Editorial Portal Diversion for Portal Hypertension in Early Childhood THE RESULTS with portal to systemic venous shunting procedures as described by the authors are truly spectacular with 21 of 23 children shunted under the age of 6 years maintaining patent shunts. Since most previous reports concerning construction of portal to systemic venous shunts for extrahepatic portal hypertension under the age of 8-10 years have indicated between a 50-90%9 shunt thrombosis rate, it would be of great interest to have the authors explain in more detail the modifications in surgical technique which they have used in order to obtain such tremendously improved operative results. Although the authors suggest that all children with extrahepatic portal venous obstruction are shuntable, this has not been the experience of most other surgeons since the inflammatory process associated with portal vein thrombosis often involves the splenic and mesenteric veins as well, making vascular anastomoses to these structures very difficult technically and very likely to result in thrombosis. Previous experience also indicates that if a shunt thromboses, the subsequent variceal hemorrhage is likely to be more severe than before shunting, and that multiple reoperations for complications are common. The authors have recommended shunting at a young age for many chil-

dren with portal vein thrombosis who have only experienced one minor bleeding episode and have operated upon 5 children who have had no bleeding. Prophylactic portal to systemic venous shunts for extrahepatic portal vein thrombosis is in direct contrast to the recommendations by almost all other authors on this subject since a sizable per cent of patients with portal vein thrombosis will experience fewer and less severe bleeding episodes as they reach adolescence. The possible harmful effects of splenectomy in infants and small children in relationship to the immune response and resistance to sepsis, have been reviewed in previous reports. Although the authors suggest that once a small child has been shunted, his future course might be anticipated to be uneventful, recent reports by Voorhees and others indicate that encephalopathy, and perhaps other deleterious effects may develop years following portal to systemic venous shunts. This report represents a unique surgical experience in the management of extrahepatic portacaval shunting in infants and young children and the authors are to be complimented for their very enviable results.

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ERIC W. FONKALSRUD, M.D.