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Stoma-related variceal bleeding: an under-recognized complication of biliary atresia
S Smith1, E S Wiener, T E Starzl
1Department of Surgery, Children's Hospital of Pittsburgh, PA 15213.
Insights
Stoma variceal bleeding is a frequent complication in children with biliary atresia awaiting liver transplantation. Complete stoma takedown and closure is crucial for prevention and treatment.
Area of Science:
- Pediatric Surgery
- Hepatology
- Gastroenterology
Background:
- Biliary atresia is a serious condition in infants requiring surgical intervention.
- Portoenterostomy is a common treatment, but complications like stoma variceal bleeding can occur.
- Patients awaiting liver transplantation are at risk for bleeding complications.
Purpose of the Study:
- To determine the frequency of stoma variceal bleeding in children with biliary atresia.
- To evaluate optimal strategies for prevention and treatment of stoma variceal bleeding.
- To reduce mortality in biliary atresia patients awaiting liver transplantation.
Main Methods:
- Review of medical records of 52 children with biliary atresia treated by portoenterostomy.
- Analysis of stoma variceal bleeding frequency and outcomes of various treatments.
- Comparison of stoma closure techniques, including preperitoneal closure and complete takedown.
Main Results:
- 100% of patients with an existing stoma experienced at least one bleeding episode.
- Local treatments for stoma variceal bleeding had a high recurrence rate (57%).
- Preperitoneal closure alone did not prevent stoma bleeding.
Conclusions:
- Stoma variceal bleeding is a significant and frequent complication in biliary atresia patients.
- Complete stoma takedown and closure is recommended to prevent and treat stoma variceal bleeding.
- Preventing bleeding episodes is essential to reduce mortality in this patient population.
Abstract:
The medical records of 52 children with biliary atresia treated by portoenterostomy and evaluated for liver transplantation were reviewed to determine the frequency of stoma variceal bleeding and the optimal strategies for prevention and treatment. Eighteen patients had had prior stoma closure, four by preperitoneal closure without takedown from the abdominal wall. Three of the four developed occult variceal bleeding from the stoma closure site. Twenty-two patients had a stoma present at evaluation. All 22 patients with stomas (100%) had at least one bleeding episode requiring transfusion. Treatment included transfusion and local pressure (9), suture ligation of the bleeding site (5), and stoma closure and/or takedown (11). Local treatment led to recurrences in eight of 14 (57%) of the cases. To reduce the high mortality in patients with biliary atresia awaiting liver transplantation, multiple variceal bleeding episodes should be prevented. To eliminate one source, stoma variceal bleeding, the stoma, whether functioning or nonfunctioning should be taken down and closed. Preperitoneal closure alone does not prevent stoma bleeding.