Management of extrahepatic portal vein obstruction in children: Experience in a tertiary care center in Northeast India

Abstract

Background: Variceal bleeding in children is often a life-threatening condition for which timely and appropriate management is mandatory. It is a great challenge, especially in resource-constrained centers, to offer the best possible treatment by optimizing the available resources. Aim: To share the experience of management of extrahepatic portal vein obstruction (EHPVO) in children in a resource-constrained setup during the last one decade. Mode of presentation of the children, treatment options available, and outcomes were analyzed. Settings and Design: The study is a hospital-based prospective study conducted between August 2000 and December 2013. Materials and Methods: Seventy six children with EHPVO who bled at least once were included in the study. Common presentations were hematemesis and/or melena, splenomegaly, pain in abdomen, and ascites. In group A, 30 patients residing within the city area were managed conservatively with variceal banding [endoscopic variceal ligation (EVL)] alone. Group B consisted of 48 patients who hailed from outside the city area and had fundal varices and were offered shunt surgery. Fisher's exact test and Chi-square tests were employed for statistical analysis. Results: The average number of EVL sessions for group A was 3.2. Variceal obliteration was achieved in 18 children and rebleeding was noted in 6. One patients from group A died and one had mild dysphagia. Fifty two shunt procedures were performed in group B patients. Mean operating time, blood loss, and hospital stay were 4.23 h, 690 mL, and 12 days, respectively. There was no operative mortality. Other complications were intestinal obstruction, ascites, rebleeding, and blocked shunt. Spleen size regressed appreciably following surgery and ascites resolved spontaneously. Two patients needed a second shunt surgery for the treatment of blocked shunt. The rates of rebleeding differed significantly between the two groups. Patients were blinded and independently evaluated in the pediatric gastroenterology clinic. Growth and development of the patients in both the groups were within normal limits. Mean follow-ups were 52.5 months for group A and 48.2 months for group B. Conclusion: Children presenting with variceal bleeding can be effectively managed with either EVL or shunt surgery depending on the available resources. However, children from far-off places are better managed with onetime shunt surgery.