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Long-term results after nonshunt operations for esophageal varices in children
M Uchiyama1, M Iwafuchi, Y Ohsawa
1Department of Pediatric Surgery, Niigata University School of Medicine, Japan.
Insights
Nonshunt operations effectively treat esophageal varices in children. Transthoracic esophageal transection (TR) is recommended for younger patients, while the Sugiura procedure offers good long-term results for older children.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Hepatology
Background:
- Esophageal varices in children often stem from congenital extrahepatic portal obstruction (EHPO), liver cirrhosis/fibrosis (C/F), or idiopathic portal hypertension (IPH).
- Nonshunt surgical operations are employed to manage variceal bleeding in pediatric patients.
Purpose of the Study:
- To evaluate the clinical outcomes of nonshunt surgical procedures for esophageal varices in 15 pediatric patients.
- To determine the efficacy and safety of different surgical techniques based on patient age and underlying etiology.
Main Methods:
- Transthoracic esophageal transection with paraesophageal devascularization (TR) was performed on 2 EHPO patients under 5 years old.
- The Sugiura procedure (TR with splenectomy and paragastric devascularization) was used for 11 patients (8 EHPO, 3 C/F).
- Splenectomy with devascularization (SP) or splenectomy alone was performed for 2 IPH patients.
Main Results:
- The Sugiura procedure demonstrated satisfactory long-term results with no rebleeding in EHPO and C/F patients over 1-20 years.
- TR in young EHPO patients (<5 years) may require additional interventions like partial splenic arterial embolization (PSE) for hemorrhage.
- EHPO patients undergoing the Sugiura procedure before age 6 may experience gastric hemorrhage requiring selective gastric arterial embolization (GAE).
Conclusions:
- Direct operative procedures are recommended: TR for patients ≤6 years and the Sugiura procedure for those >7 years old.
- Age and etiology are critical factors in selecting the optimal nonshunt surgical approach for pediatric esophageal varices.
- Potential complications like gastric hemorrhage in younger EHPO patients necessitate careful monitoring and possible further interventions.
Abstract:
The clinical results of nonshunt operations for esophageal varices in 15 children were evaluated. The varices were caused by congenital extrahepatic portal obstruction (EHPO) in 10, liver cirrhosis or fibrosis (C/F) in 3, and idiopathic portal hypertension (IPH) in 2. The operative procedures were transthoracic esophageal transection with paraesophageal devascularization (TR) for 2 EHPO patients under 5 years of age, TR combined with splenectomy and paragastric devascularization (Sugiura procedure) for 11 (8 EHPO, 3 C/F), and splenectomy with devascularization (SP) or splenectomy for the 2 IPH patients. In the EHPO patient under 5 years of age, TR is associated with a likelihood of gastric or esophageal hemorrhage resulting from hypersplenism, gastric congestion, or persistent distal esophageal varices, which can be treated with partial splenic arterial embolization (PSE), endosclerotherapy, or an additional abdominal procedure. The Sugiura procedure has provided satisfactory long-term results, without rebleeding from esophageal varices, in patients with EHPO and C/F for 1 to 20 years. But EHPO patients who undergo the Sugiura procedure before age 6 can have gastric hemorrhage, because of mucosal congestion, for more than 10 years after the procedure, and selective gastric arterial embolization (GAE) might be necessary. In some EHPO patients, especially young ones who have variceal bleeding, a significant increase in hepatopetal portal flow may not develop, but hepatofugal natural shunts may progress. Therefore we recommend direct operative procedures, ie, TR for patients < or = 6 years of age and a one- or two-stage Sugiura procedure for those over 7 years old.(ABSTRACT TRUNCATED AT 250 WORDS)