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Frédéric Gauthier, Division of Surgery, Federation of Paediatrics, Centre Hospitalier Universitaire Bicêtre, France,
Danièle Pariente, Division of Radiology, Federation of Paediatrics, Centre Hospitalier Universitaire Bicêtre, France,
Sophie Branchereau, Division of Surgery, Federation of Paediatrics, Centre Hospitalier Universitaire Bicêtre, France,
Mark D. Stringer, Children's Liver and GI Unit, St James's University Hospital, Leeds, UK
Gastrointestinal bleeding related to portal hypertension (PH) in children may be life threatening. Therapeutic alternatives used to relieve PH and reduce the risk of bleeding include various types of surgical and radiologic vascular procedures. Shunt surgery, which usually results in total diversion of portal blood flow, was introduced several decades ago. The long-term benefits and complications of this therapy have been critically reviewed in the previous edition of this book. New techniques developed during the 1990s. The transjugular intrahepatic porto-systemic stent shunt (TIPS) is now preferred to surgical shunts for treatment of PH in most cirrhotic patients. The splanchnic-to-left-portal vein bypass (Rex shunt), designed for definitive treatment of portal vein obstruction, results in restoration of physiologic intrahepatic portal blood flow. The less invasive techniques of percutaneous endoluminal dilatation or thrombectomy of the portal vein, with or without placement of a stent, have been used mainly as rescue therapies after failed shunts, TIPS or bypasses; a few attempts have been made to use them as a definitive treatment of portal vein obstruction.
Evolution of indications for shunt surgery
Different pathologic conditions cause portal hypertension in children and etiology must be considered when choosing a treatment for PH. In the case of extrahepatic portal obstruction (EHPO), which is either idiopathic or a complication of perinatal thrombosis of the portal vein, liver function is normal or near-normal, and for many years a shunt operation has been considered as the best method of providing lifetime protection against recurrence of bleeding, with an acceptable risk of complications.
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