1
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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2
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Natali GL, Cassanelli G, Paolantonio G, Parapatt GK, Gregori LM, Rollo M. Pediatric liver cirrhosis interventional procedures: from biopsy to transjugular intrahepatic portosystemic shunt. Pediatr Radiol 2023; 53:727-738. [PMID: 36121496 PMCID: PMC10027841 DOI: 10.1007/s00247-022-05492-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/15/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022]
Abstract
Cirrhosis is a complex diffuse process whereby the architecture of the liver is replaced by abnormal nodules because of the presence of fibrosis. Several pediatric diseases such as extrahepatic portal vein obstruction, biliary atresia, alpha-1-antitrypsin deficit and autoimmune hepatitis can lead to cirrhosis and portal hypertension in children. In this article the authors describe interventional radiology procedures that can facilitate the diagnosis and treatment of diseases associated with liver cirrhosis and portal hypertension in the pediatric population. These procedures include image-guided liver biopsy, mesenteric-intrahepatic left portal vein shunts, balloon-occluded retrograde transvenous obliteration, transjugular intrahepatic portosystemic shunts and splenic embolization.
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Affiliation(s)
- Gian Luigi Natali
- Interventional Radiology Unit in Oncohematology, Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio, 4, 00165, Rome, Italy.
| | - Giulia Cassanelli
- Interventional Radiology Unit in Oncohematology, Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio, 4, 00165, Rome, Italy
| | | | | | | | - Massimo Rollo
- Interventional Radiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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3
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Cifuentes LI, Gattini D, Torres-Robles R, Gana JC. Band ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2021; 1:CD011561. [PMID: 33522602 PMCID: PMC8094619 DOI: 10.1002/14651858.cd011561.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children and adolescents with chronic liver disease or portal vein thrombosis. Prevention is, therefore, important. Randomised clinical trials have shown that non-selective beta-blockers and endoscopic variceal band ligation decrease the incidence of variceal bleeding in adults. In children and adolescents, band ligation, beta-blockers, and sclerotherapy have been proposed as primary prophylaxis alternatives for oesophageal variceal bleeding. However, it is unknown whether these interventions are of benefit or harm when used for primary prophylaxis in children and adolescents. OBJECTIVES To assess the benefits and harms of band ligation compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, and two other databases (April 2020). We scrutinised the reference lists of the retrieved publications, and we also handsearched abstract books of the two main paediatric gastroenterology and hepatology conferences from January 2008 to December 2019. We also searched clinicaltrials.gov, the United States Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the World Health Organization (WHO) for ongoing clinical trials. We imposed no language or document type restrictions on our search. SELECTION CRITERIA We aimed to include randomised clinical trials irrespective of blinding, language, or publication status, to assess the benefits and harms of band ligation versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. If the search for randomised clinical trials retrieved quasi-randomised and other observational studies, then we read them through to extract information on harm. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to perform this systematic review. We used GRADE to assess the certainty of evidence for each outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We used the intention-to-treat principle. We analysed data using Review Manager 5. MAIN RESULTS One conference abstract, describing a feasibility multi-centre randomised clinical trial, fulfilled our review inclusion criteria. We judged the trial at overall high risk of bias. This trial was conducted in three hospital centres in the United Kingdom. The aim of the trial was to determine the feasibility and safety of further larger randomised clinical trials of prophylactic band ligation versus no active treatment in children with portal hypertension and large oesophageal varices. Twelve children received prophylactic band ligation and 10 children received no active treatment. There was no information on the age of the children included, or about the diagnosis of any child included. All children were followed up for at least six months. Mortality was 8% (1/12) in the band ligation group versus 0% (0/10) in the no active intervention group (risk ratio (RR) 2.54, 95% confidence interval (CI) 0.11 to 56.25; very low certainty of evidence). The abstract did not report when the death occurred, but we assume it happened between the six-month follow-up and one year. No child (0%) in the band ligation group developed adverse events (RR 0.28, 95% CI 0.01 to 6.25; very low certainty of evidence) but one child out of 10 (10%) in the no active intervention group developed idiopathic thrombocytopaenic purpura. One child out of 12 (8%) in the band ligation group underwent liver transplantation versus none in the no active intervention group (0%) (RR 2.54, 95% CI 0.11 to 56.25; very low certainty of evidence). The trial reported no other serious adverse events or liver-related morbidity. Quality of life was not reported. Oesophageal variceal bleeding occurred in 8% (1/12) of the children in the band ligation group versus 30% (3/10) of the children in the no active intervention group (RR 0.28, 95% CI 0.03 to 2.27; very low certainty of evidence). No adverse events considered non-serious were reported. Two children were lost to follow-up by one-year. Ten children in total completed the trial at two-year follow-up. There was no information on funding. We found two observational studies on endoscopic variceal ligation when searching for randomised trials. One found no harm, and the other reported E nterobacter cloacae septicaemia in one child and mild, transient, upper oesophageal sphincter stenosis in another. We did not assess these studies for risk of bias. We did not find any ongoing randomised clinical trials of interest to our review. AUTHORS' CONCLUSIONS The evidence, obtained from only one feasibility randomised clinical trial at high risk of bias, is very scanty. It is very uncertain about whether prophylactic band ligation versus sham or no (active) intervention may affect mortality, serious adverse events and liver-related morbidity, or oesophageal variceal bleeding in children and adolescents with portal hypertension and large oesophageal varices. We have no data on quality of life. No adverse events considered non-serious were reported. The results presented in the trial need to be interpreted with caution. In addition, the highly limited data cover only part of our research question; namely, children with portal hypertension and large oesophageal varices. Data on children with portal vein thrombosis are lacking. Larger randomised clinical trials assessing the benefits and harms of band ligation compared with sham treatment for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis are needed. The trials should include important clinical outcomes such as death, quality of life, failure to control bleeding, and adverse events.
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Affiliation(s)
- Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Gana JC, Cifuentes LI, Gattini D, Torres-Robles R. Band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2020; 11:CD011803. [PMID: 33164205 PMCID: PMC8078550 DOI: 10.1002/14651858.cd011803.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including haemorrhage from oesophageal and gastrointestinal varices. Variceal haemorrhage commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. In adults, numerous randomised clinical trials have demonstrated benefits of non-selective beta-blockers and endoscopic variceal ligation as primary prevention in decreasing the risk of variceal haemorrhage. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, primary prophylaxis is not the current standard of care in children because it is unknown whether those treatments are of benefit or cause harm when used for primary prophylaxis of oesophageal variceal bleeding in children and adolescents. OBJECTIVES To determine the benefits and harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase, LILACS, and Science Citation Index Expanded (27 April 2020). We scrutinised the reference lists of retrieved publications, and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from 2008 to 2019. We searched ClinicalTrials.gov, FDA, EMA, and WHO for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We planned to include randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. If the search for randomised clinical trials retrieved quasi-randomised and observational studies, then we read them through to extract information on harms. DATA COLLECTION AND ANALYSIS We planned to summarise data from randomised clinical trials by standard Cochrane methodologies. We planned to assess risk of bias and use GRADE to assess the certainty of evidence per outcome. Our primary outcomes were all-cause mortality, serious adverse events and liver-related morbidity, and quality of life. Our secondary outcomes were oesophageal variceal bleeding and adverse events not considered serious. We planned to analyse data with intention-to-treat. We planned to use Review Manager 5 to analyse the data. MAIN RESULTS We found no randomised clinical trials assessing band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. AUTHORS' CONCLUSIONS Randomised clinical trials assessing the benefits or harms of band ligation versus sclerotherapy for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of band ligation versus sclerotherapy on patient-relevant clinical outcomes such as mortality, quality of life, failure to control variceal bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of these two interventions.
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Affiliation(s)
- Juan Cristóbal Gana
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lorena I Cifuentes
- Division of Paediatrics, Evidence-based Health Care Programme, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniela Gattini
- Gastroenterology and Nutrition Department, Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Romina Torres-Robles
- Sistema de Bibliotecas UC, Pontificia Universidad Católica de Chile, Santiago, Chile
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5
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Quintero J, Juampérez J, Mercadal-Hally M, King ML, Ortega J, Molino JA, Abu-Suboh M, Dot J, Nuño R, Montferrer N, Armengol JR, Charco R. Endoscopic variceal ligation as primary prophylaxis for upper GI bleeding in children. Gastrointest Endosc 2020; 92:269-275. [PMID: 32119939 DOI: 10.1016/j.gie.2020.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Variceal hemorrhage can be a life-threatening adverse event of chronic liver disease. In contrast to the well-described guidelines for the management of portal hypertension (PH) in adults, there is limited evidence about the optimal prophylactic management of variceal bleeding in children. This study was carried out to assess the efficacy of endoscopic variceal ligation (EVL) as primary prophylaxis to prevent upper GI bleeding in children with PH. METHODS From January 2014 to April 2018, all pediatric patients with PH disease and medium to large esophageal varices or reddish spots, regardless of the grade of the varix, were prospectively included in the protocol of primary prophylaxis with EVL. A second retrospective group of patients was made after reviewing medical records of 32 pediatric patients with PH that presented esophageal varices in the upper endoscopy and had received propranolol as primary prophylaxis. RESULTS Twenty-four patients (75%) reached varices eradication in the EVL group, with a median of 2 procedures (range, 1-4) before eradication and a median time to eradication of 3.40 months (range, 1.10-13.33). No EVL-related adverse events were observed. Statistically significant differences were observed in the bleeding rate at 3 years between propranolol and EVL groups (6/32 [21.9%] vs 1/32 [3.2%], P < .02). The hazard ratio for bleeding for patients treated with propranolol compared with those treated with EVL was 2.6 (95% confidence interval, 1.53-3.67). CONCLUSIONS EVL is a safe and effective treatment to prevent upper GI bleeding in pediatric patients with PH. (Clinical trial registration number: NCT03943784.).
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Affiliation(s)
- Jesús Quintero
- Paediatric Hepatology and Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Javier Juampérez
- Paediatric Hepatology and Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Maria Mercadal-Hally
- Paediatric Hepatology and Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Mauricio Larrarte King
- Paediatric Hepatology and Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Juan Ortega
- Paediatric Intensive Care Unit, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - José-Andres Molino
- Paediatric Surgery Department, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Monder Abu-Suboh
- Digestive Endoscopy Department, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Joan Dot
- Digestive Endoscopy Department, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Rosario Nuño
- Paediatric Anesthesiology Department, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Nuria Montferrer
- Paediatric Anesthesiology Department, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Josep-Ramon Armengol
- Digestive Endoscopy Department, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
| | - Ramón Charco
- HPB Surgery and Transplants, Hospital Universitari Vall d'Hebron, Universitat Atònoma de Barcelona, Barcelona, Spain
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6
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Palaniappan SK, Than NN, Thein AW, van Mourik I. Interventions for preventing and managing advanced liver disease in cystic fibrosis. Cochrane Database Syst Rev 2020; 3:CD012056. [PMID: 32227478 PMCID: PMC7104612 DOI: 10.1002/14651858.cd012056.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive inherited defect in the cystic fibrosis transmembrane conductance regulator (CFTR) gene resulting in abnormal regulation of salt and water movement across the membranes. In the liver this leads to focal biliary fibrosis resulting in progressive portal hypertension and end-stage liver disease in some individuals. This can be asymptomatic, but may lead to splenomegaly and hypersplenism, development of varices and variceal bleeding, and ascites; it has negative impact on overall nutritional status and respiratory function in this population. Prognosis is poor once significant portal hypertension is established. The role and outcome of various interventions for managing advanced liver disease (non-malignant end stage disease) in people with cystic fibrosis is currently unidentified. This is an updated version of a previously published review. OBJECTIVES To review and assess the efficacy of currently available treatment options for preventing and managing advanced liver disease in children and adults with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search: 19 November 2019. We also searched the reference lists of relevant articles and reviews and online trials registries. Date of last search: 01 January 2020. SELECTION CRITERIA Any published and unpublished randomised controlled trials and quasi-randomised controlled trials of advanced liver disease in cystic fibrosis with cirrhosis or liver failure, portal hypertension or variceal bleeding (or both). DATA COLLECTION AND ANALYSIS Authors independently examined titles and abstracts to identify potentially relevant trials, but none were eligible for inclusion in this review. MAIN RESULTS A comprehensive search of the literature did not identify any published eligible randomised controlled trials. AUTHORS' CONCLUSIONS In order to develop the best source of evidence, there is a need to undertake randomised controlled trials of interventions for preventing and managing advanced liver disease in adults and children with cystic fibrosis.
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Affiliation(s)
- Senthil K Palaniappan
- NHS trustDepartment of Medicine, University Hospitals of LeicesterLeicester Royal InfirmaryLeicesterUKLE1 5WW
| | - Nan Nitra Than
- Faculty of Medicine, Melaka‐Manipal Medical College (MMMC), Manipal Academy of Higher Education(MAHE)Department of Community MedicineMelakaMalaysia75150
| | - Aung Win Thein
- Melaka‐Manipal Medical CollegeDepartment of SurgeryJalan Batu Hampar, Bukit BaruMelakaMelakaMalaysia75150
| | - Indra van Mourik
- Birmingham Children's HospitalLiver UnitSteelhouse LaneBirminghamUKB4 6NH
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7
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Gattini D, Cifuentes LI, Torres-Robles R, Gana JC. Sclerotherapy versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2020; 3:CD011573. [PMID: 32133620 PMCID: PMC7059883 DOI: 10.1002/14651858.cd011573.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children with chronic liver disease or portal vein obstruction. Therefore, prevention is important. Primary prophylaxis of variceal bleeding in adults is the established standard of care because of the results of numerous randomised clinical trials demonstrating the efficacy of non-selective beta-blockers or endoscopic variceal ligation in decreasing the incidence of variceal bleeding. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, it is unknown whether those treatments are of benefit or harm when used for primary prophylaxis in children. OBJECTIVES To assess the benefits and harms of sclerotherapy compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase Elsevier, and two other registers in February 2019. We scrutinised the reference lists of the retrieved publications, and performed a manual search of the main paediatric gastroenterology and hepatology conference (NASPGHAN and ESPGHAN) abstracts from January 2008 to December 2018. We searched four registries for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA We included randomised clinical trials irrespective of blinding, language, or publication status assessing sclerotherapy versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to perform this systematic review. We used the intention-to-treat principle to analyse outcome data, and GRADE to assess the certainty of evidence per outcome. MAIN RESULTS We found only one randomised clinical trial that fulfilled our inclusion criteria. The trial was at high risk of bias. The trial included 108 Brazilian children with median age of 4.3 years (range 11 months to 13 years). Fifty-six children were randomised to prophylactic sclerotherapy (ethanolamine oleate 2%) and 52 children to no intervention (control). Children were followed up for a median of 4.5 years. Eight children (six from the sclerotherapy group versus two from the control group) dropped out before the end of the trial. The follow-up was from 18 months to eight years. Mortality was 16% (9/56 children) in the sclerotherapy group versus 15% (8/52 children) in the control group (risk ration (RR) 1.04, 95% confidence interval (CI) 0.44 to 2.50; very low-certainty evidence). Upper gastrointestinal bleeding occurred in 21% (12/56) of the children in the sclerotherapy group versus 46% (24/52) in the control group (RR 0.46, 95% CI 0.26 to 0.83; very low-certainty evidence). There were more children with congestive hypertensive gastropathy in the sclerotherapy group than in the control group (14% (8/56) versus 6% (3/52); RR 2.48, 95% CI 0.69 to 8.84; very low-certainty evidence). The incidence of gastric varices was similar between the sclerotherapy group and the control group (11% (6/56) versus 10% (5/52); RR 1.11, 95% CI 0.36 to 3.43; very low-certainty evidence). The incidence of bleeding from gastric varices was higher in the sclerotherapy group than in the control group (4% (3/56) versus 0% (0/52); RR 6.51, 95% CI 0.34 to 123.06; very low-certainty evidence). The study did not assess health-related quality of life. Oesophageal variceal bleeding occurred in 5% (3/56) of the children in the sclerotherapy group versus 40% (21/52) of the children in the control group (RR 0.13, 95% CI 0.04 to 0.42; very low-certainty evidence). The most prevalent complications (defined as non-serious) were pain and fever after the procedure, which promptly resolved with analgesics. However, numerical data on the frequency of these adverse events and their occurrences in the two groups were lacking. No funding information was provided. We found no ongoing trials. AUTHORS' CONCLUSIONS The evidence, obtained from one randomised clinical trial at high risk of bias, is very uncertain on whether sclerotherapy has an influence on mortality and if it may decrease first upper gastrointestinal or oesophageal variceal bleeding in children. The evidence is very uncertain on whether sclerotherapy has an influence on congestive hypertensive gastropathy, incidence on gastric varices, and incidence of bleeding from gastric varices. Health-related quality of life was not measured. There were no serious events caused by sclerotherapy, and analysis of non-serious adverse events could not be performed due to lack of numerical data. The GRADE assessment of each outcome showed a very low-certainty evidence. The results of the trial need to be interpreted with caution. Larger randomised clinical trials, following the SPIRIT and CONSORT statements, assessing the benefits and harms of sclerotherapy compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are needed. The trials should include important clinical outcomes such as death, failure to control bleeding, and adverse events.
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Affiliation(s)
- Daniela Gattini
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Gastroenterology and Nutrition Department, Division of Paediatrics, Santiago, Chile
| | - Lorena I Cifuentes
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Division of Paediatrics, Evidence-based Health Care Programme, Lira 85, 5º piso, Santiago, Metroplitana, Chile, 833-0074
| | - Romina Torres-Robles
- Pontificia Universidad Católica de Chile, Sistema de Bibliotecas UC, Santiago, Región Metropolitana, Chile, 8330074
| | - Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile, Gastroenterology and Nutrition Department, Diagonal Paraguay 362, 8th Floor, Santiago, Region Metropolitana, Chile, 8330074
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8
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The role of surgical shunts in the treatment of pediatric portal hypertension. Surgery 2019; 166:907-913. [PMID: 31285046 DOI: 10.1016/j.surg.2019.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/10/2019] [Accepted: 05/10/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Portal diversion by surgical shunt plays a major role in the treatment of medically refractory portal hypertension. We evaluate our center's experience with surgical shunts for the treatment of pediatric portal hypertension. METHODS All patients who underwent surgical shunt at a single institution from 2008 to 2017 were reviewed. The primary outcome was intervention-free shunt patency. RESULTS In this study, 34 pediatric patients underwent portal shunt creation. The median age was 7.7 years (interquartile range 4.3-12.0). Twenty-nine patients (85%) had prehepatic portal hypertension and 5 patients (15%) had intrahepatic portal hypertension. The primary manifestations of portal hypertension were esophageal varices (97%) and gastrointestinal bleeding (77%). Eighteen patients (53%) underwent meso-Rex bypass, 10 patients (29%) underwent splenorenal shunt, and 6 patients (18%) underwent mesocaval shunt. Outcomes were notable for minimal wound complications (9%), rebleeding events (12%), and mortality (3%). In the postoperative setting, 10 patients (29%) experienced a shunt complication (occlusion or stenosis), 4 of which occurred in the early postoperative period and required urgent intervention. The 1-year and 5-year "primary patency" patency rates were 71% and 66%, respectively. CONCLUSION Children suffer significant morbidity from the sequelae of portal hypertension. Our experience reinforces the feasibility of surgical shunts as an effective treatment option associated with low rates of morbidity and mortality.
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Partial Splenic Embolization Is a Safe and Effective Alternative in the Management of Portal Hypertension in Children. J Pediatr Gastroenterol Nutr 2019; 68:793-798. [PMID: 30908386 DOI: 10.1097/mpg.0000000000002332] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE There are multiple approaches to manage the clinical complications of portal hypertension (PHTN) to treat/prevent spontaneous hemorrhage by mitigating thrombocytopenia. No single approach is ideal for all patients given the heterogeneity of this population. Our goal was to determine whether partial splenic embolization (PSE) was safe and effective in the pediatric population. METHODS This is a retrospective review of our single-center experience for all patients ages 0 to 21 who underwent PSE between January 2010 and August 2017. The embolized splenic volume targeted was 60% to 70%. RESULTS Twenty-six patients underwent PSE due to thrombocytopenia and/or recurrent variceal bleeding. Patients ranged in age from 18 months to 20 years (mean 13.1 years). The median platelet count before PSE was 53.0 (×10/L). The platelet count improved after PSE with values >100,000 in 21 patients (80.8%). Children with prior esophageal varices showed improvement after PSE with only 9 (34.6%) requiring further endoscopic therapy. After PSE, patients developed transient abdominal pain, distention, fever, and perisplenic fluid collections. Serious complications such as splenic abscess, splenic rupture, bleeding, pancreatic infarction, opportunistic infection, or death were not observed. One patient experienced thrombotic complications after PSE and was later diagnosed with myelodysplastic syndrome. CONCLUSIONS PSE is a safe and effective alternative in the management of pediatric PHTN in select populations. PSE may be a favorable alternative to splenectomy and portal systemic shunting because it preserves functional spleen mass and avoids postprocedure accelerated liver disease or encephalopathy.
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Bertino F, Hawkins CM, Shivaram G, Gill AE, Lungren MP, Reposar A, Sze DY, Hwang GL, Koo K, Monroe E. Technical Feasibility and Clinical Effectiveness of Transjugular Intrahepatic Portosystemic Shunt Creation in Pediatric and Adolescent Patients. J Vasc Interv Radiol 2019; 30:178-186.e5. [PMID: 30717948 DOI: 10.1016/j.jvir.2018.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/28/2018] [Accepted: 10/06/2018] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To examine the technical feasibility and clinical efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in children and adolescents. MATERIALS AND METHODS Retrospective review was performed of 59 patients (mean age 12.6 y [range, 1.5-20 y], mean weight 47.5 kg [range, 11.4-112.2 kg], mean Model for End-stage Liver Disease/Pediatric End-stage Liver Disease score 12.5 [range, 6-33]) who underwent 61 TIPS attempts at 3 tertiary children's hospitals from 2001 to 2017 for acute esophageal or gastroesophageal variceal bleeding, primary and secondary prevention of variceal bleeding, and refractory ascites. Pediatric liver disease etiologies included biliary atresia, cystic fibrosis, and ductal plate anomalies. Technical, hemodynamic, and clinical success and patency rates were reported at 1, 6, 12, and 24 months. Statistical analysis evaluated reasons for clinical failure. Kaplan-Meier analysis measured clinical success, patency, and transplant-free survival. RESULTS Technical success was 93.4% (57/61) in 59 consecutive patients. Most common TIPS indications were treating and preventing esophageal and gastroesophageal variceal bleeding (57/59; 96.6%). Hemodynamic success was 94% (47/50). Clinical success was 80.7% (45/56). Two-year clinical success for acute variceal bleeding and ascites was 94.1% and 100%, respectively. Overall patency at 1, 6, 12, and 24 months was 98.0%, 97.8%, 94.3%, and 91.3%. Two-year transplant-free survival was 88.8%. Overall and major complication rates were 21.2% (13/61) and 8.2% (5/61), with 3 mortalities. Gradient reduction < 12 mm Hg correlated with clinical success (P < .01). CONCLUSIONS TIPS creation in pediatric patients is technically feasible and clinically efficacious for treatment and prevention of esophageal and gastroesophageal variceal hemorrhage. High 2-year clinical success, patency, and survival rates should encourage providers to consider portosystemic shunts as a bridge to liver transplantation.
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Affiliation(s)
- Frederic Bertino
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - C Matthew Hawkins
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Giri Shivaram
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Anne E Gill
- Divisions of Pediatric Radiology and Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew P Lungren
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Aaron Reposar
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Daniel Y Sze
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Gloria L Hwang
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Kevin Koo
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Eric Monroe
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
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11
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Young V, Rajeswaran S. Management of Portal Hypertension in the Pediatric Population: A Primer for the Interventional Radiologist. Semin Intervent Radiol 2018; 35:160-164. [PMID: 30087518 DOI: 10.1055/s-0038-1660794] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Interventional radiology's role in the management of portal hypertension in the pediatric population differs from the management of adult portal hypertension. In the pediatric population, portal hypertension is frequently secondary to thrombosis and cavernous transformation of the extrahepatic portion of the portal vein. Transjugular intrahepatic portosystemic shunt can be utilized to manage portal hypertension in children with intrinsic liver disease that results in cirrhosis and portal hypertension, and is often used as a bridge to transplant. While technically feasible in extrahepatic portal vein occlusion, the sequelae of portosystemic shunting are less desirable in a child. The Meso-Rex bypass procedure, which represents the mainstay of management for pediatric portal hypertension, provides surgical relief of extrahepatic portal vein obstruction and restores mesenteric venous blood flow to the liver. This article aims to review management of portal hypertension in children as it pertains to the interventional radiologist, including preoperative assessment, postoperative evaluation, and the management of complications of the Meso-Rex bypass.
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Affiliation(s)
- Victoria Young
- Department of Diagnostic Radiology, Northwestern Memorial Hospital, Chicago, Illinois.,Department of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Shankar Rajeswaran
- Department of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois.,Department of Pediatric Vascular and Interventional Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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12
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Leung DH, Narkewicz MR. Cystic Fibrosis-related cirrhosis. J Cyst Fibros 2017; 16 Suppl 2:S50-S61. [DOI: 10.1016/j.jcf.2017.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/01/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
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13
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Palaniappan SK, Than NN, Thein AW, Moe S, van Mourik I. Interventions for preventing and managing advanced liver disease in cystic fibrosis. Cochrane Database Syst Rev 2017; 8:CD012056. [PMID: 28850173 PMCID: PMC6483789 DOI: 10.1002/14651858.cd012056.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive inherited defect in the cystic fibrosis transmembrane conductance regulator (CFTR) gene resulting in abnormal regulation of salt and water movement across the membranes. In the liver this leads to focal biliary fibrosis resulting in progressive portal hypertension and end-stage liver disease in some individuals. This can be asymptomatic, but may lead to splenomegaly and hypersplenism, development of varices and variceal bleeding, and ascites; it has negative impact on overall nutritional status and respiratory function in this population. Prognosis is poor once significant portal hypertension is established. The role and outcome of various interventions for managing advanced liver disease (non-malignant end stage disease) in people with cystic fibrosis is currently unidentified. OBJECTIVES To review and assess the efficacy of currently available treatment options for preventing and managing advanced liver disease in children and adults with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books.Date of last search: 06 April 2017.We also searched the reference lists of relevant articles and reviews and online trials registries. Date of last search: 04 January 2017. SELECTION CRITERIA Any published and unpublished randomised controlled trials and quasi-randomised controlled trials of advanced liver disease in cystic fibrosis with cirrhosis or liver failure, portal hypertension or variceal bleeding (or both). DATA COLLECTION AND ANALYSIS Authors independently examined titles and abstracts to identify potentially relevant trials, but none were eligible for inclusion in this review. MAIN RESULTS A comprehensive search of the literature did not identify any published eligible randomised controlled trials. AUTHORS' CONCLUSIONS In order to develop the best source of evidence, there is a need to undertake randomised controlled trials of interventions for preventing and managing advanced liver disease in adults and children with cystic fibrosis.
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Affiliation(s)
- Senthil K Palaniappan
- NHS trustDepartment of Medicine, University Hospitals of LeicesterLeicester Royal InfirmaryLeicesterUKLE1 5WW
| | - Nan Nitra Than
- Faculty of MedicineDepartment of Community MedicineMelaka‐Manipal Medical College (MMMC)Jalan Batu HamparMelakaMalaysia75150
| | - Aung Win Thein
- Melaka‐Manipal Medical CollegeDepartment of SurgeryJalan Batu Hampar, Bukit BaruMelakaMalaysia75150
| | - Soe Moe
- Faculty of MedicineDepartment of Community MedicineMelaka‐Manipal Medical College (MMMC)Jalan Batu HamparMelakaMalaysia75150
| | - Indra van Mourik
- Birmingham Children's HospitalLiver UnitSteelhouse LaneBirminghamUKB4 6NH
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Abstract
Pediatric portal hypertension management is a team approach between the patient, the patient's family, the primary caregiver, and specialty providers. Evidence-based practice guidelines have not been established in pediatrics. This article serves as a review for the primary care NP in the management of pediatric portal hypertension, discussing the etiology, pathophysiology, and clinical presentation of pediatric portal hypertension, diagnostic tests, and treatment and management options.
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Affiliation(s)
- Clarissa Barbon Vogel
- Clarissa Barbon Vogel is a pediatric NP at Morgan Stanley Children's Hospital of New York, New York, N.Y
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15
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Abstract
There has been extraordinary progress over the last half-century in the field of medical transplantation in which tissue, organs, or body parts from one human are placed into another. Solid organ transplants have allowed thousands of children with otherwise devastating inherited or acquired disorders to survive. Depending upon the clinical situation, there are many specific peri-transplant issues that must be carefully addressed to optimize outcomes. Although surgical, immunologic, and infectious concerns are usually in the forefront, important aspects regarding hemostasis frequently arise. The number of solid organs that can be successfully transplanted in children has expanded over the last decades and includes kidney, liver, heart, lung, intestine, pancreas, and thymus. Bleeding complications may occur in the setting of organ failure prior to transplantation, during the surgical procedure, or in the post-transplant setting, and can results in significant morbidity. This report will focus on preventing and managing non-surgical-related bleeding complications in children undergoing liver, heart, kidney transplantation, in whom there are often unique aspects of coagulation to be considered.
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Affiliation(s)
- L Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - C Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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16
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Ali A, Herndon DN, Mamachen A, Hasan S, Andersen CR, Grogans RJ, Brewer JL, Lee JO, Heffernan J, Suman OE, Finnerty CC. Propranolol attenuates hemorrhage and accelerates wound healing in severely burned adults. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:217. [PMID: 25936635 PMCID: PMC4432824 DOI: 10.1186/s13054-015-0913-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/08/2015] [Indexed: 12/03/2022]
Abstract
Introduction Propranolol, a nonselective β-blocker, exerts an indirect effect on the vasculature by leaving α-adrenergic receptors unopposed, resulting in peripheral vasoconstriction. We have previously shown that propranolol diminishes peripheral blood following burn injury by increasing vascular resistance. The purpose of this study was to investigate whether wound healing and perioperative hemodynamics are affected by propranolol administration in severely burned adults. Methods Sixty-nine adult patients with burns covering ≥30% of the total body surface area (TBSA) were enrolled in this IRB-approved study. Patients received standard burn care with (n = 35) or without (control, n = 34) propranolol. Propranolol was administered within 48 hours of burns and given throughout hospital discharge to decrease heart rate by approximately 20% from admission levels. Wound healing was determined by comparing the time between grafting procedures. Blood loss was determined by comparing pre- and postoperative hematocrit while factoring in operative graft area. Data were collected between first admission and first discharge. Results Demographics, burn size, and mortality were comparable in the control and propranolol groups. Patients in the propranolol group received an average propranolol dose of 3.3 ± 3.0 mg/kg/day. Daily average heart rate over the first 30 days was significantly lower in the propranolol group (P <0.05). The average number of days between skin grafting procedures was also lower in propranolol patients (10 ± 5 days) than in control patients (17 ± 12 days; P = 0.02), indicative of a faster donor site healing time in the propranolol group. Packed red blood cell infusion was similar between groups (control 5.3 ± 5.4 units vs. propranolol 4.4 ± 3.1 units, P = 0.89). Propranolol was associated with a 5 to 7% improvement in perioperative hematocrit during grafting procedures of 4,000 to 16,000 cm2 compared to control (P = 0.002). Conclusions Administration of propranolol during the acute hospitalization period diminishes blood loss during skin grafting procedures and markedly improves wound healing in severely burned adults. As burn patients require serial surgical interventions for motor and cosmetic repair, restricting blood loss during operative intervention is optimal.
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Affiliation(s)
- Arham Ali
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Ashish Mamachen
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Samir Hasan
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Clark R Andersen
- Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Ro-Jon Grogans
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Jordan L Brewer
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Jamie Heffernan
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA. .,Institute for Translational Sciences and the Sealy Center for Molecular Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
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17
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Zurera LJ, Espejo JJ, Lombardo S, Gilbert JJ, Canis M, Ruiz C. Safety and efficacy of expanded polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunts in children with acute or recurring upper gastrointestinal bleeding. Pediatr Radiol 2015; 45:422-9. [PMID: 25430967 DOI: 10.1007/s00247-014-3181-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 07/28/2014] [Accepted: 08/28/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND The transjugular intrahepatic portosystemic shunt (TIPS) is effective for treating complications of portal hypertension in cirrhotic adults but the experience in children is limited. OBJECTIVE To retrospectively review the safety and efficacy of expanded polytetrafluoroethylene (ePTFE)-covered TIPS in children with acute or recurrent gastrointestinal bleeding. MATERIALS AND METHODS We reviewed the medical records of children who received implants of 10-mm-diameter PTFE-covered endoprostheses for acute or recurring upper gastrointestinal bleeding caused by medically or endoscopically uncontrollable varices. The recurrence of upper gastrointestinal bleeding, associated complications and permeability were assessed with Doppler sonography sequentially or up to transplantation. RESULTS In all children (n = 12; mean age 9 years; mean weight 30 kg) a single endoprosthesis was implanted with no associated mortality. The mean initial transhepatic gradient was 15 mmHg (range 3-21 mmHg), dropping to 7 mmHg (range 1-12 mmHg) after TIPS. Immediate complications were mild encephalopathy (n = 1) and acute occlusion of the TIPS (n = 1). Stenosis of the TIPS was observed in two children, at 9 months and 54 months follow-up, and thrombosis was observed in two children, at 7 months and 12 months follow-up. All four stenoses/occlusions were resolved with coaxial endoprostheses. CONCLUSION The safety profile and efficacy of expanded polytetrafluoroethylene (ePTFE)-covered TIPS were satisfactory in this small series of children with acute or recurrent gastrointestinal bleeding.
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Affiliation(s)
- Luis J Zurera
- Interventional Radiology Unit, Hospital Universitario Reina Sofía, Menendez Pidal s/n, 14004, Córdoba, Spain
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18
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GUO SHIBIN, LI QING, DUAN ZHIJUN, WANG QIUMING, ZHOU QIN, SUN XIAOYU. Octreotide attenuates liver fibrosis by inhibiting hepatic heme oxygenase-1 expression. Mol Med Rep 2015; 11:83-90. [PMID: 25338529 PMCID: PMC4237075 DOI: 10.3892/mmr.2014.2735] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 07/21/2014] [Indexed: 01/05/2023] Open
Abstract
The aim of the present study was to investigate the effects of octreotide treatment on hepatic heme oxygenase-1 (HO-1) expression, together with the influence of altered hepatic HO-1 expression levels on hepatic function and fibrosis in bile duct-ligated rats. The rats were divided randomly into sham, cirrhotic, cobalt protoporphyrin and octreotide treatment groups. The expression levels of hepatic HO-1 mRNA were measured by reverse-transcription polymerase chain reaction, while the protein expression was determined by western blotting and immunohistochemical analysis. Hematoxylin and eosin, and Van Gieson's staining, along with determination of the hydroxyproline content in the liver, were performed to determine the degree of liver fibrosis. The serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and carboxyhemoglobin (COHb) in arterial blood, and the mean arterial pressure and portal vein pressure were also measured. As compared with the sham group, hepatic HO-1 mRNA and protein expression levels, serum levels of ALT, AST and TBIL, COHb in arterial blood, hydroxyproline and collagen type I content were all significantly increased in the cirrhotic group. As compared with the cirrhotic group, the octreotide-treated group exhibited significantly reduced hepatic HO-1 expression levels, serum levels of ALT, AST and TBIL, COHb in arterial blood and the extent of hepatic fibrosis, whereas the cobalt protoporphyrin group exhibited significantly increased hepatic HO-1 expression levels, as well as aggravated hepatic function and fibrosis (P<0.05). In conclusion, octreotide inhibited hepatic HO-1 overexpression in cirrhotic rats, reduced hepatic HO-1 expression levels to relieve liver injury and attenuated liver fibrosis.
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Affiliation(s)
- SHI-BIN GUO
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - QING LI
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
- Department of Gastroenterology, Dalian Friendship Hospital, Dalian, Liaoning 0086-116011, P.R. China
| | - ZHI-JUN DUAN
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - QIU-MING WANG
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - QIN ZHOU
- Department of Pharmacology, Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
| | - XIAO-YU SUN
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 0086-116011, P.R. China
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Zárate Mondragón F, Romero Trujillo JO, Cervantes Bustamante R, Mora Tiscareño MA, Montijo Barrios E, Cadena León JF, Cázares Méndez M, Toro Monjaraz EM, Ramírez Mayans J. Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014; 79:244-9. [PMID: 25453721 DOI: 10.1016/j.rgmx.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 07/22/2014] [Accepted: 09/25/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehepatic portal hypertension in children can be asymptomatic for many years. Once diagnosed, the therapeutic measures (pharmacologic, endoscopic, and surgical) are conditioned by the specific characteristics of each patient. In Mexico, there are no recorded data on the incidence of the disease and patient characteristics. AIMS To determine the main clinical, radiologic, and endoscopic characteristics upon diagnosis of these patients at the Instituto Nacional de Pediatría within the time frame of January 2001 and December 2011. METHODS A cross-sectional, retrolective, descriptive, and observational study was conducted in which all the medical records of the patients with portal hypertension diagnosis were reviewed. RESULTS There was a greater prevalence of prehepatic etiology (32/52) (61.5%) in the portal hypertension cases reviewed. Males (62.5%) predominated and 11 of the 32 patients were under 4 years of age. The primary reason for medical consultation was upper digestive tract bleeding with anemia (71.9%) and the main pathology was cavernomatous degeneration of the portal vein (65.6%). Splenoportography was carried out on 17 of the 32 patients. A total of 65.5% of the patients received the combination therapy of propranolol and a proton pump inhibitor. Initial endoscopy revealed esophageal varices in 96.9% of the patients, 12 of whom presented with gastroesophageal varices. Congestive gastropathy was found in 75% of the patients. The varices were ligated in 8 cases, sclerotherapy for esophageal varices was carried out in 5 cases (15.6%), and sclerotherapy for gastric varices was performed in 2 patients. Seventeen patients (53.1%) underwent portosystemic diversion: 10 of the procedures employed a mesocaval shunt and 7 a splenorenal shunt. Nine patients (28.1%) underwent total splenectomy. CONCLUSIONS The primary cause of the disease was cavernomatous degeneration of the portal vein; it was predominant in males and the first symptom was variceal bleeding.
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Affiliation(s)
- F Zárate Mondragón
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México.
| | - J O Romero Trujillo
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - R Cervantes Bustamante
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - M A Mora Tiscareño
- Departamento de Radiología, Instituto Nacional de Pediatría, México D.F., México
| | - E Montijo Barrios
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - J F Cadena León
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - M Cázares Méndez
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - E M Toro Monjaraz
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
| | - J Ramírez Mayans
- Servicio de Gastroenterología y Nutrición, Instituto Nacional de Pediatría, México D.F., México
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20
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Zárate Mondragón F, Romero Trujillo J, Cervantes Bustamante R, Mora Tiscareño M, Montijo Barrios E, Cadena León J, Cázares Méndez M, Toro Monjaraz E, Ramírez Mayans J. Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2014. [DOI: 10.1016/j.rgmxen.2014.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Zurera L, Espejo J, Canis M, Bueno A, Vicente J, Gilbert J. Transjugular intrahepatic portosystemic shunting with covered stents in children: A preliminary study of safety and patency. RADIOLOGIA 2014. [DOI: 10.1016/j.rxeng.2012.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
The survival of patients with cystic fibrosis (CF) has progressively increased over recent decades, largely attributable to early diagnosis through newborn screening and advances in nutritional and respiratory care. As the life expectancy of patients with CF has improved, non-respiratory complications such as liver disease have become increasingly recognized. Biochemical derangements of liver enzymes in CF are common and may be attributed to a number of specific hepatobiliary abnormalities. Among them, Cystic Fibrosis-associated Liver Disease (CFLD) is clinically the most significant hepatic complication and is believed to have a significant impact on morbidity and mortality. However, there remains much conjecture about the extent of the adverse prognostic implications that a diagnosis of CFLD has on clinical outcomes. The purpose of this review is to give an overview of the current knowledge regarding liver disease in children with CF.
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Affiliation(s)
- Lisette Leeuwen
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia; Medical School, University of Groningen, Groningen, The Netherlands
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Australia
| | - Kevin J Gaskin
- Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Australia; Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, Australia; James Fairfax Institute of Paediatric Nutrition, University of Sydney, Sydney, Australia.
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Effect of experimentally induced portal hypertension on the fundic mucosa of adult male albino rats and the possible protective role of quercetin supplementation. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/01.ehx.0000425561.09044.f9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Flass T, Narkewicz MR. Cirrhosis and other liver disease in cystic fibrosis. J Cyst Fibros 2013; 12:116-24. [PMID: 23266093 PMCID: PMC3883947 DOI: 10.1016/j.jcf.2012.11.010] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/14/2012] [Accepted: 11/15/2012] [Indexed: 12/25/2022]
Affiliation(s)
- Thomas Flass
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics University of Colorado School of Medicine and The Pediatric Liver Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael R Narkewicz
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics University of Colorado School of Medicine and The Pediatric Liver Center, Children's Hospital Colorado, Aurora, CO, USA.
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Guidelines for the diagnosis and treatment of extrahepatic portal vein obstruction (EHPVO) in children. Ann Hepatol 2013; 12 Suppl 1:S3-S24. [PMID: 31207845 DOI: 10.1016/s1665-2681(19)31403-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 10/15/2012] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Extrahepatic portal vein obstruction is an important cause of portal hypertension among children. The etiology is heterogeneous and there are few evidences related to the optimal treatment. AIM AND METHODS To establish guidelines for the diagnosis and treatment of EHPVO in children, a group of gastroenterologists and pediatric surgery experts reviewed and analyzed data reported in the literature and issued evidence-based recommendations. RESULTS Pediatric EHPVO is idiopathic in most of the cases. Digestive hemorrhage and/or hypersplenism are the main symptoms. Doppler ultrasound is a non-invasive technique with a high degree of accuracy for the diagnosis. Morbidity is related to variceal bleeding, recurrent thrombosis, portal biliopathy and hypersplenism. Endoscopic therapy is effective in controlling acute variceal hemorrhage and it seems that vasoactive drug therapy can be helpful. For primary prophylaxis of variceal bleeding, there are insufficient data for the use of beta blockers or endoscopic therapy. For secondary prophylaxis, sclerotherapy or variceal band ligation is effective; there is scare evidence to recommend beta-blockers. Surgery shunt is indicated in children with variceal bleeding who fail endoscopic therapy and for symptomatic hypersplenism; spleno-renal or meso-ilio-cava shunting is the alternative when Mesorex bypass is not feasible due to anatomic problems or in centers with no experience. CONCLUSIONS Prospective control studies are required for a better knowledge of the natural history of EHPVO, etiology identification including prothrombotic states, efficacy of beta-blockers and comparison with endoscopic therapy on primary and secondary prophylaxis.
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Curcio G, Pisa MD, Miraglia R, Catalano P, Barresi L, Tarantino I, Granata A, Spada M, Traina M. Case of obscure-overt gastrointestinal bleeding after pediatric liver transplantation explained by endoscopic ultrasound. World J Gastrointest Endosc 2012; 4:571-4. [PMID: 23293728 PMCID: PMC3536855 DOI: 10.4253/wjge.v4.i12.571] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 11/07/2011] [Accepted: 04/27/2012] [Indexed: 02/05/2023] Open
Abstract
Portal hypertension, which is a common finding in children awaiting liver transplantation, is also found after transplantation. It’s reported the case of a 6-year-old girl, transplanted for biliary atresia, who had a severe obscure-overt bleeding presenting with melena. An esophagogastroduodenoscopy showed several duodenal small, bulging lesions, with some red signs. Near the lesions, a depressed area of 2 cm, covered with mixed hyperemic and white mucosa, was observed. To better evaluate these lesions, we performed an endoscopic ultrasonography (EUS) that showed multiple, round hypoechoic areas 0.5-5 mm in diameter, compatible with duodenal varices, and several periduodenal anechoic lesions compatible with collaterals. A consecutive computed tomography scan showed a stenosis of the portal vein anastomosis confirmed with a transhepatic portography, which was successfully treated with balloon angioplasty. No further episodes of bleeding were observed during the follow-up. This case report suggests that EUS is safe and feasible in young children when using echoendoscopes designed for use in adults. However further studies are needed to validate the employment of this technique in the management and follow-up of pediatric portal hypertension.
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Affiliation(s)
- Gabriele Curcio
- Gabriele Curcio, Marta Di Pisa, Luca Barresi, Ilaria Tarantino, Antonino Granata, Mario Traina, Department of Gastroenterology, Liver Transplantation Unit, IsMeTT, 90100 Palermo, Italy
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de Ville de Goyet J, D'Ambrosio G, Grimaldi C. Surgical management of portal hypertension in children. Semin Pediatr Surg 2012; 21:219-32. [PMID: 22800975 DOI: 10.1053/j.sempedsurg.2012.05.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The management of children with portal hypertension has dramatically changed during the past decade, with an improvement in outcome. This has been achieved by improved efficiency of endoscopic variceal control and the success of liver transplantation. Emergency surgical shunt procedures are rarely required, with acute bleeding episodes generally controlled endoscopically or, occasionally in adults, by interventional radiological procedures. Portosystemic shunts may be considered as a bridge to transplant in adults but are rarely used in this context in children. Nontransplant surgery or radiological interventions may still be indicated for noncirrhotic portal hypertension when the primary cause can be cured and to allow normalization of portal pressure before liver parenchyma is damaged by chronic secondary changes in some specific diseases. The meso-Rex bypass shunt is used widely but is limited to those with a favorable anatomy and can even be performed preemptively. Elective portosystemic shunt surgery is reserved for failure to respond to conservative management in the absence of alternative therapies.
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Affiliation(s)
- Jean de Ville de Goyet
- Department of Paediatric Surgery and Transplantation, Bambino Gesù Children's Hospital, Rome, Italy.
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Pre- and postoperative imaging of the Rex shunt in children: what radiologists should know. AJR Am J Roentgenol 2012; 198:1032-7. [PMID: 22528892 DOI: 10.2214/ajr.11.7963] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this article is to illustrate the imaging features of patients with extrahepatic portal venous obstruction who are evaluated before or after a Rex shunt surgery. CONCLUSION The Rex shunt is a potentially curative surgical procedure that reestablishes physiologic hepatopetal portal flow. It is typically accomplished by interposing a vascular conduit between the superior mesenteric vein to the still patent intrahepatic portal venous system. This procedure results in resolution of portal hypertension.
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Vo NJ, Shivariam G, Andrews RT, Vaidya S, Healey PJ, Horslen SP. Midterm Follow-up of Transjugular Intrahepatic Portosystemic Shunts Using Polytetrafluoroethylene Endografts in Children. J Vasc Interv Radiol 2012; 23:919-24. [DOI: 10.1016/j.jvir.2012.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 03/30/2012] [Accepted: 04/04/2012] [Indexed: 02/06/2023] Open
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[Transjugular intrahepatic portosystemic shunting with covered stents in children: a preliminary study of safety and patency]. RADIOLOGIA 2012; 56:339-45. [PMID: 22704684 DOI: 10.1016/j.rx.2012.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 01/07/2012] [Accepted: 01/07/2012] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children. MATERIAL AND METHODS We present 6 children (mean age, 10.6 years; mean weight, 33.5kg) who underwent TIPS with 8mm diameter Viatorr(®) covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation. RESULTS A single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16mmHg (range: 12-21mmHg) before the procedure to 9mmHg (range: 1-15mmHg) after TIPS. One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent. Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up after implantation (mean: 8.1 months). CONCLUSION Our results indicate that TIPS with 8mm diameter Viatorr(®) covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series.
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