Novel Bedside Ligation for Staged Closure of Congenital Portosystemic Shunts: A Single-Center Experience in 20 Children

Purpose To report our institutional experience with a portal venous pressure (PVP)-guided surgical strategy for congenital portosystemic shunts (CPSs) and introduce a novel bedside ligation technique for staged shunt closure. Methods We retrospectively reviewed 20 children who underwent surgical CPS closure between 2013 and 2023. The surgical approach was determined by intraoperative PVP during temporary shunt occlusion. One-stage ligation was performed when PVP remained < 25 mmHg, whereas shunts with PVP ≥ 25 mmHg were banded for staged closure using either bedside ligation or endovascular completion. Results Fourteen patients (70%) underwent one-stage closure (median PVP: 22.0 mmHg, interquartile range IQR: 18.0-22.5), and six (30%) required two-stage closure (median PVP: 28.0 mmHg, IQR: 25.8-29.5). Among the latter, five achieved complete shunt occlusion through the bedside technique, avoiding reoperation or readmission. The primary composite outcome—radiologic closure, fasting blood ammonia normalization, and absence of severe complications—was achieved in all 20 patients (100%) at 1-year follow-up. Significant intrahepatic portal vein (IPV) remodeling was observed, with median left and right IPV diameters increasing from 1.4 mm and 1.6 mm to 4.8 mm and 5.0 mm, respectively (both p < 0.0001). The overall complication rate was 15% (3/20), all Clavien-Dindo Grade I-II. Conclusion In children with CPSs unsuitable for endovascular closure, a PVP-guided surgical strategy appears safe and effective. For those requiring two-stage closure due to elevated PVP, bedside ligation after Endoloop banding provides a feasible, less invasive alternative to reoperation. However, larger studies are needed to confirm its safety and efficacy.