The aim of the thesis is to increase the efficacy of surgical treatment for portal hypertension in children, by optimizing the choices of mesocaval bypass. We analyzed the direct and long-term outcomes of different types of mesocaval bypass surgery in 68 patients in different ages. The average age was 9 years ±6 months. Prior to operation all children underwent clinical investigation that consisted of performing: blood tests, ultrasound study of the abdomen, upper endoscopy, contrast enhanced computed tomography. To detect the variance of portal hypertension we measured the portal pressure during operation before and directly after performing the bypass. After the operation all children underwent laboratory testing and instrumental studies: blood tests, and an ultrasound of the abdomen to see the level of decompression of the portal system according to the change in spleen size (reduction) and to study the blood flow in the bypass and see how the surgery effected the portal liver perfusion. We also conducted contrast enhanced computed tomography to visualize the anastomosis in the post- operative period. According to a retrospective study of unsatisfactory results of portosystemic shunting, we implemented the growth factor technique for fine vascular anastomosis (T.E. Starlz, 2009) for mesocaval shunting in children with portal hypertension. This gave us the ability to prevent and lessen early thrombosis and stenosis of anastomosis in the follow- up period.After a detailed analysis of the anatomical particularities of the portal system found in children with portal hypertension at computed tomography, we stated three types of splenomesenteric confluence.According to the different types of splenomesenteric confluences we made up a statistical probability and possibility of conducting different variants of mesocaval shunting. Approaching the individual topographical anatomy in children that underwent surgery, we underlined how the preference for different types of mesocaval shunting should be made. In children who had prior operations to mesocaval bypass we explained the choice of mesocaval shunt. As a result of such study we developed a differential approach for performing different types of mesocaval shunting. We performed 30 (44,1%) side-to-side mesocaval shunts and 38 (55,9%) were H-type mesocaval operations.Cases where children received a mesocaval bypass as primary surgery made up 31 (45,6%) occasions, and in 37 (54,4%) cases children had prior operation. There were 12 (17,6%) patients who had surgeryperformed againts the backgroung of bleeding, and in all cases we achieved reliable hemostasis. In the follow- up during different time periods (1-3-6-12-24 months) we observed the dynamical change in portal perfusion and spleen size after different variants of mesocaval bypass.Thus gave us the ability to understand the degree of deportalization after bypass surgery. After surgical treatment we also studied the regression of varicose vessels to understand the decompression effect on the portal system after different types of mesocaval shunts. Based on the comparison of treatment results after various types of mesocaval shunts it was proved that the biggest decompression effect was observed after performing a side-to-side shunt as opposed to the H-type anastomosis, and the difference in changes of hepatic perfusion after these types of shunts was not significant. Mesocaval bypass surgery can be performed as a primary operation (in cases when the splenic vein is unfit for shunting) and as repeated surgery. The selection of the type of mesocaval shunt depends on the particularities of the splenomesenteric confluence. Clear indications for performing the various types of mesocaval shunts were developed, which allowed the reduction of recurrent bleeding from varicose veins in children with portal hypertension.In general we detected that after performing the mesocaval bypass preassure in the portal system decreased by 33,6% (р<0,05) in average, and reduction in the spleen size was by 28,4% (р<0,05). Regresion of varicose was seen in 82,4% (р<0,05) of children, and only 8 (11,8%) patients presented with recurent bleeding which required redo- surgery. Conclusively we state that a mesocaval bypass can be the method of choise when conductingsecondary shunt operations for children with portal hypertension.It can also bee used as primary surgery under the surcumstances of inability to perfom a shunt with the splenic vein. The mesocaval shunt privides adequate decopresion of the portal system, prevents recurent bleeding and is a reliable method of surgical hemostasis for children with acute bleeding from the varicose veins.
