Shunts In Children Research Articles

Intracardiac shunting and stroke in children: a systematic review.

In adults, patent foramen ovale or other potential intracardiac shunts are established risk factors for stroke via paradoxical embolization. Stroke is less common in children and risk factors differ. The authors examined the literature on intracardiac shunting and stroke in children, identifying the methods employed, the prevalence of detectible intracardiac shunts, associated conditions, and treatments. PubMed searches with keywords related to intracardiac shunting and stroke in children identified articles of interest. Additional articles were identified via citations in these articles or in reviews. The authors found that studies of intracardiac shunting in children with stroke are limited. No controlled studies were identified. Detection methods vary and the prevalence of echocardiographically detectible intracardiac shunting appears lower than reported in adults and autopsy studies. Defining the role of intracardiac shunting in pediatric stroke will require controlled studies with unified detection methods in populations stratified by additional risk factors for paradoxical embolization. Optimal treatment is unclear.

224 Novel Ultrasound Dilution Technique Detects Left-To-Right Shunts with High Accuracy in Children

Objectives: Recently introduced paediatric cardiac output monitor (COstatus, Transonic Systems Inc. Ithaca, NY) also measures blood volumes and detects cardiac shunts. The current study assessed its ability to identify left-to-right shunts and measured associated blood volumes during cardiac catheterisation in children. Patients and Methods: Cardiac catheterisation was performed in 20 children and adolescents (3.5 kg- 102 kg). Shunts and pulmonary (Qp) versus systemic blood flow (Qs) ratio were determined by routine oximetry. Subsequently three measurements with COstatus were performed while the monitor software announces the recognition of left-to-right shunt. Dilutions curves were recorded and validated. Results: Left-to-right shunts due to various types of cardiac defects were detected in 6 patients by oximetry. Applying COstatus diagnostic accuracy was very convincing, with a sensitivity of 100% (6/6) and a specificity of 92.8% (13/14). The threshold for determination a left-to-right shunt was an Qp/Qs ratio of 1.3. In one case of a hypertrophic obstructive cardiomyopathy the distortion of the dilution curve led to a false positive result. A significant difference was detected for means of central blood volume index between patients with left-to-right shunts and controls with no cardiac shunts (95% CI; 24.9 versus 18.2 ml/kg; P< 0.05). Conclusion: Novel ultrasound dilution technique identifies left-to-right shunts in children with a high sensitivity and detects even small shunts with an Qp/Qs ratio of 1.3. Raised central blood volume index corresponds well with clinical features in patients with left-to-right shunts and may become helpful a diagnostic parameter in the future.

Assessment of modified Blalock–Taussig shunt in children with congenital heart disease using multidetector-row computed tomography

The purpose of this study was to assess the feasibility of multidetector-row computed tomography (MDCT) for the evaluation of modified Blalock-Taussig (B-T) shunt in children with congenital heart disease associated with reduced pulmonary blood flow. A total of 25 consecutive patients (mean age, 2.6 ± 3.6 years; range, 2 months-16 years) underwent MDCT angiography of the thorax with a 16-detector row scanner prior to cardiac catheterization. A total of 39 shunts (right, 22; left, 17) were included in the study. Conventional angiographic findings were used as the gold standard for the detection of B-T shunts. Shunt diameter was measured quantitatively and independently at four sites (the subclavian artery site, the pulmonary artery site, the widest site, and the stenotic site) on MDCT and on conventional invasive angiography. All B-T shunts were depicted on multiplanar reconstruction (MPR), maximum intensity projection (MIP), curved planar reconstruction (CPR), and three-dimensional volume-rendered (VR) images, enabling evaluation in all patients except for one with occluded shunt. There were excellent correlations between MDCT- and conventional angiography-based measurements of shunt diameter at the subclavian artery site, pulmonary artery site, and the widest site (R² = 0.46, 0.74 and 0.64, respectively; p < 0.0001 for each), although systematic overestimation was observed for MDCT (mean percentage of overestimation, 23.1 ± 32.4%). Stenotic site diameter and degree of stenosis showed a mild correlation (R² = 010 and 0.25, respectively; p < 0.01 for each). This study demonstrates that MDCT is a promising tool for the detection of lesions in B-T shunts.

The relationship between migraine and right-to-left shunt in children

Migraine is the most common headache in childhood, and there are some reports that suggest the relationship between migraine and right-to-left shunt. The aim of this study was to evaluate the frequency of right-to-left shunt in children with migraine with aura and compare it with children with migraine without aura, and in healthy children. In a cross-sectional case-control study, we assessed 20 children with migraine with aura, 20 migraine without aura and 20 healthy age, and gender-matched control group. We determined the frequency of right-to-left shunt by transcranial doppler with contrast and transthoracic echocardiography without contrast. The dopplers and echocardiograms were performed blindly by the same examiners during headache-free periods. The presence of right-to-left shunt was found in 13/20 patients with migraine with aura compared with five of 20 migraine without aura and four of 20 control subjects. The frequency of right-to-left shunt in migraine with aura was statistically different from the other two groups (P < 0.005). There was no association between right-to-left shunt and frequency of attacks, duration and intensity of attacks, uni/bilateral occurence, familial occurrence, gender and age of patients. our findings suggest possible association of migraine with aura and right-to-left shunt. It seems that right-to-left shunt does not influence the clinical features of migraine.

Relationship between migraine and right-to-left shunt in children: editorial

Migraine is a common type of headache and is considered to be one of the most important disabling disorders worldwide. The prevalence of migraine increases with age until it reaches the peak prevalence of 27% in women and 8% in men in the fourth decade of life [11]. Migraine is a complex disorder in which genetic, environmental, behavioral, and other unidentified factors interact to trigger typical migraine attacks. In the late 1990s, it was suggested for the first time that migraines, especially those with aura, are associated with the presence of a right-to-left shunt (prevalence of 23% for migraine without aura, 48% for migraine with aura) [1]. Moreover, in patients with a rightto-left shunt, migraine was more prevalent (48% for migraine with aura) than in those without a shunt [14]. These observations were independent from the structural anomalies causing the right-to-left shunt: patent foramen ovale, atrial septal defect, or pulmonary arteriovenous malformation. In this issue, Sarisoy et al. [10] reported similar findings: 65% of the children with migraine with aura had a documented right-to-left shunt, which was significantly higher than the prevalence of a right-to-left shunt in patients with migraine without aura or with no migraine (25% and 20%, respectively). These authors are the first to show an association between migraine with aura and right-to-left shunt in a pediatric population (mean age 11 years). A few hypotheses were proposed to explain the potential relationship between a right-to-left shunt and migraine. First, vasoactive trigger substances of the venous circulation may enter through a right-to-left shunt into the systemic circulation, inducing cerebral vascular instability, thereby provoking a typical migraine attack. It is suggested that these trigger substances, such as serotonin and/or (micro)thrombi, are normally neutralized in the lung filter. However, a right-to-left shunt may bypass this neutralization process so that these non-deactivated substances enter the systemic circulation [1]. This hypothesis fits with the increased risk for stroke or transient ischemic attacks in patients with migraine, especially in those with aura. Second, a particular genetic substrate may determine migraine. Migraines seem to be more prevalent in patients with congenital heart defects or connective tissue diseases, even independent from the existence of a right-to-left shunt [3, 13]. In the presence of a right-to-left shunt, migraine occurs even more frequently. All these hypotheses are referring to adolescents and adults, but as suggested by Sarisoy et al., it may also be applied to children.

Transient Hepatic Nodular Lesions Associated with Patent Ductus Venosus in Preterm Infants

We report on two cases of low-birth-weight preterm infants with patent ductus venosus associated with hepatic hypoechoic lesions of the fourth segment in an otherwise normal liver. Although tumorlike hepatic lesions have been previously reported in association with portosystemic shunts in children and adults, they were never described in preterm infants during physiological patency of ductus venosus. In our patients, hepatic lesions disappeared shortly after the spontaneous ductus closure. Physiopathologic interactions are discussed regarding altered portal blood supply caused by ductus venosus shunt.

Intracardiac Shunts in Children with Sickle Cell Disease and Stroke

Source: Dowling MM, Lee NL, Quinn CT, et al. Prevalence of intracardiac shunting in children with sickle cell disease and stroke. J Pediatr. 2010; 156(4): 646– 650; doi: 10.1016/j.jpeds.2009.10.012Investigators from the University of Texas Southwestern Medical Center studied the prevalence of intracardiac shunts in children, 2 to 19 years old, with sickle cell disease (SCD) and a history of stroke, either symptomatic or silent. All patients underwent transthoracic echocardiography (ECHO) using three techniques to compare their utility for the detection of an intracardiac shunt: conventional 2-dimensional imaging, color Doppler ultrasound, and intravenous contrast injection with agitated saline.A total of 40 children, 39 with SCD and one with sickle beta thalassemia, were enrolled. Ten of these children had either a patent foramen ovale (PFO) or other intracardiac shunt detected. Two-dimensional ECHO was the least sensitive technique, detecting shunts in only 2 of the 10 children with SCD and shunt. Color Doppler was positive in 6 of 10 children, while agitated saline was positive in 5 of 10. Pain crisis at the time of the stroke onset and acute headache were more likely in those with an intracardiac shunt than those with no detectable shunt (40% vs 7%, P=.026, and 40% vs 3%, P=.014, respectively).The authors conclude that intracardiac shunts are common in children with SCD and stroke and that detection requires a combination of imaging techniques. They speculate that early detection and closure of intracardiac shunts in children with SCD might decrease strokes in this high-risk population.SCD is a well-recognized risk factor for pediatric stroke, although the causes of stroke in this population have not been completely delineated. An association between PFO and stroke has been hypothesized for over 20 years.1,2 That a PFO is an independent risk factor for stroke, however, has been more difficult to substantiate3,4 and supporting evidence is based largely on case-control studies. Population-based studies have not demonstrated PFO as an independent risk factor.5 The present study does little to clarify this controversy. For example, the majority (75%) of patients in this series with SCD and stroke did not have a PFO or other identifiable intracardiac shunting. In addition, most of the clinical characteristics of the stroke victims (eg, demographics, vascular infarct distribution, hemoglobin, platelet count, etc.) did not differ between those with a PFO and those without. Finally, no data on the prevalence of PFO in SCD patients who have not had stroke are presented.Presently, the association between PFO and stroke remains too speculative to recommend medical treatment or closure of PFOs for primary prevention. However, catheter-based device closure of PFOs or selective use of anti-platelet and anti-coagulation therapy for secondary prevention in high-risk patients with PFO may reduce recurrent stroke risk.6,7 Defining precisely those SCD patients who will benefit from this therapy remains challenging.4The authors have demonstrated that evaluation for the presence of a PFO in a child with SCD and a stroke may be fruitful. What to do when a PFO is detected in this clinical scenario remains unclear.Routine screening for intracardiac shunts in children with SCD obviously remains investigational. However, transcranial Doppler (TCD) screening, followed by prophylactic transfusion (PT) in patients with increased internal carotid and middle cerebral artery blood flow velocity has documented benefits. A recent retrospective study from The Children’s Hospital of Philadelphia demonstrated a greater than 10-fold reduction in strokes following the institution of TCD screening and PT in their institution.8 Yet, nought comes without a price. PT increases the risk of infection and iron overload, for which the pediatrician must be ever-vigilant.

Complications of Congenital Portosystemic Shunts in Children: Therapeutic Options and Outcomes

Congenital portosystemic shunts are rare vascular malformations that lead to severe complications. Their management is controversial. The aim of this study was to propose a clear definition of the risks and management of congenital portosystemic shunts in children according to our experience and a review of the literature. Twenty-two children with a complicated congenital portosystemic shunt were studied in our institution. When necessary, management included portal pressure measurement and portal vein angiography during an occlusion test and closure of the shunt by surgical and/or endovascular methods. Five neonates with intrahepatic shunts presented with cholestasis that resolved spontaneously, and 17 older children presented with liver tumors (13) and/or hepatopulmonary syndrome (2), pulmonary artery hypertension (3), portosystemic encephalopathy (3), heart failure (1), and glomerulonephritis (1). The portosystemic shunt was extrahepatic (11) or intrahepatic (6). Portosystemic shunts were closed by endovascular methods in 5 children and surgically in 10, 4 of whom had portal pressure during occlusion above 35 mmHg and extremely hypoplastic or undetectable portal veins requiring banding of the fistula before closure. Shunt closure resulted in restoration of intrahepatic portal flow in all, with complete or partial regression of benign liver masses, and regression or stabilization of pulmonary, cardiac, neurological, and renal complications. Congenital portosystemic shunt carries risks of severe complications in children. Closure of a shunt persisting after age 2 years should be considered preventively. Intrahepatic portal flux restoration can be expected, even when intrahepatic portal veins are extremely hypoplastic or undetectable.

A Single-Institution Review of Portosystemic Shunts in Children: An Ongoing Discussion

Purpose. Review the safety and long-term success with portosystemic shunts in children at a single institution. Methods. An IRB-approved, retrospective chart review of all children ages 19 and undergoing surgical portosystemic shunt from January 1990–September 2008. Results. Ten patients were identified, 8 females and 2 males, with a mean age of 15 years (range 5–19 years). Primary diagnoses were congenital hepatic fibrosis (5), hepatic vein thrombosis (2), portal vein thrombosis (2), and cystic fibrosis (1). Primary indications were repeated variceal bleeding (6), symptomatic hypersplenism (2), and significant liver dysfunction (2). Procedures performed were distal splenorenal bypass (4), side-to-side portocaval shunt (3), proximal splenorenal shunt (2), and an interposition H-graft portocaval shunt (1). There was no perioperative mortality and only minor morbidity. Seventy percent of patients had improvement of their symptoms. Eighty percent of shunts remained patent. Two were occluded at a median follow-up of 50 months (range 0.5–13.16 years). Two patients underwent subsequent liver transplantation. Two patients died at 0.5 and 12.8 years postoperatively, one from multisystem failure with cystic fibrosis and one from post-operative transplant complications. Conclusions. The need for portosystemic shunts in children is rare. However, in the era of liver transplantation, portosystemic shunts in selected patients with well-preserved liver function remains important. We conclude that portosystemic shunts are safe and efficacious in the control of variceal hemorrhage and symptoms related to hypersplenism.

Bilateral pneumothorax during subdural-peritoneal shunting

Pneumothorax is a very rare complication of ventriculoperitoneal shunting in children. We report a case of an iatrogenic bilateral tension pneumothorax during the placement of a subdural-peritoneal shunting. After the placement of peritoneal catheter, oxygen saturation of the patient quickly decreased, hypotension and bradycardia occurred. Intraoperative x-rays showed the pneumothorax. A thoracostomy tube was inserted and attached to an underwater seal. Vital signs improved in a short time period. The radiological improvement had been achieved in four days. Early diagnosis and prompt intervention are life-saving for this complication. To avoid this complication, the tip of the shunt tunneler should be always palpable during the placement of the peritoneal catheter, especially in children's shunt surgery.

Prevalence of Intracardiac Shunting in Children with Sickle Cell Disease and Stroke

To determine the prevalence of potential intracardiac shunts, including patent foramen ovale (PFO), in children with sickle cell disease (SCD) and stroke. We performed a transthoracic echocardiogram (TTE) on 40 children with SCD (39 with hemoglobin SS and 1 with sickle-beta0 thalassemia) and earlier stroke (overt stroke in 30, silent infarction in 10). We compared 3 TTE techniques: conventional 2-dimensional imaging, color Doppler ultrasound, and intravenous agitated saline contrast injection for the detection of intracardiac shunts. We also evaluated the clinical, laboratory, and radiographic findings of the children with and without shunts. We identified PFO or other potential intracardiac shunts in 10 of 40 children with SCD and earlier stroke (25%; 95% CI, 11.6-38.4). With contrasted TTE, we failed to detect potential shunts in 2 children. In a comparison group of 60 children with stroke but without SCD, retrospective review of clinical echocardiograms identified PFO in 7 of 60 (11.7%; 95% CI, 3.6-19.8). Clinical features significantly associated with the presence of intracardiac shunts were stroke in the setting of vaso-occlusive crisis (P = .026) and headache at stroke onset (P = .014). One-quarter of children with SCD and stroke have potential intracardiac shunts. A combination of echocardiographic techniques is required for optimal shunt detection. Intracardiac shunting could be a risk factor for stroke in children with SCD because they are predisposed to thrombosis and elevations of right heart pressure, which could promote paradoxical embolization across an intracardiac shunt.

First experience With the biostar‐device for various applications in pediatric patients With congenital heart disease

Interventional closure of atrial septal defects (ASD) and surgical tunnel fenestrations in Fontan patients has become the procedure of choice for many years. Recently, the BioSTAR Occluder, a modification of the Starflex device with a resorbable matrix has become available. Ten Biostar devices were implanted in nine children with interatrial septal defects, one within a fontan baffle, eight with secundum atrial septal defects. The age of the patients ranged from 11 months to 17 years, the body weight ranged from 12.9-78 kg. 10 BioSTAR devices were implanted in nine patients. In one patient, two BioSTAR devices were used to occlude multiple defects within the oval fossa. All defects were successfully and uneventfully occluded. Mean procedure time was 56 (range 28-125). Mean fluoroscopy time was 4.8 (range 1.1 to 13.0) min. None of the nine patients showed residual shunts after device implantation. After 30 days no shunt was seen in the control transthoracic echocardiography. No adverse effects like allergic reactions, tachyarrhythmia or thrombembolic events occurred in any of the patients. The BioSTAR closure device is a safe and effective device for the closure of a variety of interatrial shunts in children including multifenestrated interatrial defects and fontan fenestrations, however, possible long term consequences (e.g., fractures, recurrent shunts after scaffold degradation) remain to be studied.

P030 Long term outcome of Lumboperitoneal shunt in children with Idiopathic Intracranial Hypertension

P030 Long term outcome of Lumboperitoneal shunt in children with Idiopathic Intracranial Hypertension

Quality of life in obstructive hydrocephalus: endoscopic third ventriculostomy compared to cerebrospinal fluid shunt

In the current literature, there are essentially no comparisons of quality of life (QOL) outcome after endoscopic third ventriculostomy (ETV) and shunt in childhood hydrocephalus. Our objective was to compare QOL in children with obstructive hydrocephalus, treated with either ETV or shunt. A cross-sectional survey was conducted at SickKids, Toronto of children between ages five and 18 years, with obstructive hydrocephalus due to aqueductal obstruction and no other brain abnormalities. Measures of QOL were the Hydrocephalus Outcome Questionnaire and the Health Utilities Index Mark 3. A subset of patients was given the Wechsler Intelligence Scales for Children (WISC-IV). A total of 47 of 59 (80%) eligible patients participated (24 had ETV as primary treatment, 23 had shunt as primary treatment), with a mean age of 12.1 years (standard deviation 3.9) at assessment. The ETV group was older at initial surgery (p < 0.001) and had larger ventricle size at last follow-up (p = 0.047). In all QOL measures, there were no significant differences between the ETV group and shunt group (all p > or = 0.09). Treatment failure, hydrocephalus complications, and the presence of a functioning ETV at assessment were not associated with QOL differences. Among the 11 children (six ETV, five shunt) who were given the WISC-IV, there were no significant differences between the scores of the ETV group and shunt group (all p > or = 0.11). This is the first study to provide a meaningful comparison of QOL after ETV and shunt in children. These preliminary results suggest that there is no obvious difference in QOL after ETV and shunt.

Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension

Portal vein thrombosis can occur as a result of primary anomalies, after liver transplantation, and for other reasons. It may result in severe complications secondary to portal hypertension, such as bleeding from esophageal or gastric varices, hypersplenism, or impaired somatic growth. In this retrospective study, we analyzed the outcome of 25 children who underwent a Rex shunt procedure. The following venous grafts were used as the shunt: the autologous internal or external jugular vein (n = 17) or a cryopreserved graft (n = 5); in three patients the umbilical vein was recanalized. The median follow up time was 109 months (range 18 days-146 months). The best results were achieved in patients in whom an autologous jugular vein segment was used as a vascular graft for the Rex shunt (shunt patency of 88%). In patients with a functioning shunt no further lower or upper gastrointestinal bleeding occurred. And in the entire study population hypersplenism syndrome improved after surgery. In our large cohort of pediatric patients, the Rex shunt has shown to be an effective method to eliminate portal hypertension and to revascularize the liver and thereby prevents the possible consequences of long-term portosystemic shunting.

Laparoscopic-Assisted Placement of Ventriculo-Peritoneal Shunt Tips in Children with Multiple Previous Open Abdominal Ventriculo-Peritoneal Shunt Surgeries

Placing a ventriculo-peritoneal shunt in children with hydrocephalus is the standard of care. Many of these children will require revision of this portion of the shunt for a variety of reasons. Previously, it was thought that in a child with multiple previous ventriculo-peritoneal shunt (VPS) revisions, laparoscopy was contraindicated. This study aims to show that laparoscopy can be used safely and effectively in children with multiple previous ventriculo-peritoneal shunt surgeries. Laparoscopically assisted placement of the peritoneal portion of the ventriculo-peritoneal shunt in children with multiple previous VPS revisions was performed in 8 consecutive children (4 female) with ages ranging from 7 months to 18 years between May 2003 and September 2007. All eight children had undergone more than two previous VPS operations. All shunts were placed in areas free of adhesions and flow was observed under direct visualization. All of the procedures were successful; none needed conversion to the standard mini-laparotomy approach. No obvious or occult injury to the abdominal components was noted during hospitalization or during follow-up. Six of 8 patients required lysis of adhesions at the time of the revision. Average length of hospital stay was 2.6 days and no revisions of the abdominal portion of the VPS have been required by any of the 8 patients after laparoscopic revision. Previously unknown complications of shunt surgery were corrected in 1 of 8 children. Laparoscopic placement of the peritoneal portion of a ventriculo-peritoneal shunt can be done safely and effectively in children with multiple previous VPS revisions due to improved visualization and placement of the shunt tip in a virgin area of the abdomen. Additionally, any known or unknown complications from previous VPS surgeries can be corrected with the laparoscopic approach. When combined with the reduction in pain, shorter hospital stay, and fewer immediate and future complications, this is the procedure of choice for patients requiring revision VPS surgeries in our hospital.

Short-term complications of ventriculoperitoeal shunt in children suffering from hydrocephalus

To assess various complications in children with hydrocephalus after ventriculoperitoneal shunt surgery. This de- scriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital and Al-Ibrahimi Hospital, Peshawar, Pakistan, from September 2005 to April 2007. A total of 86 children, 48 male and 38 female patients, with male to female ratio of 1:1.3 were included. Age range of patients was from 2 months to 13 years with mean age of 4.3 years. Seventy-nine cases were operated electively while seven cases operated in emergency due to poor clinical condition. Shunt malfunctioning due to obstruction of upper end was noted eight cases (9.3%), shunt infection in seven (8.1%) cases, seizure four (4.7%) cases, paralytic ileus in five (5.8%) cases, shunt extrusion per rectum in two (2.3%) cases, bilateral subdural hematoma in three (3.5%) cases, hydrocele and shunt erosion in two (2.3%) cases each. Two (2.3%) deaths were recorded in the study, which was not related with the surgery or with shunt complication. It is concluded that various complications may develop during and after ventriculoperitoneal shunt surgery. Shunt malfunction and infection are main causes for its failure and poor prognosis, although a list of other rare possible complications can also be expected.

Reducing CSF shunt placement in patients with spinal myelomeningocele.

Object:The incidence of hydrocephalus requiring shunts in children with myelomeningocele (MMC) is reported to be very high. Shunt-related complications are a significant cause of morbidity and mortality in this population. In order to minimize shunt placements, we used very rigid clinical selection criteria and followed them in all patients who had myelomeningocele and enlarged ventricles. The follow-up outcome of this retrospective study is reported.Methods:From 2000 to 2007, 23 patients with myelomeningocele and variable degree of hydrocephalus were treated at our institute with primary surgical closure of their myelomeningoceles without a CSF diversion procedure. Patients with severe hydrocephalus who required immediate shunt insertion, and those with no significant associated hydrocephalus were not included in this study. Data regarding the surgical results and complications, postoperative management, and the outcome at follow-up were obtained from their hospital records.Results:Initially increased size of the ventricular system was found to have decreased or stabilized in 17 (81%) patients postoperatively. However, ventriculomegaly continued to progress further in 4 (19%) out of 21 patients. Of 11 patients who presented with enlarged head, eight (73%) patients showed reduction or stabilization in their head circumference. Three (27%) children continued to have progressive head enlargement in the postoperative period and required shunt placement. Signs of raised intracranial pressure observed in six patients on admission, improved in two (33%) and persisted or worsened in four (67%) patients who eventually improved after the insertion of a shunt. Eight (35%) patients experienced wound-related complications following closure of the MMC, including CSF leak in four, wound infection in three, wound breakdown in three, and pseudomeningocele in two patients. Shunt placement was required in the postoperative period in 13 (56.5%) patients to treat raised intracranial pressure in 11 and CSF leak from the wound in two patients.Conclusions:Our experience suggests that the placement of shunts can be reduced by adopting a policy with strict clinical and radiographic criteria. Shunt insertion should be reserved for only those patients who have severe hydrocephalus with clinical features of elevated intracranial pressure. Mild to moderate ventricular dilatation, persistent ventriculomagaly, and some increase in ventricular size after myelomeningocele repair can be treated successfully without a shunt.

Successful preemptive surgical division of type 2-congenital extrahepatic portosystemic shunt in children

A congenital extrahepatic portosystemic shunt (CEPS) is a rare abnormality. The shunts are classified into 2 types. Of these, a type 2-shunt is a side-to-side one, which may be treated by a simple shunt division. The aim of this retrospective study was to clarify the effects of a surgical shunt division on 4 children with type 2-CEPS. Between June 2002 and June 2008, 4 children with type 2-CEPS underwent a surgical shunt division. Various clinical factors of each patient, including shunt types, shut ratios evaluated by portal scintigraphy using (123)I-iodoamphetamine, serum levels of ammonia and total bile acids before and after surgery were evaluated. Two children had a conventional open surgery and the other two had a laparoscopic surgery. The serum levels of ammonia as well as total bile acids of these children decreased significantly to the normal levels within a month after the surgical shunt divisions. All the children had a better clinical course. A shunt division, especially by laparoscopic surgery, is an effective therapy for type 2-CEPS. To the best of our knowledge by reviewing literatures, our cases are the youngest ones treated by laparoscopic shunt division.

Extrahepatic portal venous obstruction: The effects of early ligation of splenic artery during splenectomy

Aim:To objectively demonstrate the gain in blood volume and blood components following early ligation of splenic artery during splenectomy and splenorenal shunts in children with extra hepatic portal venous obstruction (EHPVO).Methods:Twenty-eight children (20 males and 8 females, mean age: 9.9 (±3.2) years) with EHPVO and hypersplenism were recruited. We followed a protocol of systematically locating and ligating the splenic artery first, followed by a 30-minute waiting period to allow the massive spleen to decongest via the splenic vein and venous collaterals and then completing the splenectomy by standard procedure. No intravenous fluid was administered during this 30-minute period. Blood samples were drawn just prior to splenic artery ligation and soon after splenectomy for the estimation of hematological and biochemical parameters.Results:We noticed a highly significant increase in the hemoglobin, hematocrit, leukocyte, platelet, and RBC counts by early ligation of the splenic artery (p < 0.0004). The gain in hemoglobin and hematocrit was equivalent to a transfusion of atleast 100-150 ml of packed RBC. The increase in platelet count was equivalent to a platelet transfusion of atleast 4 units of platelet concentrates in an adult. There is a positive correlation between the splenic weight and the platelet gain (p= 0.0568) and the splenic volume on preoperative imaging and the platelet gain (p= 0.0251).Conclusion:Early ligation of the splenic artery during splenectomy results in passive splenic decongestion and thereby a significant gain in blood components. This protocol appears to be a feasible blood conservation method to avoid blood transfusions in this group of hypersplenic EHPVO patients.