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SHIBUYA S, TAKASE Y, SHARMA N. Endoscopic Sclerotherapy for Esophageal Varices After Surgical Procedures for Congenital Biliary Atresia. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1991.tb00320.x] [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: 02/23/2023]
Affiliation(s)
- Susumu SHIBUYA
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuhiro TAKASE
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Niranjan SHARMA
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
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Sökücü S, Süoglu OD, Elkabes B, Saner G. Long-term outcome after sclerotherapy with or without a beta-blocker for variceal bleeding in children. Pediatr Int 2003; 45:388-94. [PMID: 12911472 DOI: 10.1046/j.1442-200x.2003.01743.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Esophageal variceal bleeding is a life-threatening complication of portal hypertension. Optimal treatment for the prophylaxis of variceal rebleeding in children has not yet been determined. In the present study, we aimed to compare the long-term efficacy of endoscopic sclerotherapy with or without oral beta-blocker therapy in the secondary prophylaxis of variceal bleeding. METHODS Thirty-eight children who had undergone endoscopic sclerotherapy (EST) sessions for variceal bleeding in the Department of Pediatric Gastroenterology, Istanbul University Istanbul School of Medicine, were entered into this retrospective cohort study. Twenty patients (mean +/- SD age 7.0 +/- 2.7 years) had undergone only sclerotherapy sessions (SG), whereas 18 patients (mean age 6.8 +/- 3.4 years) had received oral propranolol (1-2 mg/kg per day) additionally for 2 years (SPG). The number of patients with successful obliteration, the time required for obliteration and variceal recurrence rate were analyzed as primary indicators of the effectiveness of therapy. RESULTS Variceal obliteration was achieved in 16 of 20 patients (80%) in the SG group and in 16 of 18 patients (88%) in the SPG group. Time required for variceal obliteration was significantly shorter in the SPG group compared with the SG group (4.1 +/- 1.4 vs 3.2 +/- 0.9 months; P < 0.05). The variceal recurrence rate was 65 and 38.8% in the SG and SPG groups, respectively. Compared with the SG group, less variceal rebleeding was observed during EST in the SPG group (25 vs 16.6%, respectively).However, these differences were not statistically significant. CONCLUSIONS Endoscopic sclerotherapy combined with oral propranolol treatment shortens the time required for variceal obliteration. However, the other indicators of treatment effectiveness are not influenced statistically by the addition of propranolol to the treatment regimen. Randomized prospective clinical studies in larger pediatric series are needed before offering a combination of EST with oral propranolol as the most rational approach in the secondary treatment of esophageal variceal bleeding in children.
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Affiliation(s)
- Semra Sökücü
- Departmentof Pediatric Gastroenterology and Hepatology, Istanbul School of Medicine and Instituteof Child Health, Istanbul University, Istanbul, Turkey
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Thalhammer GH, Eber E, Uranüs S, Pfeifer J, Zach MS. Partial splenectomy in cystic fibrosis patients with hypersplenism. Arch Dis Child 2003; 88:143-6. [PMID: 12538318 PMCID: PMC1719430 DOI: 10.1136/adc.88.2.143] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We report three cystic fibrosis (CF) patients with hypersplenism who underwent partial splenectomy. The postoperative course was uneventful in two patients; one patient developed a complication necessitating resection of the rest of the spleen. Haematological parameters improved and oesophageal varices regressed in all patients. On follow up, one patient showed a normal spleen, the other a normally functioning accessory spleen; the third patient again developed splenomegaly with hypersplenism. Partial splenectomy is a promising therapeutic option for CF patients with hypersplenism.
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Affiliation(s)
- G H Thalhammer
- Respiratory and Allergic Disease Division, Paediatric Department, University of Graz, Austria
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Abstract
Liver disease is the second most common cause of death in patients with cystic fibrosis (CF). Improvement in surgical techniques, medical management, and imaging modalities has broadened the range of options for treatment of these patients. Medical management with ursodeoxycholic acid and nutritional support may help decelerate the progression of liver disease. A timely evaluation of CF patients with liver involvement for transplantation is important. Such evaluation should not be delayed until signs of hepatic decompensation occur. Combined lung-liver transplant can be considered for patients with advanced pulmonary disease. Pretransplant management of portal hypertension with a portosystemic shunt procedure is an option for patients with well-preserved synthetic liver function. Improvement in lung function after liver transplantation and no significant risk of pulmonary infection with immunosuppressive therapy have been reported. Review of individual center experiences have shown satisfactory survival and improved quality of life for CF patients undergoing liver transplant.
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Affiliation(s)
- Y S Genyk
- Division of Pediatric Gastroenterology and Pediatric Liver Transplant Program, Childrens Hospital Los Angeles, University of Southern California, Los Angeles, California 90027, USA.
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Kato T, Romero R, Koutouby R, Mittal NK, Thompson JF, Schleien CL, Tzakis AG. Portosystemic shunting in children during the era of endoscopic therapy: improved postoperative growth parameters. J Pediatr Gastroenterol Nutr 2000; 30:419-25. [PMID: 10776954 DOI: 10.1097/00005176-200004000-00013] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical portosystemic shunting has been performed less frequently in recent years. In this retrospective study, recent outcomes of portosystemic shunting in children are described, to evaluate its role in the era of endoscopic therapy. METHODS Retrospective chart review of children who underwent surgical portosystemic shunt procedures between October 1994 and October 1997. RESULTS Twelve children (age range, 1-16 years) underwent shunting procedures. The causes of portal hypertension were extrahepatic portal vein thrombosis (n = 6), congenital hepatic fibrosis (n = 2), hepatic cirrhosis (n = 2), and other (n = 2). None of the patients were immediate candidates for liver transplantation. Types of shunt included: distal splenorenal (n = 10), portocaval (n = 1), and other (n = 1). Median follow-up was 35 months (range, 24-48 months). All patients are currently alive and well with patent shunts. The mean hospital stay was 8 days. Three patients required readmission for further interventions because of shunt stenosis in two and small bowel obstruction in the other. Mild portosystemic encephalopathy was seen in one child with pre-existing neurobehavioral disturbance. Excluding a patient who underwent placement of a portosystemic shunt for a complication of liver transplantation, mean weight-for-age z score in nine prepubertal patients improved from -1.16 SD to +0.15 SD (P = 0.023), and mean height-for-age z score from -1.23 SD to 0.00 SD (P = 0.048) by 2 years after surgery. CONCLUSIONS Surgical portosystemic shunting is a safe and effective method for the management of portal hypertension in childhood. Patients show significant improvements in growth parameters after the procedure. Surgical portosystemic shunting should be actively considered in selected children with portal hypertension.
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Affiliation(s)
- T Kato
- Division of Transplantation, University of Miami, School of Medicine, Florida 33136, USA
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Abstract
Gastrointestinal (GI) bleeding is an alarming problem in children. Although many causes of GI bleeding are common to children and adults, the frequency of specific causes differs greatly, and some lesions, such as necrotizing enterocolitis or allergic colitis, are unique to children. This article reviews the spectrum of GI bleeding in infants and children. The causes, diagnostic evaluation, and management are discussed, and differences with adult medicine are highlighted.
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Affiliation(s)
- V L Fox
- Harvard Medical School, Boston, Massachusetts, USA
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Reyes J, Mazariegos GV, Bueno J, Cerda J, Towbin RB, Kocoshis S. The role of portosystemic shunting in children in the transplant era. J Pediatr Surg 1999; 34:117-22; discussion 122-3. [PMID: 10022155 DOI: 10.1016/s0022-3468(99)90240-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE Variceal bleeding in children generally presents in the setting of cirrhosis but may also occur in the absence of liver disease and after successful liver transplantation. The authors reviewed their experience with portosystemic shunting in children to better define its efficacy in sclerotherapy failures, as primary therapy, and its role before and after liver transplantation. METHODS Between 1983 and 1997, 21 children with recurrent variceal bleeding underwent portosystemic shunting at the authors' institution. Patients were divided into two groups: 13 patients in group I presented with intrinsic liver disease (cirrhosis) as a cause for portal hypertension; eight patients in group II with no liver disease had extrahepatic portal venous thrombosis, five of which occured after successful liver transplantation. The mean age was 8.6 years (range, 3 to 18). Shunt procedures were semielective, and were performed successfully in all children without any operative morbidity or mortality. Follow-up ranged from 6 months to 15 years. RESULTS Shunt procedures included splenorenal (n = 15), splenocaval (n = 1), side-to-side splenorenal (n = 1), inferior mesenteric vein to renal vein (n = 1), mesocaval (n = 1), and transcutaneous intrahepatic portosystemic shunt (TIPS; n = 2). All patients in group II are alive and well with no further bleeding or occlusions. Of the 13 patients in group I, three had bleeding postshunt, and three patients went on to require liver transplantation because of worsening liver disease. One child died of liver failure with encephalopathy 4 years after shunting. There were two shunt occlusions. CONCLUSIONS Portosystemic shunting is effective therapy in patients with intrinsic liver disease, with salvage amenable by liver transplantation in the treatment failures. It is definitive therapy in patients with extrahepatic venous thrombosis.
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Affiliation(s)
- J Reyes
- Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, PA 15213, USA
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Abstract
This chapter reviews the common causes of portal hypertension in children. It specifies how the treatment strategy for portal hypertension in patients without significant hepatic dysfunction differs from the management of children with cirrhosis. It describes the application of newer treatment modalities such as TIPS and partial splenic embolization in children and reviews the current recommendations for surgical intervention in these patients.
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Affiliation(s)
- E M Alonso
- Department of Pediatrics, University of Chicago Children's Hospital, Chicago, Illinois 60637, USA
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Ando H, Ito T, Seo T, Ito F, Kaneko K. Splenectomy in biliary atresia patients with recurrent jaundice following partial splenic embolization. TOHOKU J EXP MED 1997; 181:167-74. [PMID: 9149352 DOI: 10.1620/tjem.181.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Splenectomy was performed for three patients with biliary atresia because of re-exacerbation of their jaundice following treatment by partial splenic embolization (PSE). The subjects' red blood cell count and hemoglobin, serum level of hepatic enzymes (glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, gamma-glutamyl transpeptidase, alkaline phosphatase, and lactic dehydrogenase), and total bilirubin (TB) were evaluated both before and after splenectomy in order to analyze the effects of splenectomy on these patients. The TB decreased significantly within 3 months after splenectomy in all three patients (13.0 +/- 1.6 mg/100 ml to 5.4 +/- 0.3 mg/100 ml, p < 0.05). The red blood cell count and hemoglobin increased gradually. There was a statistically significant correlation between the TB and the red blood cell count, and/or concentration of hemoglobin. The hepatic enzymes after splenectomy were not significantly different from those before splenectomy. The change in TB following splenectomy was essentially similar to that following PSE. These results suggested that the postoperative improvement in jaundice following splenectomy may not be due to improved hepatic function but merely a reflection of decreased red blood cell turnover. Splenectomy is a useful palliative procedure for jaundice in patients with biliary atresia for whom PSE is no longer effective.
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Affiliation(s)
- H Ando
- Department of Surgery, Branch Hospital, University of Nagoya School of medicine, Japan
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Abstract
Endoscopic variceal ligation, a mechanical mode of variceal obliteration, was used in the management of patients having extrahepatic portal vein obstruction. Fifteen patients (10 males, 5 females) had grade III varices. Their mean age was 8.13 years (range, 3 to 14 years). Obliteration was achieved in 14 patients (93.33%) after a mean number of 1.86 (range, 1 to 4) sessions. The mean number of bands required for variceal obliteration was 4.33 (range, 1 to 9). The number of bands required to obliterate each variceal column was 1.38. No patient required a blood transfusion, and there was only one recurrence of varices during the mean follow-up period of 9 months (range, 4 to 12 months). Postligation hemorrhage was encountered in one patient; there was no other complications. Endoscopic variceal ligation is an effective and safe method for early variceal obliteration in children.
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Affiliation(s)
- S Nijhawan
- Department of Gastroenterology, SMS Medical College, Jaipur, India
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Van Thiel DH, Dindzans VJ, Schade RR, Rabinovitz M, Gavaler JS. Prophylactic versus emergency sclerotherapy of large esophageal varices prior to liver transplantation. Dig Dis Sci 1993; 38:1505-10. [PMID: 8344108 DOI: 10.1007/bf01308612] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
From January 1985 through July 1987, adult patients accepted for liver transplantation with large esophageal varices were enrolled in a study evaluating the use of prophylactic vs emergency sclerotherapy. Six hundred forty-eight subjects received prophylactic sclerotherapy, and 172 received emergent sclerotherapy. Esophageal stricture formation was increased 12.9-fold (P < 0.001), esophageal perforation 6.4-fold (P < 0.005), and postsclerotherapy bleeding esophageal ulcers 3.7-fold (P < 0.001) in those receiving emergency sclerotherapy as opposed to prophylactic sclerotherapy. These differences were even greater if the number of sclerotherapy sessions rather than the number of patients was used as the denominator for the comparisons. In total, 19.6% of emergency sclerotherapy cases were associated with an untoward outcome of sclerotherapy; only 1.9% of cases receiving prophylactic sclerotherapy experienced an untoward outcome (P < 0.001). These data demonstrate that emergency sclerotherapy is associated with a greater prevalence of complications and support earlier studies that show that sclerotherapy prevents variceal bleeding over the short term. The data also suggest that when applied to patients with large varices awaiting orthotopic liver transplantation, it enhances the chance of a patient surviving to be transplanted by preventing a variceal bleed and the spiral of liver failure and death that frequently follows an episode of acute variceal bleeding.
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Affiliation(s)
- D H Van Thiel
- Division of Gastroenterology, University of Pittsburgh, School of Medicine, Pennsylvania 15261
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Goenka AS, Dasilva MS, Cleghorn GJ, Patrick MK, Shepherd RW. Therapeutic upper gastrointestinal endoscopy in children: an audit of 443 procedures and literature review. J Gastroenterol Hepatol 1993; 8:44-51. [PMID: 8439662 DOI: 10.1111/j.1440-1746.1993.tb01174.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The safety, effectiveness and capabilities of therapeutic upper fibreoptic endoscopy in children undergoing therapeutic endoscopic procedures (n = 443) was studied. Therapy for gastrointestinal bleeding formed the major group (injection sclerotherapy for varices, n = 197 procedures; thermocoagulation for haemorrhagic gastritis, n = 1; and photocoagulation for Dieulafoy's disease, n = 1). Sclerotherapy was 97% effective in controlling acute bleeding and 84% effective in obliterating varices with no serious complications or deaths. Oesophageal dilatations for surgical, caustic, congenital and peptic strictures and achalasia (n = 193) were performed with no oesophageal perforations or deaths. Foreign bodies were retrieved (n = 34) with no failures or complications. Percutaneous endoscopic gastrostomy was performed (n = 11) with one failure, proceeding to an unsuccessful surgical gastrostomy. Miscellaneous procedures included endoscopic transpyloric tube placement (n = 5) and endoscopic diathermy of pyloric web (n = 1). Therapeutic fibreoptic endoscopy is therefore concluded to be safe and effective in children, replacing rigid oesophagoscopy and some traditional surgical approaches.
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Affiliation(s)
- A S Goenka
- Department of Gastroenterology and Nutrition, Royal Children's Hospital, Brisbane, Queensland, Australia
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Abstract
Gastrointestinal (GI) bleeding in infants and children provokes alarm in parents, and often anxiety in pediatricians. While this clinical situation has not changed over the years, advances in endoscopy and radiology, as well as new therapeutic modalities allow more accurate identification of the cause of bleeding and more effective treatment. Although the majority of GI bleeding in the pediatric population is self limiting, a systematic approach including prompt assessment, diagnosis, and treatment is necessary to preclude undue morbidity.
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Affiliation(s)
- T A Williams
- Department of Pediatric Gastroenterology, Henrico Doctors Hospital, Richmond, Virginia
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Sood S, Chopra AK, Minocha VR. Management of extrahepatic portal hypertension in children. Indian J Pediatr 1991; 58:317-20. [PMID: 1937641 DOI: 10.1007/bf02754957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- S Sood
- Department of Surgery, University College of Medical Sciences, Delhi
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Abstract
One hundred and twenty two patients who presented with variceal bleeding as a result of extrahepatic portal vein obstruction (EHPO) were entered into the sclerotherapy programme with a mean follow up of 23.69 months (range four to 60 months). Eighteen (14.7%) patients were lost to follow up, three (2.4%) patients underwent surgery, and six (4.9%) patients died. Variceal obliteration was achieved in the remaining 95 patients requiring 5.4 (2.4) sessions of sclerotherapy (range 2-18). Seventeen episodes of upper gastrointestinal bleed occurred in 15 patients during sclerotherapy. Recurrence of oesophageal varices was seen in 15 patients. Ten patients developed bulbous gastric varices after obliteration. Major complications including perforation and strictures were seen more commonly in children. Sclerotherapy was associated with a significant reduction in the bleeding rate (bleeds/month/patient) as compared with the presclerotherapy period (p less than 0.001). Endoscopic sclerotherapy is an effective and safe modality in the prevention of variceal bleeds in patients with extrahepatic portal vein obstruction.
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Affiliation(s)
- Y K Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Caulfield M, Wyllie R, Sivak MV, Michener W, Steffen R. Upper gastrointestinal tract endoscopy in the pediatric patient. J Pediatr 1989; 115:339-45. [PMID: 2671326 DOI: 10.1016/s0022-3476(89)80829-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M Caulfield
- Department of Pediatrics, Cleveland Clinic Foundation, Ohio 44106
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Abstract
Ten children with extrahepatic portal hypertension who had major bleeding from esophageal varices were treated with sclerotherapy of esophageal varices by means of flexible fiberoptic endoscopy and intravenous sedation. Four had had no previous therapy, five had had previous surgery for variceal bleeding, and five had received propranolol orally. During therapy and follow-up monitoring of 1.4 to 7.1 years (mean 4.7 years), only two patients bled again from esophageal varices, one before complete obliteration of varices and one who temporarily defaulted on follow-up. The few complications were easily managed, and only three required any specific therapy. No child bled from gastric varices. Frequency of sclerotherapy sessions and quantity of sclerosant could be decreased with time, usually after 3 years of sclerotherapy, suggesting that the natural history of decreased bleeding with time in extrahepatic portal hypertension may be accelerated by sclerotherapy. Esophageal varices in children with extrahepatic portal hypertension may be treated safely with sclerotherapy, which is effective in preventing chronic and recurrent gastrointestinal bleeding.
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Affiliation(s)
- E Hassall
- Division of Pediatric Gastroenterology, University of British Columbia, Vancouver, Canada
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Abstract
This report describes a series of 553 flexible upper gastrointestinal (GI) endoscopies performed on 382 children in two surgical centers between 1975 and 1987. Indications included abdominal pain (180), reassessment of known disease (149), upper GI bleeding (99), foreign body ingestion (77), vomiting (14), dysphagia (10), and miscellaneous (24). Findings were chronic peptic ulcer (47), gastritis/duodenitis (63), healing disease (92), nonhealing disease (22), recurrent disease (32), foreign body impaction (22), stricture (9), esophagitis (7), varices (7), mass (6 [3 polyp, 1 lymphoma, 1 fungus ball, 1 inflammation]), normal (209), and miscellaneous (37). Endoscopic diagnosis was uniformly correct except on two occasions, when the presence of recurrent tracheoesophageal fistula in small infants was missed due to use of an inadequate instrument. A pathologic lesion is likely to be identifiable in GI bleeding (84.8%). Endoscopic surveillance for progress of known disease was found to be valuable, particularly in peptic ulcer management, as both incomplete healing after standard therapy as well as recurrence are frequent. The recent practice of routine antral biopsy in children with severe "nonspecific abdominable pain" enabled four cases of Campylobacter pylori colonization in the stomach to be diagnosed, thus allowing appropriate treatment. Endoscopy was therapeutic on 61 occasions: injection sclerotherapy (32), foreign body removal (20), polypectomy (3), and stricture dilatation (6). Endoscopy-guided bougienage, in particular, represents a recent major advance. There was no morbidity or mortality in the entire series. It is concluded that pediatric upper GI endoscopy performed by experienced surgeons is safe and effective. As a result of better understanding and technological advances, a changing trend of wider and more rational applications of the procedure is now evident.
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Affiliation(s)
- P K Tam
- Division of Pediatric Surgery, University of Hong Kong
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Abstract
With the availability of orthotopic liver transplantation as a definitive treatment option for most cases of end-stage liver disease in children, there is renewed interest in this hitherto universally fatal condition. The potential for long-term survival after liver transplantation without disability is a realistic prospect for the majority, although the surgery is one of the most difficult surgical procedures available and represents a daunting prospect. The success of liver transplantation (80% one year and approximately 70% five year survival) has required virtually a re-definition of the diagnosis of end-stage liver disease with a view to predicted outcome and timely intervention. This includes a more aggressive approach to supportive treatment in order to maintain (if not improve) the patient's clinical status, if the treatment option of transplantation is decided upon. Preferably this treatment option should be considered and offered immediately the condition of end-stage liver disease is realised, in order to allow time for full and frank discussion of treatment options, to optimize supportive therapy, to evaluate suitability for liver transplantation and to maximize prospects of obtaining a donor organ. In Australia, particularly in children, liver transplantation is limited by the scarcity of suitable donor organs, although the development of reduction hepatectomy of an adult organ has allowed access to a much larger donor pool. This development has particular advantages in Australia, allowing organs from 80 kg adults to be transplanted successfully into 5 kg or 6 kg infants and has, at the time of writing, virtually eliminated potential paediatric recipient deaths while awaiting a suitable donor.
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Affiliation(s)
- R W Shepherd
- Department of Child Health, Royal Children's Hospital, Brisbane, Australia
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Howard ER, Stringer MD, Mowat AP. Assessment of injection sclerotherapy in the management of 152 children with oesophageal varices. Br J Surg 1988; 75:404-8. [PMID: 3390666 DOI: 10.1002/bjs.1800750504] [Citation(s) in RCA: 139] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A total of 152 consecutive children with oesophageal varices have been endoscopically reviewed since 1979. In all, 108 of these children presented with variceal bleeding which was managed by injection sclerotherapy. Variceal obliteration was achieved in 33 (92 per cent) children with extrahepatic portal hypertension and 54 (75 per cent) with intrahepatic portal hypertension. Prophylactic injection sclerotherapy was used to obliterate large varices in 11 children with no history of haemorrhage. Bleeding episodes occurred in 38 (39 per cent) children before variceal obliteration was complete. However, the mortality rate from variceal bleeding was only 1 per cent. Complications were oesophageal ulceration (29 per cent) and stricture (16 per cent) which both resolved with conservative management. During a mean follow-up period of 2.9 years after sclerotherapy, recurrent oesophageal or gastric varices developed in 12 (12 per cent) cases, with rebleeding in 9 (9 per cent), but all responded successfully to a second course of treatment. These results are superior to contemporary surgical management and injection sclerotherapy should therefore currently be the primary treatment of choice for bleeding oesophageal varices in children.
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Affiliation(s)
- E R Howard
- Department of Surgery, King's College Hospital, London, UK
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Abstract
Fiberoptic upper intestinal endoscopy has been shown in the last decade to be the most sensitive technique to diagnose upper gastrointestinal disease. Diagnostic endoscopy has been shown to be safe, with a low complication rate of less than 2 per cent, and most of those reported have been minor. Furthermore, therapeutic endoscopy has been used to treat bleeding varices by sclerotherapy, avoiding the need for shunting procedures, which often fall in young children. Dilation of strictures with wire-guided dilators, endoscopic incision of antral mucosal diaphragms, and percutaneous placement of gastrostomy tubes are other ways endoscopy is being used as a means of treatment. Electrocoagulation and photocoagulation of bleeding upper gastrointestinal lesions have not been used.
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Affiliation(s)
- M E Ament
- Department of Pediatrics, UCLA Medical Center
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