This is an invited talk on the topic "Portal Hypertension in Children: Shunt and non-shunt Surgery" Dr Omar Khamag, Pediatric Hepato-biliary and Transplant Surgeon, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa. This video is for health care professional ONLY and NOT for general public. This is an invited talk on the topic "Portal Hypertension in Children: Shunt and non-shunt Surgery" Dr Omar Khamag, Pediatric Hepato-biliary and Transplant Surgeon, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa. This video is for health care professional ONLY and NOT for general public. #PortalHT #Children #Surgery #PaediatricSurgery #EastLondon #Zoom #AcademicMeetings
"Portal Hypertension in Children: Shunt and non-shunt Surgery" Dr Omar Khamag, Pediatric Hepato-biliary and Transplant Surgeon, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
Summary
Join Dr. Omar Kamar, a renowned pediatric hepatobiliary and transplant surgeon, as he offers valuable insights on portal hypertension in children, focusing on shunt and non-shunt surgery. With experience in highly regarded medical institutions in South Africa and abroad, including the Red Cross War Memorial Children’s Hospital and Birmingham Children's Hospital, Dr. Kamar will delve into the intricacies of portal hypertension in the pediatric population. Throughout this session, he will explore the causes, complications, and surgical management strategies for this condition. Drawing from anatomical models and systematic reviews, he will provide a detailed understanding of diagnostic and treatment pathways. This webinar is highly useful for those seeking a comprehensive learning experience on portal hypertension, a condition that demands attentiveness, discipline, and communication for optimal patient outcomes. Don't miss this opportunity to learn from a seasoned expert committed not only to his profession but also to the dissemination of knowledge.
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Learning objectives
- To understand the causes of portal hypertension in children and the difference between intrahepatic and extrahepatic factors.
- To examine the impact and potential risk of various medical procedures like neonatal umbilical vein catheterization, liver transplant, or abdominal surgery on the development of portal hypertension in children.
- To explore the modes of intervention available for children suffering from portal hypertension and identify the benefits and challenges of shunt and non shunt surgeries.
- To appreciate the importance of anatomy in diagnosing and treating portal hypertension in a medical perspective; and identifying the crucial role of understanding the portal circulatory system.
- To evaluate the complications of portal hypertension such as upper GI bleeding, hypersplenism, ascites, and hepatic encephalopathy, and exploring management strategies based on the status of the liver, the underlying cause, and the child's overall health condition.
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Ok. Uh Good afternoon, good evening, good morning, wherever you are from, welcome to the Zoo Academic Meeting of the Department of pediatric Surgery in East London, South Africa. And uh we are really happy um that uh we have doctor Omar Kamar who is going to talk about portal hypertension in Children shunt and non shunt surgery. So doctor Cag um I came to know uh him uh when he started his uh supernumerary registrar training at Red Cross Childrens Hospital in Cape Town. That was uh a few years ago. And I'm so glad, happy and proud to see him uh full general pediatric surgeon, pediatric hepatobiliary and transplant surgeon and oncological surgeon. So currently he is a consultant, pediatric hepatobiliary and transplant surgeon at Red Cross War Memorial Children's Hospital at the University of Cape Town in South Africa. He is also the current head of trauma division um and, and uh so he completed his full training here in South Africa and did the fellowship in 2021. He completed his ED also from the UC in the same year. Then he did the Libyan Board exam in 2022 and then he was really fortunate to get a fellowship in Birmingham Children's Hospital. So he did HEPA and transplant surgery fellowship in 2023 and pediatric thoracic and oncological surgery fellowship in 2024. So you will imagine how his life must be so busy at, at Red Cross. But he still finds time for cycling, cooking. He says mainly Mediterranean dishes I haven't tasted, but I'm quite keen to taste his Mediterranean food. And he says that I'm a professional beekeeper. I learned a lot from bees and I believe that honey bees provide a model for a precise compassionate community that can be achieved only through attentiveness, discipline, communication, and hard work. And there cannot be any better example than Doctor Omar Kak, who is our guest speaker today. So Omar, I will stop sharing and I welcome you. Uh uh and, and I would request you to share uh your screen and then give your talk to us. Thank you. Thank you so much, bro. Um Thanks for this uh nice uh presentation and this um uh talk. Um Thank you, bro Chest. Thanks for giving me this um opportunity to share my experience and to um you know, disseminate the knowledge um all over Africa and out of Africa. Um Thanks for all the support. Yes, I remember the first days we've met, you know, it was in SA ps actually 2014, we met in Cape Town and we've, since then, we've been, it was actually my second or third week in South Africa 10 years ago and, uh, since we've been in communication and, uh, yeah, all over and here we go now. And yes, so I'm gonna start my talk. Would you please remind me that when we are 30 minutes so that I just don't keep going on and on. So, just gonna make it a resource. And thank you. Yeah, cool. So today, um, we're gonna be speaking about uh portal hypertension in Children, we'll discuss the shunt and non shunt surgery and we will focus on our like African circumstances where transplant is not the first option usually and it's available only limited circumstances. However, we still faced with Children who needs, who are diagnosed with portal hypertension, either intra or extrahepatic portal hypertension where they bleed and they have symptomatic and they need some intervention. So there is still room for other measures, you know, to be done to, to improve, you know, the patients survival, to improve the quality of life, to reduce the morbidity and mortality of this. So I have nothing to disclose. And as um for me, I um anatomy is the main, is the key, you know, like, and it's like it's anatomy is like the um roadmap or like, you know, the um um um um the roadmap of surgery. And so knowing the anatomy is very important, you have to know the anatomy extremely well. So this is the border circulation, you know, um splenic vein, suberu meric vein, the main vein, inferior centric vein drains to the sublecta where both forms the portal vein trunk and that goes into the liver. And then this is the stomach where it lays. This is the portal vein. Here, we can see the right gastric, left, left gastric and right gastric veins both drain into and it's very important to know about these things. Um So a portal hypertension is defined as a portal pressure more than an 11 millimeter, mercury, speaking about numbers. However, clinically, usually we start getting this complication when it goes beyond 12 when it gets up to 15, you know, so only when you start getting the clinical complications, you know, of portal hypertensions, otherwise less than 11, it's still concerned, the normal shouldn't exceed five from 5 to 11, subclinical from 11 to 15. You see the clinical um um signs and symptoms, which is like, but normally upper gi for bleeding splenic enlargement, what's called hypersplenism. And then in the later stages, you might see ascitis and hepatic encephalopathy if the liver function is affected and the management of this depends entirely on the um status of the liver, the underlying cause and the child. Again, this is one of the models of the liver anatomy that we developed at cross hospital here. And um in, in our skills lab, that's the portal circulation and that's how the blood flow and that's where it normally needs to go here. And we've got um the segment two, segment three, portal venous duct and segment four. So this is just the liver anatomy. The segment of the liver segment 1238456 and seven and eight. So the liver is made of four of eight segments. If each segment got its own hepatic arterial supply its own biliary drainage, its own portal venous drainage and its own um um um hepatic venous um like tributary from there, combining all of this together gives you the um the like, how's the liver is coming into communicating with the, with the, with the biliary and uh uh vasculature all around. That's how it plays normally in the body. So, coming to the causes of portal um hypertension here. So it can be either intrahepatic as we all know or extrahepatic prehepatic or, or intrahepatic prehepatic. It's, we're talking about the portal vein, either it's a thrombosis if that's something happened after birth or congenital portal vein abnormalities like portal vein, hypolasia. We do see that and those Children born with congenital portal hypertension secondary to embed outer flow. Um But what we see commonly is the extrahepatic boal vein thrombosis slash obstruction. Um That's, that's the cause of extrahepatic. The intrahepatic causes. The main number one cause in pediatric is biliary, congenital hepatic fibrosis, neonatal, autoimmune hepatitis or other metabolic. And then the posthepatic x-ray, it's a bit out of scope of this um lecture. So I'm not gonna go deeper on that again, coming back to the, um, blood supply and venous drainage mainly. So, these are just here to show the, um, how is the blood, um, the venous drainage from the esophagus? So this is all the esophageal venous system. The bar isopal veins above, you know, up in the thoracis, the, the, the, the, the, the, the spleen drains into the azygos and he a Azy and Barra hemi Azy veins which goes into the suber vena cava and below the diaphragmatic junction, it, the, the um the, the, the esophagus drains into the um the short gastric vessels which goes into the spleen and through the left and right gastric veins, which they drain into the portal vein. It's very important to know this. But because it has an implication in the shunt, it has an implication in the transplant. It has an implication on Children who has been shunted and going to transplant. There are different ways of, of, of, of um dealing with this anatomy. Um So this is the portal. Uh you know, this is when there is a portal vein obstruction. Here, there's thrombosis or there's fibrosis in the portal vein, then the blood is not gonna flow properly and it will result in increased blood uh portal pressure. And that's when portal systemic shunts start opening the varices and then with time the pressure goes up and then it goes up in size and then they rupture and eventually the child bleeds and presents with signs and symptoms of upper gi bleeding. So, um in extrahepatic water vein obstruction, 50% of them actually have no clear reason. You know, there is no clear reason of why this happened. They just present at certain age, usually in the first decade of age from four, usually 3 to 4, up to 10 years with a eye bleeding. However, and the other 50 person, there might be a history of neonatal umbilical vein catheterization, which I'm gonna put lots of emphasis in the UVC and use of UV C in a unit. And part of that can be both liver transplant. They, they do because you, you in liver transplant, you do portal vein to portal vein anastomosis. So this is there is a risk of thrombosis even if you've done it properly, the risk of thrombosis is always there. Then omphalitis. Actually, omphalitis, we do see lots of omphalitis, especially in African circumstances, you know, and, and, and, and, and management of omphalitis needs to be taken like seriously because one of the major complication of omphalitis is portal vein, thrombosis. You know, we know how the portal vein is connected with the umbilical vein and sepsis through the umbilicus will disseminate through the umbilical vein through the left to the left portal vein and then from the left portal vein to the entire border circulation. And that usually results if it is not treated or delayed treatment. And diagnosis or results in portal vein, thrombosis and a huge sly on the patients and the family. And you know, the health care resources, neonatal sepsis in general, mainly um the um um N ECs, that's also one of the causes of of border vein thrombosis. And then any abdominal surgery, you know, it might, you know, if there is recurrence, there is recollection even like a appendicectomy, recollection of B and appendicectomy. You know, both appendicectomy can result in initiation of inflammatory process. That inflammatory process will interfere with aboral venous flow and will result in in thrombosis. So its umbilical catheter, um um umbilical vein catheter has been associated strongly with thrombosis of the border vena system. Just from the systematic review. They had reviewed all the studies about border vein thrombosis from 1980 to 2 hun 2020. There was 16 studies, there was more than 1406. The pediatric patient included in this and they came up with a day with, with, with um conclusion of that significant association of portal vein thrombosis with use of umbilical vein catheterization. Even if this umbilical vein catheter doesn't end up um septic. You know, even if it was inserted for one day, the mechanism is not sepsis when it comes to umbilical vein um catheterization, it is more like creating a hostile environment in the center that I was drained. We used. Well, there was a habit of measuring the in and the he the bal vein at the time of doing biliary atresia, you know, where we opened the umbilical vein, you know, we cannulated it. We attach the um arterial um um arterial venous arterial like transducer that measured arterial. It used to be practiced before. But they found that it's been associated also with umbilical vein, um uh with, with, with, with the portal vein, thrombosis, although it's done under complete aseptic technique. so it looks the mechanism is like creating a hostile environment in that endothelium that results in thrombosis in the in the portal vein. So, um this brings us to the the neonatal umbilical vein. Um um a neonatal portal vein thrombosis, this topic, diagnose and management because I'm sure all of us have seen it or have heard it or have been consulted at some point about a child who's been diagnosed with a brutal vein thrombosis. It's kind of recently usually, you know, as I'm not talking about the child who presents with symptomatic as the child was like a baby presented, you know, and then detected. Unfortunately, usually those one detected and kind of and incidentally, you know, we I don't II feel that, ok, I can't see that there is under diagnosed because there is under investigation of um bal vein after sepsis, which I think we need to change this habit. It only requires an ultrasound Doppler ultrasound to detect those after a child diagnosed with severe sepsis. Either he's been diagnosed with ac or with omphalitis or have multiple recollections or major abdominal trauma. I think a follow up ABDO ultrasound is a good idea to detect um the umbilical ve uh the um portal as early as possible because you've got a very short window to act if you've got a criteria to act on that, you know, there is no consensus in the literature about the indication. However, um there are one of the absolute indication where you, when you diagnose a thrombus that that is extending, you know, if you follow up on that and you feel and you see that this thrombus is getting bigger and bigger, then that's an absolute and it's the only absolute indication to start an anticoagulation on this baby or this child. But again, you need to detect this, you need to have high risk of high indic of suspicion to see which one was at high risk of throb. And you can, if you detect it early, you have a window 5 to 6 weeks to react. Unfortunately, if this got um missed and diagnosed after six weeks, that thrombus will be organized will be fibrotic and then anticoagulant at six weeks after six weeks will not be an effective and will make, will make no difference. So, the usual history of portal vein thrombo is that 70% of them actually resolve spontaneously. The other 30 person, um 18% of them are not complete. Um obstructive thrombus and only 12 person who are the one who developed thrombus, complete thrombus obstructive causing portal and um extrahepatic portal vein hypertension. So, once detected, if it is extending it, of course, it needs to be taken from patient to patient, discussed with the family. But then you need to see if you would like to start anticoagulation. Again. There is very weak evidences. There is there is very little literature about this. Um but um yes, but um starting um anticoagulation if there is extension of thrombus is is very important. So other associated finding with extrahepatic portal vein obstruction can be failure to thrive neurocognitive function, deranged liver function. Also that something has been introduced because um um um historically, it was thought that portal vein, extrahepatic portal vein obstruction, it's just something that not affecting the liver. Usually you you've got normal liver function. No, there isn't. This is not true anymore. There is the liver function with time would affected what's called volte biliopathy. You will get to prolong the PT PTT and I NR and the albumin liver will be low. All of those usually get reversed with, with, with, with, with, with a proper faso shunting. So this is this is what we are talking about. So, procedure for both hypertension has undergone significant changes over the time from nonselective shunts from both systemic shunts to fistulation shunt from completely nonselective to the selective ones. So we will go through those one quickly just gonna highlight some of them of historic and significance and some of them are, are, are, are very important to know about them and parameters we should consider before thinking about portal hypertension and, and shunting. Is that the course, what's the course prehepatic intrahepatic, what is the liver function tests? And if there is a biopsy that definitely will make the decision much easier. So the biopsy is very important whenever possible. And then the symptoms and complications both hypertension. Are we talking about a child who's got upper gi bleeding or he's got hypersplenism? Sometimes it's a bit different, difficult or a bit different actually to deal with with one of the decision making wise and then the status of the portal circulation. Do you have an be portal vein? Do you have a bit suber mesentary vein? How is the inferior mesenteric vein and a and a subic vein doing you know, how is the left renal vein doing all of the status of the portal circulation? You need to have a full understanding and a full information before embarking to any kind of surgery and the choice of cc choice of the surgical intervention. I said it depends on, on all of these factors needs to be all processed together and and then um a decision needs to be made. And of course, the choice of the shunt depends on availability of radiography for a specific diagnostic modalities all and the experience of the um um you know, of the team about and how comfortable they are with that. So, from the entire presentation today, I would focus on this slide if you go home with this slide. I think you get the, um, the message of the, of the, of the, um, uh, presentation. So, surgeries for both hypertension broadly divided into shunt surgery and non shunt surgery in shunt surgery. You've got the non filer shunt and you've got the fist allergic shunt that restores the blood towards the liver in the non f allergic shunt. Basically, we're diverting the blood away from the liver. So we're trying to divert part or all the blood from the liver away from the liver. So that will decompress the border circulation. It's, it's subdivided into nonselective shunts which was of historic and no one is doing those anymore. And I don't really advise for those. And then we've got the selective shunts which still both to systemic nonphysiologic, but they are selective shunts. So they have less complication, less morbidity. And then the facio shunts which should restore the hepato be flow, which we're talking about the MS shunts, we will go through it quickly and then we have the non shunt surgery which is either surgical control of varices, which is also not being done anymore these days where you tie all of these communications between the upper esophagus and lower esophagus. Those um, like, um, um, blood vessels does the the, the venous drainage tributaries that, that causes um the varices. It has, it used to be practiced in, in, in the past. But it, it, it, it um it, it, the outcome is extremely poor. Then we've got the splenectomy and splenic embolization that also can be considered. But if we are talking about hypersplenism in a child that is a lot of bleeding, but he got hypersplenism, then splenectomy can be considered. Then sigo procedure. Also, it is one of the hysteric things. However, it's still been practiced actually in some countries and they have very good results in terms of controlling the bleeding. However, it carries a huge morbidity. Yes, but it controls the bleeding if you don't have any other options. And of course, liver transplantation is the gold standard, you know, for management of portal hypertension regardless or despite the cause of that. So, nonphysiologic shunts we've got in the non under the nonselective one, we've got Porto Caval shunts or Mesocaval shunts from the name Porto Caval from the portal vein to the cava vena cava meso cava or blue exhibit severe renal shunt. Then we've got the distal um non uh the distal nonphysiologic is a selective one, distal spin renal shunts war shunt or side to side spin renal shunt. Um um So as we mentioned, so we'll start with the two side, Porto Caval shunt. So basically, as it says, as we can see here, the portal circulation is gonna be decompressed through the portal vein to the side. So from in and so from end to side, end of the portal vein to the side of the IVC, it from the name and you can see it will divert the entire border circulation there. Um that will result in encephalopathy. It will result in reduction of the blood supply to the liver. As we know the blood supply of the liver comes from diabetic artery on the bal vein. The portal vein provides 60% of the volume of the blood comes to the liver and 40% of the oxygenation and mainly it goes to the bear chem of the liver, hepatic artery. It's uh provides 60% of the oxygenation, about 40% of the volume. And mainly it supplies the bear chema but mainly supplies the bile ducts. So if you've got a problem with diabetic artery, we're gonna end up with um multiple strictures in the bile ducts. But the liver will survive, the liver will survive mainly on the on the on the portal vein. So it support the blood flow is very important for. So this is this is really not an ideal situation for the child to give side to side baso caval shunt that can be a bit more selective. So where where the portal vein, the side of the portal vein is an Asma to the side of the er vena cava that allows some portal flow to the liver. Um However, it will affect your um operation. Technically, if you planning this child later for liver transplant, because the portal vein has been already violated. There, there is a hole, there is anastomosis that you need to close, you know, and that will make the further the subsequent portal to portal liver transplant, anastomosis a bit more um unsafe and and and will increase the risk of further um um thrombosis H type misu shunt which is um also one of the Barkley like it is not a complete shunting um or it is not um yeah, a total diversion of the portal flow. It's basically an um an um either A N or synthetic uh vein between the subrecent vein and the in and vena. So in this one, they, they, they, they developed this trying to maintain a normal portal vein so that you don't um affect the further surgery of transplant there so that you operate on the severe mesenteric vein. However, to get to the severe mesenteric vein, you need to dissect really in the root of the mesentery. There is a risk of vascular injury there, there is risk of thrombosis in the border circulation. And then at the time of transplant, you need to come and tie this um this uh um um um graft, you know, or if you've got like angio um angio um um interventional radiology, it can be angio embolized, you know, prior to the surgery. But again, this is a partially diverting this is one of the option. But again, it's not the, it's not the ideal one in a proximal splen shunt. And we're still under the nonphysiologic and nonselective or selective and, and uh go to systemic shunts in the proximal splenorenal shunts. You take the, the, the, the, the splenic vein. Here, you cut the splenic vein, your anastomosis to the renal vein and need you to do a splenectomy because the spleen is going to be left without venous drainage. So, in this, you see you divert most of the blood virus inferum is in vein. And if you both high resistance in the liver and the border circulation, also the blood from part of the blood from the suber mesenteric vein will flow retrograde through the through, through the, through the splenic vein and to the in the renal vein and back to the systemic circulation via the inferior meric vein. So that's also is really not advised for these two reasons. It will cause encephalopathy. And again, you're gonna deprive this child from the spleen. And with it's all um immunologic um and overwhelming sepsis, then we come to the selective shunt. So of the selective shunt, we will talk about the distal screen shot was first described by the um the, the um American surgeon William Dean Warren in 1967. When he published his 67 patients series, you know, in the annual of pediatric surgery about distal sp and shunt, he described it the original um distal splenorenal shunt um where he ties the um Infero meric. Uh he ties the Infero Meric vein, you know, to the uh splenic vein. However, um and, and he ties the left and right gastric veins, you know, to the portal vein, which is not advised these days. So what we're practicing these days is what's called modified Warren Shunt. Actually, we don't really practice the exactly what Warren Shunt described. What he described is to take the, the splenic vein anastomosis to the left renal vein, tie the the the inferior mesenteric vein, tie the left and right gastric veins here. Um um However, tying those veins, you know, will make the subsequent liver transplant is a bit more problematic because we need to think about that these days. So in this, in this sh this is a selective chance. It doesn't expose a child to the risk of. Um a measure. I would say there will be a minor encephalopathy, but there is no measure an encephalo because you're only diverting, you're only decompressing this part of the circulation, the splenic part of the border circulation. So, trying to decompress the stomach, you decompress the esophageal viruses. At the same time, you maintain blood flow uh through the main portal circulation from the small bowel and also from the stomach here as we can see. So you maintain, you try to maintain a some flow from the left and right gastric to the portal vein. So that in subsequent um liver transplant, you know, you can tie this shunt and by tying that shunt, you need to take the splenic vein. But by doing that, you're still maintaining flow from the stomach flow from the esophagus, flow from the esophagus. Then it's gonna go through the bath of least resistance and it will flow back again through the right and left gastric veins. And at the time of the shunt, before liver transplant, there will be a resistance to the mortal vein. So the blood will prefer to drain through the short gastric to the splenic vein uh to the left renal vein. And it's not gonna go through the right and left gastric veins because there is an increased portal pressure. However, when you do a liver transplant, you solve the portal vein problem or the liver cirrhosis. So there will be an reduced um resistance of flow of the portal vein through the liver. So tying the um the the this shunt and taking the spleen will be the best option and then the blood will restore flow through these gastric veins. So that's why we practicing a modified Warren shunt with trying not to tie the left and right gastric veins. So that leaving the liver transplant as an open option for this shot whenever available again. So this is just to show the anatomy of the um aboral flow. And how's that going through there? So here this is just an A CT scan um to show um um the bo the the splenic vein here, we can see this is a child with a portal hypertension. And we are considering still for um um um distal splenorenal shunt. This is the splenic vein here that's going from the spleen. This is the subir mesenteric vein. If you can see here, they both beat with each other behind the neck of the pancreas. You can see this is the pancreas and then forming the trunk of the portal vein. And all of a sudden the portal vein disappear and got replaced with so many veins there. This is the portal cavernoma. So this is exactly explains what's happening with the portal veno. So instead of having one trunk of the portal vein, you've got b small branches, collaterals that trying to um bypass the obstruction in the portal vein here and drains back to the liver. If we continue with the scan here, we are not gonna be able to identify proper portal vein vein trunk. There is no proper, proper portal venous branches inside of the liver making um the option of distal sp sp renal shunts is impossible for this child. Um ok. So we're just gonna go to the next one and another um selective shunt is the side to side splenorenal shunt. We don't really recommend this. It is a selective, however, because it's side to side, it maintains splenic flow and renal flow. The problem here, it gets thrombosed quickly. The success rate is very poor because the flow is not the best. So there is always low flow here because the blood is going through 22 veins. So you don't achieve that the needed flow and for to maintain your, your, your, your, your, your shunt working, you need a very good flow through that shunt. Otherwise it's gonna thrombo. So this is one of the downsides of this um of this shunt. One of the other shots are both two systemic shots, which it's 30 minutes. Huh? Thank you. OK, cool. I will go quickly. Now um it's the um in the transjugular intrahepatic portal systemic shunts, which is uh they go through the internal jugular vein to the hepatic veins and then they shunt, you know, the interventional radiology, they, they, they introduce a shunt that connect directly between the portal vein and the hepatic vein. Usually it's those ones are very good to bridge the patients to the liver transplant without me exposing the child to major surgery and all of that and adhesions. Um Omar please don't rush. It's going very, very well. So I OK, I request you to go uh at a normal pace or even a bit slowly it's going OK? Even if we're talking in a bit more time. Ok. Don't worry. Please don't r OK. Thank you. OK. Ok. Ok. So um yes, so that's the um transjugular intrahepatic systemic shunts. So, and it's really good. Uh Again, in the terms that it takes a, it, it, it bridge the child to liver transplant. It doesn't need to expose the child to open surgery. Yes, it comes with its own like complication of um encephalopathy because you, you, you, you, you're gonna di divert the blood directly from the portal vein to the hepatic vein, bypassing the bench of the liver, which usually it, it um fibrotic and resistant to the flow. However, it, it has the advantage of not messing with the vasculature of the child and making the further liver transplant a straightforward procedure. So it's, it's, it's important. We're trying to work that we in Red Cross. Currently, we're trying to regain back our interventional radiology which most of hopefully by the middle of next year, we'll be able to, to do this and, and uh we will see how things go. Um Then we come to the physiologic shunts and of the physiologic shunts, we only got the um the mesh shunts. It completely um changed the paradigm of extrahepatic portal vein obstruction on all days. Extrahepatic portal obstruction was approached as an liver like intrahepatic, you know, it's been the same options offered to the patients here. This is a completely different options. Um It restores the blood flow back to the liver and results in a normal flow and it doesn't um impact the liver um function and or accelerate the liver deterioration. So, in this here, we can see the obstruction in the portal vein and there is a flow, there is a blood that can't flow there. And then, and what happens then these are, this is the, this, this is the collateral that open. This is the portal cavernoma, this blue blue blood vessels that you see here. This is the portal cavernoma. So this is the part of the body physiology trying to overcome the obstruction at the portal venous um like trunk. So small tributaries will open and there will be like lots of them and open and that will maintain part of the flow there. But the flow will be going through these veins with resistance and that will increase the pressure in the border circulation. However, we will provide blood supply to the liver through this cavernoma. So this is the border vein carcinoma. These are the many branches the tribu that we see on the CT angios and making surgery um especially in the later stages. When someone with this problem for a long time, the longer it takes, the more um complex cavernoma and the more difficult the operation it gets because you need to dissect around the porta habitus and you will end up with like a huge like complex network of small veins around. So the dissection needs to be meticulous, needs to be very slow and um under very well controlled environment. In expert hands here, this is the rex vein here. This is the red arrow here, I'm pointing to the area of the R vein. So, rex vein, it is the part of the portal vein that communicate with the umbilical vein. We're all aware of the um um uh fetal circulation where the blood goes through the umbilical vein. The oxygenated blood goes through the umbilical vein and from the vein goes, goes to the left portal vein and then from ductus Veno from the left portal vein to the IVC and then goes back to the heart and go to the brain. So the communication between the umbilical vein and the left portal vein is called Rick's vein, which is the area of, of, of, of the shunt of this, of, of this skull. Before considering a child for misery, there are prerequisites that must be available in this child to make him eligible for, for, for, for, for this. First of all, the pre it, it needs to be a prehepatic moral veno obstruction doesn't work. And if there is a liver cirrhosis and there need to be a bat Rix vein, there's, there will be, it must be be because the anastos needs to be there. The blood needs to flow flow there. So confirming bat C of Rix vein is another point is a complete whole topic, whether you need to use CT Angio. It is really not specific. The specific diagnostic accuracy of CT angio to detect be Andri vein is only 50% and we will come to that quickly. And then you need to have a bat and superior mesenteric vein because the anastomosis is gonna between these two veins and you need a bat and left renal vein just in case if this doesn't work, then you need to consider this shot for another shot. So it is good to know beforehand. What option you have, you cancel the, you counsel the be about the option in case you can't do this or you, you've been told that there is a risk vein, then you go, you dissect it around it, there is no blood flow. Now, what to do are you gonna close? Are you gonna, so it's good to consider all of these options and to discuss beforehand, this is my first option and um splenorenal shunt and then my second option. If that is not working, I'm gonna do a distal spleen shunt and see, explain the advantage disadvantage of every one of them. So you've got a Plan b in theater. If you, if one gland is not working also, you need to have adequate size vein for interposition um to use it as a native um venous conduit. The best vein to use is the internal jugular vein. Before that you need to make sure that you've got patent two internal juggler veins, both of them are patent. So, um that's, that's, that's very important to know pre preoperative um imaging ri vein, as I said is a whole topic but quickly going through that the gold standard of imaging R vein to make sure. So this is the rex vein here. It is the vein between segment two and segment three. And we can see it here. So the best technique to use or the best modality is what's called widget heba vein portography. Ct Angio can give you information MRI Angio can give you some information, but the accuracy rate of them is only 50% in widget hepatic vein portography. Um It is up to 90% accuracy like sensitivity and specificity in this procedure. The interventional radiologist use a catheter. He, they go through the right internal jugular vein, they cannulate right internal jugular vein. They go into the er uh the suberu vena cava and then to the inferior vena cava and through the inferior vena cava, they cannulate the left hepatic vein and then through the left hepatic vein, they push a contrast, they, they inject a contrast. This contrast thing goes through the bench of the liver and then contrast the portal vein system and tells you exactly if there is an be an eri vein you can see here. This is the left portal vein, this is S two vein, segment three vein and the piece of the left portal vein between sig two and segment three is the um rex vein. Um Widget hepatic vein portography is the best modality. Yes, it is not available. Used to be available at Red Cross. Unfortunately, at the moment, it is not available. Again, we've got to plans to make it available hopefully in the next six months or so. It's really important, gives valuable information and it makes the decision making much easier. Um This is just to show um again, this is the, this is the ri vein here. This is segment two vein up there. This is segment three vein. These are branches of the bal vein to segment four and it is the vein. So this is the whole left um uh Boral vein. So this is how the um mesor shunts works or how is the anastomosis. So it's between, you've got an obstruction in the main trunk, you need to bypass this obstruction. So that that was they call it mesh bypass. So you anastomose a venous conduit between the sub me in vein. And that's why it's important to know if the sub me in vein is ba or not. You don't want to discover this in theater. You need to know that this hands and then and the other part of the anastomosis as the vein. And by that, you're creating a bypass as like a detour where you, you divert the blood away from the obstruction back to the left um portal vein and from the left portal vein through the communication goes to the right portal vein and through the bench of the liver because it should be normal liver and going back to the circulation. So this is just one of the photos that one of the patients that we operated three or four years ago. And yes, this is the umbilical vein where it shows the left portal vein. We dissect, we take bridge of the liver there, we dissect around it. This is the dissection here and this is, this is the rex vein opened here and then this is the final anastomosis. This is the venous conduit, internal jugular vein um between the um left um, rex vein and, and the severe is in vein. And we published our series in 2023. We operated in 15 me shunt and seven shunt over the last um like 18 or 17 years, 21 shunts has been done at Red Cross Hospital with very good um um success rate, um complication of shunt surgery just to make it short. Mainly it's shunt thrombosis. That's the nightmare for surgeons shunt thrombosis. When you they, when you ask for a double ultrasound, they tell you, unfortunately, we can't identify the shunt or there is no flow or if they said we can't identify that's um, it equals to there is no flow. So that's what you don't want to hear. You don't, you wanna hear that? Yes, there is a clear flow which got a very good Doppler signal. So, shunt thrombosis, you can mitigate this by doing a proper surgery by the big wide anastomosis, maintaining the child on anticoagulation heparin infusion, um 10 to 15 units per kg per hour over like 5 to 6 days until um like the child is recovered, you know, until the flow and the other like collaterals closes because as we know the blood flow follow the the bath of least resistance. So when you do the shunt, initially, there will be lots of other O2 shunts like open here and there throughout the entire body. When you uh do a shunt, the blood will follow the bath of least resistance. If you've got a good anastomosis and a good caliber white anastomosis, the blood will start flowing through the this. If you maintain it for 5 to 7 days, the other collateral varices that has opened will start closing slowly and pushing the blood to flow through this. So you 5 to 7 days are the the like the the best days that you can work on to prevent thrombosis on there. Then you need to maintain this child on, on, on aspirin or clopidogrel, both of them and plate it for at least three months after that until full indication of the new shunt. And then you see how this and you follow up with, with, with a double ultrasound bleeding. It's usually rare. But remember you are operating usually on Children with or hypertension, there will be lots of collaterals, there will be lots of oozing, there will be lots of tributaries that's open. So you need to go slow, you have a blood on board, you have blood products available, you know, and consent for blood transfusion. And all of this K ascitis also is one of the significant complication because you do dissection at the root of the mesentery where all the main lymphatic is going through. So try to use bipolar rather than mono bo during dissection. If you feel that you um opening a big lymphatic channels, you can take a stitch, you can trans, you know, fix or ligate or figure of eight to minimize the, um, the, the, the, the, the callus ascitis at the end of surgery have a look for five minutes. See if there is a clear leak, you can leave the drain. Um, otherwise you don't really need to leave a drain there. But yes, chus ascitis is one of the, of the significant risks in dissection whenever you dissect in the retroperitoneal, but mainly in the shunt surgery. If you go into the root of the mesentery, looking for the S MV and the um, and the portal vein. So that was about the shunt surgery. And the other part of it is the non shunt surgery. I have to say most of those surgeries is not really done in regular basis, but it, it, if you go and look at the literature at some centers, it's still really practicing this and, and, and, and it gives some options. As I said, if you don't have other options of shunt, you don't have an option of liver transplant, then you might it, it worth looking at other other available option in your center. And I know the circumstance in Africa, if some, you know, in some that will be looking at this option as no, no one is doing those anymore. It's of historic importance. Why you need to expose the child. Well, if you don't have any other options, you know, the child is gonna die, you know, like if you don't have liver transplant option, if you don't have shunt, you know, option to do it, then then what else you can do? You can't just watch this child if you don't have the ability to do and regular endoscopic ligation and sclerotherapy every three weeks, you know, if the Children don't have an access for that and the Children, unfortunately, one day they're gonna bleed and then they will die, you know, in the community. So I think it's still, there's still a rule for those um options, but it depends, you know, on availability of expertise or availability of, of access to theater to do these things. So, ligation of vs I said this is the least um preferable option where you, you ligate the is the communication between the um gastric and esophageal, you know, um connections, you know, you go and via laparotomy, you identify the connections and you tie them. However, it's a, a high failure rate because the child will develop more and more. So um that for, for this option, I don't really think that's a very good option. Splenectomy and splenic embolization. As I said, it works on certain contexts. So only works well or the best result if we're dealing with an a one of the complications for hypertension, which is hypersplenism when you've got a big spleen that consuming the platelets, consuming the white cell count and, and, and, and causing, and you know, and consuming the red blood cells also. So, and, and, and, and, and expose the child to the risk of bleeding. Some Children present with a massive spleen that going through the pelvis down. So it's minor trauma in this child will result in uncontrollable splenic and bleeding, you know, and the child will die within a couple of minutes. So, considering splenectomy, either partial or total or splenic embolization if it is available, otherwise open or laparoscopic splenectomy can be an option to treat hypersplenism in those patients. And then we've got what's called esophageal transection and anastomosis, what's known as Siga procedure and other procedure described it by a Japanese surgeon where you disconnect and the uh and you disconnect the, the, the stomach from the esophagus. So, so you cut through the esophagus, you disconnect the stomach from the esophagus and you redo anastomosis at the same time there and you do a splenectomy with it. This will will cut off or will terminate, eliminate all the connections, all the naturally occurring, um, normal anastomosis or that is not opened, it will be completely disconnected and it's not gonna regain, um, communication anymore. So, when you anastomose, you know, yes, you will have a risk of esophageal leak, that's the problem. You will have a massive laparotomy. It's a, it's an, a procedure with a morbidity. However, the result actually of this is very good, um, in terms of controlling the bleeding, if we're talking about bleeding itself, it really has a good result. Yes, it's a, it's a procedure with a measure morbidity. It's a pro procedure that I do not really advise to go through this. But sometimes, you know, when your body is sinking, you know, if you don't have any other option of that, you can't just sit and look at the child, you know, and, and, and, and, and just saying, oh, ok, I'm gonna leave him to, you know, I can't do this procedure. This is a high morbidity. You, well, a bleeding is, is, has a high mortality. So sometimes you need to choose between something bad and the worst. You don't have the luxury to choose between the best and, and something else. So, um sour procedure, it's yes, it used to be a strength thoracic operation then modified to be completely via the abdomen and disconnection of the stomach from the esophagus and ligation of that recommunication. So, which patient you can consider with is the patient with recurrent bleeding with sufficient viruses who are not cirrhotic ideally. But even in cirrhotic, it can work and they have no shunt shunt options and there is no access to transplant. Those ones you still can consider. And I think from in a, in a pediatric surgeon dealing with Nissen, dealing with IC Atresias dealing, we got expertise on doing this if it is needed. As I said, it is not the ideal, it's not the first options but even the second option but stays at the bottom of the list. It is an available option. If the only option for the child is to die, then that that that will provide some relief. We did mention just going back to this slide, we did mention about varies ligation. There was lots of literature reviews about this was done in five fifties and sixties and eighties and all of them has proven that this is unsatisfactory outcome and it's I think it can be taken out of the options for water hypertension. Um final thought in this um presentation. So portal hypertension can be controlled with different um aspects, medical endoscopic surgical modalities. You need to understand the anatomy, the anatomy is the most important things. Um Before you go in there, you need to have a proper um um uh like diagnostic modality liberate, you need to use CT Angio liberally. If, if this is the only technique that's all modalities available, you need to have a very good and you go with the radiologist, speak with the radiologist, discuss with other centers, discuss with people who got the expertise with that. They can guide you through either, uh, National South Africa or out of South Africa. And we're happy to have any discussion with any patients about this and see if any options can be offered for this patient, you know, online or, um, if we meet in any meeting. So shunt surgery, particularly me shunt is the best for extrahepatic definitely. But if this shunt is this option is not available, distal spleen renal shunt, what's called Warren shunt would be the next option. Please avoid uh you umbilical vein catheterization to the best of your ability. I know it's sometimes needed, try to use peripheral lines, try to use central lines, you know, try to avoid umbilical vein catheterization. It has a huge implication on portal vein thrombosis and on and on, on on portal hypertension. And it has a huge sequel of that and it definitely can be replaced with something else even if you take care of it, even if it's the best, you know, um antiseptic technique used, it still has 50 to 70% brisk portal vein thrombosis. And the problem is not just in the portal vein thrombosis, you know, sorry, even Children. And in our study in many other studies that have been done on, on extrahepatic portal vein obstruction, Children who's got extrahepatic portal vein obstruction, secondary to um umbilical vein catheterization. They do extremely bad with meso shunt. You do the C angio or wid hepatic vein orography. You see a bait and thrix vein, you do the anastomosis and the shunt doesn't work. They got very extremely high risk of thrombosis like one out of six, uh only might work and, and, and, and even doesn't work properly with, with, with appropriative law, five out of six will thrombo even if they are candidate with fulfilling all the criteria, just the fact that they're having a history of umbilical vein catheterization carries an extremely high risk of shunt failure. So please try to avoid using umbilical vein catheterization. At least that's a life saving. Of course, that's a completely different circumstance and completely different scenario. But don't jump and use this as a first option as an IV access for a baby, a liver transplantation, of course is the gold standard for management of this and uh Children with portal hypertension and embedded liver function or for those that they don't have an access to shunt um surgery. This is the end of my presentation. Thank you so much, so much and sorry for taking this time. I think I've taken an almost an hour for that. No, no, no, Omar, please. Uh I didn't want you to stop honestly. Uh You, you taught us so well, Omar, I'm so pleased that, that, that we invited you to give this talk. And uh and I see there are lots of uh registrars uh uh who are attending uh the, the, the meeting and they must just um they may just uh uh go back ii will make the recording available to them and they must watch it repeatedly. Um And, and understand what you have taught us in these 50 minutes. And it is really invaluable lessons you have taught us Omar and I wish you convey this message to our pediatric and neonatology colleagues. Please do not use umbilical vein catheterization because I think even in private a few years ago until uh probably uh a younger colleague came in, they were doing umbilical vein catheterization for almost all premature newborns who needed uh TPN and things like that. But you have highlighted it strongly enough for us to really not consider it at all. So I thank you for that. And um I there are lots of senior colleagues who are attending and I'm going to take their opinions and their comments. Just um one very sad experience, Omar. Uh We were waiting for you to get appointed here in at Red Cross and we had a child, a four year old boy who had extrahepatic portal hypertension. And he we we um banded his varices multiple times and one of our colleagues from other part of the country, uh they did uh a shunt, I think it was a distal shunt and I'm not sure whether they followed the protocol which you just told us about intravenous heparin, Clexane, uh, aspirin. I certainly don't think the child was on aspirin. Maybe. I'm, I'm, I don't have enough information. Unfortunately. Exactly. Within a month the shunt got blocked and, and, and we couldn't get the child back into the unit where the child had the surgery because there was no ICU bed and the child died. He bled to death in front of us. So, our entire department was massively traumatized because you exactly said the child was died. We were pouring blood and blood products and he was pouring them out. So, so I think it just because you have done a formal fellowship in transplant and and you have worked with people starting, you started with Prof Miller who was our teacher and guru about uh these things like me. I still remember these things were asked regularly in the exam. What is the X ray? Well, how do you do me and exactly how you described the procedures and tips, etcetera is because those things are very important. So I will, I will get one question at a time. Uh Doctor B Nandi is here. I'm sure you know him. He is, he is a pediatric surgeon in L Malawi. Thank you for attending. And he says that we have seen a few Children with hepato portal vein, thrombosis and portal cavernoma that have mild intrahepatic duct dilatation, normal bilirubin and normal or near normal. Uh It's uh I don't know what exactly he means does the cavernoma cause some biliary obstruction or what causes this? And does this have any bearing on the surgery you choose? Yes. Um So we, you, you remember like when I showed that cavernoma transformation, so all of these dilated veins, you know, it will dilate at the border hebitis, you know, and it will cause compression, you know, and, and compression on the small bile ducts, you know. So, so this, this these veins are going to bypass the border veins, going to go inside the liver. And it will cause compression on these small bile ducts or intrahepatic biliary just at the time where they coming into the right and left main hepatic duct. So it will cause some sort of obstruction. So that's one part of it yet, it will cause some sort of obstruction and interruption of the flow and it will cause edema around the porta hebitis and it will interfere with the peristalsis through these ducts, you know, because they need the peristalsis of that. So that's one thing. The other thing is the reduction in the portal flow, you know, to the liver also will cause this, as we mentioned because the portal blood, the portal vein brings the substrate, brings the nutrition, brings the amino acids, glucose and also brings the the the the trophic hormones, you know, from the sp planning. So the splanchnic circulation actually acts like an endocrine organ where it secretes some hormones, some trophic hormones that stimulate the growth, you know of the liver. So I depriving the liver from this blood because there is an obstruction and most of the blood is bypassed through the collateral shunts. You know, either from spleen from the lumbar or some of them, they develop spontaneous spleen renal shunts, but a huge one. So most of the blood in sub and by the liver and that derives the liver from these substrates from this amino acid, from this trophic hormones. And that results the combined effect of this results in what's called bi bi bi biliopathy, hepatic biliopathy, orta biliopathy. Yes. Thank you very much. Omar. Uh uh We have doctor Ka uh Hermona, you probably know her. She is. Yes, of course. She was very maybe corear with you. Um And, and yes, thank you, Congea for joining. She's joining from win. And she has asked you a specific question with governors transformation of the portal vein if planning for a mod, how far from the portal vein is the, is the splenic vein transected, transected? Ok. Yes. So, and you need to go and decide. Yes. So what you're trying to achieve in this, you need to have a smooth angle, you know, you need that splenic vein to go smoothly. So it's going to be anastomosed end to side, end of the splenic vein to the side of the, of the, of the renal vein, you know, so what you don't want to have an acute angle where the splenic vein comes directly down there because that's going to affect the flow through the vein. So you need to have enough lens that allows you to do a smooth to side with very like like minor angulation, you know there. So I would say it's difficult to give a number but you can get as much as possible. However, you don't also want to end up with a tortious, you know, like vein, you know, so you need to have a straight anastomosis that is not tor but it is not under tension and it is not going entering the renal vein at an acute angle. The best angle to enter is at 45 degrees with the renal vein. Even when you cut, you cut it oblique, you know, it's like when you do a bowel anastomosis, you know, where you do sometimes like you tib or you cut back, you know, like um spatulate back. So it's something the same, you try to get in a 45 angles that's going into the, through the, through the renal vein. So try to get as much as possible. You know, you need to maintain, you can give half a centimeter or something so that you don't violate the portal vein there, you know, so don't get into the confluence because you might need that influence, you know, for anastomosis. And when you do a subsequent, you know, yeah, subsequent um um um liver transplant but leaving half a centimeter one centimeter should be enough with the confluence of the portal vein. So that's one thing. The second thing just to make sure that you don't twist the splenic vein, you know, when you anastomose to the renal, it's very easy to get twisted, you know, to the right or to the left, you know, and that will result in a twist. This vein is very thin, it will be dilated. A minor twist will result in shunt thrombosis. You know, it will interfere with the flow and result in shunt thrombosis. So it's very important to take a stitch, decide what is the superior part and what's the inferior part before you, you cut the vein. You know, before you dissect it, you got to resect this vein. Take a stitch decide where is the upper part, where is the lower part and then you can cut the vein and then you plan your anastomosis so that you knew that you did not um twist that and you always test it, you know, and if you feel if there is a any twist, you have to redo the anastomosis. Otherwise there there will be high risk for thrombosis. I hope this answers the question. No, II loved your answer. Omar the way you explained in minute details. I think cona if I can give you some unasked for advice, if you have a patient, just get uh Omar to visit you and, and line up the surgery and he will do the surgery with pleasure with you because there are so many minor technical details which I think only a person who with transplant experience can, can deal with these facts. But thank you so much. I need to go, I can't live without my colleague here. We work together so they must um I can I make a comment? Thank you very much for joining. I didn't know when you joined. So please. Yeah, sorry, I was traveling and, and I miss the first part of the and it's very nice to see you were talking about that. You just got to be care that you the the the retractors because if you have the retractors on intention and, and then do a very nice anastomosis, you might find that when you release the, the um retractors, you actually have a kink in the uh in the splenic vein as it comes down onto the renal vein. So just to be careful of that, but just a comment, the uh what do you do? Um because I've usually put basically all the patients that have a, a a warrant shunt on Duac lifelong. Um because I'm sure that they eventually develop a degree of encephalopathy as the, as the uh pressures, more or less equalize. And I don't know what the practice in Birmingham is at the moment, but they, they, they, they don't broth honestly, like I haven't seen, they, they don't they don't give them any, um, doac, any lactulose, you know? Yes. Um, to avoid, you know. So, so they, they really don't, um, practice that anymore and I have to say, like they've done it a couple of times and I, II have, we haven't really seen, you know, that bad, you know, encephalopathy. There, there, there might be some degree but it looks like it's quite tolerable. I don't know, maybe in the long run. But what I've seen, no, it's, it's, I think it's very, very, I think it's very, very subtle and it really comes on often in adulthood and I've discussed it with Wendy Spearman and she agrees that maybe it's a good idea too anyway, it's a thought. But, but the other thing is, what is the strategy when you've had a splenorenal? Yes. And the patient comes up with transplant. Yes. What do you do with the splenorenal shunt? Well, you need to tie that and do a splenectomy. So that's what they, you know, it's because that's going to affect the portal flow. Unfortunately, if we keep that shunt working there, it's going to compromise the portal flow, you know, the volume of the blood go to the portal vein. So that will increase the risk of um thromb vein, thrombosis. So, um I have to say it's been different practice. But what we've been practicing and what I found also in, in literature is that you need to tie that shunt and you do a splenectomy by that you're going to augment. And for that reason, and I've seen that, you know, when we do it, we try not to tie the right and left gastric vein, we leave them so that when you tie the shunt the blood now is gonna flow back, you know, from the stomach because otherwise you're gonna lift without lift the stomach, without any venous drainage. If the spleen is taken out short, gastric is taken out left and right. Gastric is taken out and, you know, the stomach is not going to drain properly, you know, or the stomach circulation. So, taking, tying the shunt and taking the spleen, that's to augment the blood flow. Not everyone has been um practicing this and it doesn't mean that if you don't do that, there will be definite boal vein thrombosis, but it looks that there is an increased risk of thrombosis if you don't die. It. All right. Thanks very much. But I'm very sorry. I missed the first part of your talk, but it's lovely to see you back. And, um, obviously, uh, you've got a great responsibility on your shoulders being the HPV surgery for the part of the country. Thank you so much. Thank you very much. Thank you so much. The pleasure is really ours and, uh, and, uh, we are so honored that, uh, you could find time, uh, and, and you joined, uh, and, and I'm sure like me you are also delighted to see one of your students Omar now teaching us all about uh about what is right and what is not right? So those who do not know, I think everybody in South Africa knows Professor Miller. So Professor Miller and South Africa. So everywhere I take, but still for the newcomers who do not know him, he is actually the teacher of our teachers. So he's one of the ultimate gurus in pediatric surgery in South Africa. And uh he was previous Professor Emeritus at Red Cross. He also worked in, in Birmingham for 3 to 4 years where Omar worked recently and, and we are really very, very happy and delighted to have him and, and give his comments. Prof thank you again. Um I've got a few other, I think I have to say that um, II have to think a very good colleague in Birmingham who we mentored through pediatric surgery. And as who um I think worked with, uh with for most of the period that he was there, I think we all have a great deal of respect for. Absolutely. Thank you. There was a great luck trans dissemination of experience from, from you directly to college and our team and to us and we're trying to teach everyone here. So, um, thank you so much. You started this journey and you've been pushing us, we're trying to continue and to add as much as possible and of what we can. Thank you so much. Thank you. See you. We are completing the circle. The circle is getting completed. Coming back to South Africa. Yes, exactly. Thank you. Yes, thank you. I've got a few other colleagues to ask their comments. Uh I see Nira Patel is here. Doctor Nira Patel is a, is a pediatric surgeon at Baragwanath Hospital in Johannesburg. He has special interest in Hepatobiliary surgery, uh nea um uh any comments from you? Uh No, no, thanks. Thanks. A very nice do um I do have one question. Yes. What's your, what's your experience with um centralization? Uh Basically failure of Dean warrants over time. Um Yeah. No, no, no, no, no, no. I mean, like, like uh what's your experience of success rates for Dean Warrens over time? So, if you do a patient and he's five years old, how, how long, I mean, if, if the shunt stays patent, do you expect him to have no um recurrence of esophageal varices? No recurrence of um is splenomegaly throughout the course of his life or do you think that over time? Um You know, the, yeah, exactly the portal pressures were equalized with the systemic pressures and uh you'll develop um you'll develop uh port like vision after that or symptoms of vision. A very good question. Thank you. It is actually. So we all agree like if thrombosis happened, you know, that's a very bad thing and, and, and, and the symptom is gonna come back immediately. You know, the problem, what happens actually is reduction in the floor. So it's stenosis, you know, what's more common to happen is the stenosis first. So usually if the ch did not throw immediately in the first, like I would say, when I say immediately, I'm pointing to like the first month or something after surgery, usually it gets the nose before it gets thrombosed. You know. So if it's like thrombosed or closed, like within two years, it means that this shunt has gone through, reduced the flow first where this shunt could have been actually salvaged, you know. So the problem is why it got stenos. There are multiple reasons. One of the things actually of theories, you know, any anastomosis is at, at the risk of stenosis. So that's just to start with. The other thing is remember, like we usually use brule, you know, and continuous suture to do the anastomosis, then the child and you do it for a child who's like two years old or three years old, something he's gonna grow, you know, but then this um circumferential brule six or 70 ANAs is not gonna grow, you know, at least you use a growth factor, you know, depends on what kind of, but usually what's been done is um continuous suture all around, that's not gonna allow further growth. So what has been accepted for this child in terms of dime and flow when it's three years not gonna be enough when it's five years or seven years. And that will unfortunately will result on in, in, in one of the factors that will result the other things, as I said, if, if it got to know what, what's the, the, the, the, the, the, the resistance is gonna go more, the pressure is gonna go more, then another um collaterals will open in other, you know, parts and then it will contribute to the reduction in the flow and the reduction in flow is equal to thrombosis. So there are a couple of factors. But what I would say, if there is a possibility or ability to do a close, very close, they need very close follow up, they need very close and they need almost lifelong actually, anticoagulation, you know, if there is a risk of thrombosis or if there is the reduction of flow and the other thing is interventional radiology, dilatation, you know, of the shunt if you did take this year. So um the problem I understand here and in, in, in South Africa and African General, even if it is done, usually the the the follow up is not as great as it should be, you know, they need very close follow up in the first couple of weeks, you know, and they need to be on actually. And I said I've seen them like abroad, they use an aggressive anticoagulation, you know, approach, you know, they keep them on heparin infusion for seven days when they use a huge large doses of heparin up to 10 to 20 international unit per kg per hour and heparin infusion for seven days, then they keep them in um a clopidogrel and double like clopidogrel and aspirin, you know, for a very long time can be up to one year or two years. And some of them actually, they continue with that, you know, until they transplant them. And this is the other thing, you know, they usually end up with transplant. But in our circumstances, usually some of them, they don't end up and they entirely depend on this. So we do see this uh complication more often and, and with longer time. So yes, um I would say it's reduction in flow stenosis and, and, and the, the, the not a block that needs a bit more aggressive, you know, approach with anticoagulation. Can I just make a comment that although it's a bit of a pain, but I almost always did interrupted ans for the anterior layer? Exactly. I think that's the right thing to do because it has been happening. It's been reported and one of the main problem is this thing, you know, and, and you know what I think part of it because most of the shot has been done by adult surgeons. So they deal with adult, like dealing with pediatric and they forget that they did with the three years old who's still gonna double the size of everything within another 34 years. So using interrupted suture, thanks for is, is at least for the interior wall will make a difference on the long term, will allow a growth of this and they will reduce the risk of thrombosis later on. Such a such a fine technical point. Thank you, prof yes, Nira. Yeah, I just wanted to say Omar you make like like like the most important point is that we do it when the Children are young and then they grow and then if you don't monitor them intensively, if you don't put as much work into following them up as you do into working them up and doing the operation at some point, you're going to have the same problem, the patient will develop portal hypertension even if you've done the best operation there, you know, you might have done the best operation for that child, but you need to accommodate for the change in the circumstances, you know, for what's going on, you know, do we need to add more? Is the reduction flow? Can we add more? Can we admit, do we need to do dilatation, balance, dilatation and all of these things that will mitigate if you don't do that? And you know, the child get released or the child doesn't default, you know, the follow up. Unfortunately, at some point, you know, it it it will, it will close, you know, I think, I think, you know, has has raised uh a very valid point as surgery, uh preoperative preparation, surgery, but postoperative follow up and management and early diagnosis of complications and a prevention. Basically, as you have repeatedly told us about extensive anticoagulation for a prolonged period of time. So, thank you. I've got two or three questions and comments to take for one question from Dr Arua Obasi. I is a pediatric surgeon from Nigeria. He's asking please any advice on the proper placement of umbilical catheters to minimize the incidence of this pathology. Ok. So the best not to watch it at all honestly and not to use it. But I do understand again, I don't wanna be like that person who's being, you know, I do understand that sometimes it's life saving. So that's a completely different if it is life saving and you can't find any other, you know, uh central access because intraosseous access is another, you know, thing that can be used. However, I'm not sure about in unit, but I would avoid it to the best of my ability, you know, unless it's a life saving, then that's a completely different. If you've done that, at least, at least within 4 to 6 weeks. If you can have a Doppler ultrasound and follow up on the portal vein, it will be very good to detect. If there's a thrombus, you detect it within the first six weeks before it becomes organized thrombus fibrotic and it's still at the golden window, you know, the where, where, where they can respond, you know, to some anticoagulation, whatever is that, you know, so that will be great, you know, but doing that umbilical vein catheterization and then completely ignoring, removing that and sending the child to the community, you know, he will have a 70% possibility of portal vein thrombosis, you know, so like it's very high. So it needs at least it worth a follow up if you have to do it. But there is no specific way to mitigate this. But as I said, even what they found out in the Children during biliary atresia, you know, when um we used to practice this regular at Birmingham where we measured the portal vein pressure immediately on theater. When we do, when we want to do like CAA we open the abdomen, we open, we cut the umbilical vein, you know, and we put a catheter, you know, a JCO there and then we attach a transducer from the arterial pressure um monitoring, you know, system and then we read and we check the pressure there just to compare it and to see did the child develop portal hypertension already or not? So it gives you a very good reading, you know, of what is the portal pressure, you know, at that time because it's in their communication with the left portal vein, you know, and then you die. However, in a study, it, it showed that actually those Children who had been um used this practice with had a higher risk of thrombosis. Although it's done under complete aseptic technique in theater with a pediatric surgeon doing that, you know, there is no risk of sepsis, still creating a hostile environment in that area will increase the risk. So, umbilical veins, catheter will always cause this risk whatever you use. No, I like your answer. Omar do it only if it is absolutely life saving. Use it for the shortest period of time and at least 4 to 6 weeks later, do a proper color Doppler ultrasound and and find out what's happening to the portal vein. Thank you very much. I've got two people to ask comments. Sorry, go ahead if you wanted to say something. Yes. And if you start it, if you committed, you know, to treatment as I said, the only, yeah, um absolute indication is you have a progressive, you know, thrombus. Yeah, or if you choose, you need to go to at least, you know, three months, you know, a minimum of three months of treatment, you know. Yeah, of anticoagulation with heparin. And um if you start it, yes. So I've got 22 weeks or three weeks or something. I think you need up to three months. Yeah. Yeah. So, so I've got two more people to ask their comments. One of them has already asked a question. Professor Saro is one of the senior pediatric surgeons in the country. And he has asked you, do you ever use PTFE grafts? Um The answer is it so it, it can be used? But the answer is no, we try to avoid that because within 3 to 4 years or within two years, the risk of thrombosis is higher and within two years, you need to change it, you know, three years, you know. So the answer in pediatric again, we try not to use it. You know, we always try to look for a native event. Again. There is no right or wrong answer if this is only what is available, if you don't have any other option, if this is gonna save his life, of course, I would use it, you know, we can bridge him, you know, for 23 years and then you never know what can happen if he's got a chance to have a liver transplant or something else or, you know, it does not absolute no, but it's not preferred is not the first option. No. Thank you Omar. And I think uh the last person I would like to uh ask for comment is your own colleague, doctor to Tula who uh most of us know in the country. Uh a bright uh lady pediatric surgeon. Uh she's there, she's there. So she's with me. Hi, how are you? I'm good. And you? Well, thank Yeah. So, so I think now you are, are partnering with him about liver transplants and the transplant programs. So I think uh your comments probably will be the last comment. Yeah. No, thank you. I won't take up much time because I can, you've already gone. But I think um we really have great ideas with regards to Hepato Bi and transplants. Um But I think the most important thing from almost talk is identifying the right patient, having a good indication of what you're actually doing, understanding the anatomy of what you're doing, having really great imaging with an understanding of that imaging and, and the distinction between the medical and the surgical approach with regards to how you're going to approach this um this patient as well. I'm also trying to at some point centralize a service so that you can really get and get good outcomes. Yeah, that's a, that was a great, yeah. Yeah, perfect. I think, I think you have really summarized it very well and I support both s uh views and, and you are both of you. I think these surgeries should not be attempted by occasional pediatric surgeons at all. They need to be done in a center like exactly what you have um uh uh taught us now, told us now and, and uh you need to have experience, you need to have all other uh colleagues like interventional radiology imaging and I, by the way, I loved your um interactive uh models. Yes. So just to explain, you know, yeah, to make it or you know, so that people doesn't get this and fall sleep. You know, I was worried that people, I love them. I really love them so well. Thank you. I think now your final take home message one minute. Yes. So, um, as I think has, has summarized it, everything they so choosing the correct patient, early diagnosis, follow up, you know, very important. You can't just do a surgery on a child and see him once in one year or two years or expect him to continue. You know, if you're doing a surgery, if you're committing to doing a surgery, you need to also commit to follow up on that postoperative care is as, as important as the surgical technique and preoperative, you know, having an aggressive, I would call it aggressive postoperative, you know, um, um, care protocol clear, you know, and protocol and understood by everyone, you know, and it's, it's very important. So, and selecting the patient as, as mentioned, that's all, uh all of these factors interact with each other and will impact your success. It is not just one factor enough. They have done a good surgery, then the child must know you might done the best surge. You might be the best surgeon in the ward and your, your shunt will close the second day if you didn't do the right, you know, precautions, if you didn't select your patient properly, if you did not follow, you know, the, the, the, the the steps that has been thoroughly investigated and, and advised in the literature and all of these factors, as I said, interact together and, and, and, and gives you the best outcome for the patients. Thank you very much, Omar. It was really, it's, I can say it was the pinnacle of our 2024 Zoom invited talks. It really uh II can't, I just didn't realize how 100 minutes have passed and we still uh enthusiastically talking and, and, and, and uh to learn. So if you, if you don't mind, stop sharing, I just want to share um our about, about our. So, so thank you very much. Uh uh everybody so who has, has um attended today and uh and uh and uh sorry, so, so and, and, and uh posted uh very interesting questions and participated in the discussion and I certainly have learned a lot today and I'm sure uh the other colleagues, especially the, the registrars have learned a lot. And um so II wish you well for, for the holiday period and, and wish you well for the new Year. The next Zoom academic meeting will only happen on the second Tuesday of February. And uh as we are completing 30 years for the foundation of our Department of pediatric Surgery in East London. We have been honored to host the B South African Association of Pediatric Surgeons Conference from the first to the fourth of May 2025 at a beautiful Beach Resort, which is just outside East London. And uh we have uh a really um uh uh enlightened and, and uh faculty uh as, as you can see, eb from Malawi who works with Dr Be Nandi and then Dr Simon Abib from Brazil, Dr Shah from Mumbai, Dr Hafiz Abdela from Professor John LA. Most of us, you know in South Africa from Cape Town, Dr Sujit Chaudhury from New Delhi, Dr Sait Annan from New Delhi and Dr Raju Saui from Nur in India. These are all the invited guests. So the registration will open early in the new year and it will be widely advertised in all the available platforms. So I encourage not only colleagues from South Africa but also from the rest of Africa and outside to consider visiting this beautiful part of the world and be our guest in the first week of May. So again, thank you very much. Thank you Omar and we will meet on the zoom in the second week of February. Bye bye now. Thanks broth. Have a lovely day.