Alternative technique for transjugular intrahepatic portosystemic shunt in a young child

Abstract

Liver transplantation is safer, more readily available and is increasingly being carried out in younger patients. Therapeutic bridging procedures such as transjugular intrahepatic portosystemic shunt have therefore become more relevant to paediatrics, especially in the group of patients who are too unstable for surgery or in whom a liver graft is not available. We describe a transjugular intrahepatic portosystemic shunt procedure in a 4-year-old child with life-threatening variceal bleeding in whom the conventional procedure had failed. This technique may provide an alternative to conventional transjugular intrahepatic portosystemic shunt in this group.

Portosystemic shunt as a bridge to liver transplantation in infants: A comparison of two techniques

“…DIPS has not been shown to cause worse encephalopathy or have greater incidence of this complication compared to TIPS. [9][10][11][12] Both patients in our case series developed signs of hepatic encephalopathy, including hyperammonemia and agitation, and both were managed with aggressive medical treatment until they received a liver transplant.…”

“…Adopting a percutaneous transabdominal approach to cannulating these vessels makes this part of the procedure more feasible to accomplish. Transabdominal access to a portal vein branch for portosystemic shunt creation was previously described by Fasulakis et al., who reported a case of a 4‐year‐old patient with biliary atresia who presented with severe gastrointestinal bleeding. A conventional TIPS procedure was attempted and failed.…”

Surgical portosystemic shunts and the Rex bypass in children: a single-centre experience

“…Although survival rates were similar in both groups, rates of re-intervention, stenosis and thrombosis were significantly higher in the TIPS group compared with the DSRS group. 14 However, TIPS can be technically difficult to perform in small children; 5 in another paediatric series, 15 only two of nine children in whom TIPS was attempted had a functioning shunt at last follow-up. In our series, 15 children were aged <10 years at the time of the shunt surgery and eight of 15 were aged <5 years.…”

“…Although expertise in TIPS in adults is not uncommon, the procedure can be technically difficult in children, especially in children aged <5 years. The smaller size of the venous structures and liver and the presence of anatomic variants are limiting factors for success in paediatric patients 5 …”

“…The smaller size of the venous structures and liver and the presence of anatomic variants are limiting factors for success in paediatric patients. 5 The superior mesenteric vein to left portal vein (Rex) bypass is described as re-directing the portal flow into the liver, and therefore should not, either anatomically or physiologically, be considered a shunt procedure. 6,7 This operation restores portal flow by bringing mesenteric venous and splenic blood around the extrahepatic portal obstruction into a patent intrahepatic portal venous system.…”