Therapeutic strategies for recurrent upper gastrointestinal hemorrhage in children undergoing Rex shunting

Abstract

Objective To explore the therapeutic strategies for re-bleeding children after Rex shunting. Methods From June 2008 to January 2017, 126 children with portal cavernous underwent Rex shunting.And 26 children had a recurrence of upper gastrointestinal hemorrhage.Occluded bypass veins were detected by postoperative ultrasound or computer tomography (CT) in 13 children.There were stenosis of bypass vein (n=10) and patency of bypass vein (n=3). Upper gastrointestinal imaging was performed in 21 children and esophageal varices detected in 20.Transfusion and hemostasis were offered for 10 children and Warren shunting was performed (n=5). One child suffered from re-bleeding after a second Rex shunt and required conversion into Warren shunt.A second Rex shunt was performed in 8 children (one underwent a conversion to Warren shunt ultimately and one underwent endoscopic sclerotherapy before a second Rex shunt). One child underwent main portal vein-right portal vein with interposition of inferior mesenteric vein.One child underwent venoplasty of bypass vein after failed conservative therapy and three children received endoscopic sclerotherapy (ES) (one underwent a conversion into a second Rex shunt). Results The rates of postoperative rebleeding and esophageal gastric varices were significantly different among children undergoing Rex shunt, Warren shunt and conservative therapy.It was the lowest in Warren shunt (rate of postoperative rebleeding: 62.5% vs 20% vs 90%, P=0.027; rate of esophageal gastric varices: 75% vs 20%, 100%, P=0.015). No significant difference existed in follow-up duration among children undergoing Rex shunt, Warren shunt conservative therapy [(22.9±24.4) vs (26.6±24.1) months vs (26.0±20.4) months, P=0.939]. No significant difference existed in rate of bypass vein patency among children undergoing Rex shunt and Warren shunt (62.5% vs 100%, P=0.118). One quarter of ten children undergoing conservative therapy had no rebleeding during a follow-up period of 43 months.One child had a patent bypass vein while other nine children with an occluded or narrowed bypass vein suffered from rebleeding. Conclusions Warren shunt is effective for Rex shunt.Conservative therapy and ES are recommended for children with patency of bypass vein.And surgery is reserved for those with occluded or narrowed bypass vein. Key words: Portal hypertension; Alimentary system; Hemorrhage; Relapse