Portal Hypertension

Surgical Treatment

With the advent of advanced modern pharmacological therapy, surgical intervention is generally reserved for the management of acute complications, such as perforation or bleeding.

In the majority of cases, bleeding responds well to nasogastric decompression, volume replacement and transfusion therapy. For major or persistent bleeding, endoscopic treatment modalities include therapeutic injections (i.e., hypertonic NaCl, epinephrine, absolute ethanol) and cauterization with heater probe, bipolar coagulator, or laser (or argon). If medical and endoscopic treatments fail, surgery is indicated.

The surgical procedures used to treat peptic ulcer disease include:

· Simple closure of a localized perforation overlaid with omental patch

· Gastrotomy or duodenostomy with over-sewing of the base of a bleeding ulcer

· Partial and subtotal gastrectomies

· Vagotomy with either pyloroplasty or antrectomy

· Proximal gastric vagotomy

Vagotomy with pyloroplasty is the traditional approach that provides good long-term results causing minimal disturbance of growth and development. The choice of the operation should be individualized, taking into account the likelihood of recurrence, the comorbid factors and the nutritional and developmental needs of the growing child.

The portal venous system drains blood from the stomach, pancreas, gallbladder, spleen and intestines into the liver. The portal vein arises in the embryo as the left and right vitelline veins, which form numerous anastomoses among developing hepatocytes. Following gut rotation, the left vitelline vein is obliterated and the right vitelline vein persists as the main portal vein. Portosystemic anastomoses exist in four main areas:

1. the gastroesophageal veins via the cardiac vein and perforating esophageal veins;

2. the retroperitoneum via the pancreaticoduodenal veins and the retroperitoneal-paravertebral veins;

3. the gastrorenal-splenorenal vein;

4. the hemorrhoidal plexus.

The portal venous system lacks valves, making blood flow entirely dependent upon the pressure gradient within the system. Normal flow toward the liver is termed hepatopedal. Significantly increased portal venous resistance can result in hepatofugal flow away from the liver. Normal portal venous pressure is 5-10 mm Hg greater than central venous pressure. In children, portal hypertension is defined as elevation of the portal venous-IVC (inferior vena cava) pressure gradient above 10-12 mm Hg or a parenchymal spleen pressure greater than 16 mm Hg.