments due to anatomical variances and technical difficulties. We present our experience with pediatric patients underwent unconventional shunt procedures with satisfactory outcome.

Methodology: Retrospectively between June 2019 and July 2024; all patients underwent unconventional or "alternative shunts were included in the study. The patients' information was collected from hospital electronic and operative records, and all available data was analyzed.

Result: Seven (7/112; 6.3%) patients were operated as unconventional shunt for various reasons in total of 112 patients during study period. Five were males and median age was 11 years (ranged 3-17 years). The most common symptoms were splenomegaly with hypersplenism (6/7; 85.7%) growth retardation (7/7; 100%) abdominal pain/discomfort (4/7; 57.2%), hematemesis (5/7; 71.4%) and melena (4/7; 57.2%) in the combination with each other. Various unconventional shunts, including spleno-adrenal, inferior mesenteric-vena caval, and collateral-based shunts, were performed. The median shunt diameter was 7 mm [7-8 mm (25th - 75th Percentile)] and post-surgery reduction in median omental vein pressure was significant (p=0.017). All patients showed improved hematological parameters and variceal regression. One patient experienced shunt thrombosis, successfully managed with interventional radiology. Follow-up ranging from 5 to 56 months showed good outcomes with improved appetite, weight gain.

Conclusion: Unconventional shunts are a viable alternative in select cases where conventional shunt options are not feasible, providing a valuable surgical rescue plan when anatomical constraints are encountered.

Type of study: Retrospective observational cohort study LEVEL OF EVIDENCE: 4.