Mitra shunt (spleen preserving, side to side lieno-renal shunt) for portal hypertension with hypersplenism in early infancy
A 4-month-old male child was referred to us with repeated episodes of melena and progressive abdominal distension. The baby had umbilical sepsis at 3rd week, treated with intravenous antibiotics for 7 days. At 2 months of age, baby developed progressive abdominal distension, associated with a low grade fever, and repeated bouts of melena. During hospitalization in a remote district Hospital, he was found to have low hemoglobin (5 g/dl), leukopenia, and thrombocytopenia requiring blood transfusion. A second admission for melena prompted the physician treating the baby to refer the baby for further investigation and management.\nAt admission, the baby was mildly dehydrated, had pallor with marked abdominal distension. Massive splenomegaly was present along with ascites and melena. Blood investigations revealed hemoglobin levels of 6.5 g/dl, total leukocyte count of 2,800/mm3 and a platelet count of 39,000/mm3. The liver function tests were normal. A complete coagulation profile done to rule out any congenital coagulation defects was found to be normal. The endoscopic examination revealed Grade 4 esophageal varices with daughter varices, with a normal stomach and duodenum.\nUltrasonography (USG) [], contrast computed tomography (CT) scan, magnetic resonance imaging (MRI) abdomen [Figures and ] and endoscopy were done in another hospital before admission to our center. The diagnosis at this stage was established as extrahepatic portal venous obstruction (EHPVO) leading to portal hypertension and esophagogastric varices with hypersplenism. The parents were offered medical or surgical management for the condition highlighting the outcome of both approaches. Since they were from a remote district with no local medical facility and baby was small, they opted for surgical management.\nOn midline exploration, he was found to have ascites, large congested spleen. Splenic vein was identified by lifting the transverse colon cranially so that the pancreas got rotated along the whole body and tail. Pancreaticosplenic vein disconnection was done with individual ligation of tributaries and a good segment of splenic vein dissected for side-to-side anastomosis with left renal vein. The rest of the surgery was performed as the original description of Mitra et al., several years ago from Chandigarh.[] It was possible to construct a 1 cm long patent wide anastomosis despite the splenic vein being 5 mm across. The spleen was visibly changing on the operating table itself after the shunt was allowed to function. Postoperatively, the child required 1 day of ventilatory support without any inotropic support. Intravenous anticoagulation was started in the perioperative period and continued till the 10th postoperative day. Oral feeds were started by day 7 after surgery.\nIn the postoperative period, the hematological parameters steadily kept improving and spleen gradually regressed to half its size. The platelet count had reached over 100,000/mm3, total leukocyte count had risen to 6,400/mm3 and hemoglobin was 10.5 g/dl. Doppler evaluation was done on the 10th postoperative day to confirm shunt patency. At 6 months follow-up, spleen is just palpable with no features of hypersplenism and esophageal varices have regressed.