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Treatment of portal hypertension in children
1Department of Surgery, University of São Paulo Medical School, Brazil.
Insights
Endoscopic sclerotherapy has become the preferred treatment for bleeding esophageal varices in children, significantly reducing the need for surgical interventions like the distal splenorenal shunt (DSRS). Shunt procedures remain an option for refractory cases, showing improved patency rates.
Area of Science:
- Pediatric Gastroenterology
- Hepatology
- Surgical Innovation
Background:
- Management of pediatric portal hypertension (PH) has evolved with advancements in endoscopic sclerotherapy and liver transplantation.
- Historically, open surgical procedures like devascularization, transection, and portosystemic shunts were primary treatments for variceal bleeding.
- Pediatric experience with non-shunt surgical procedures is limited, though portosystemic shunts can be successful even in young children.
Purpose of the Study:
- To evaluate the shift in treatment strategies for children with portal hypertension and esophageal varices.
- To assess the efficacy and outcomes of distal splenorenal shunt (DSRS) and endoscopic variceal sclerotherapy (EVS) in pediatric patients.
Main Methods:
- Retrospective analysis of pediatric patients treated for variceal bleeding between 1974 and 1993.
- Comparison of outcomes between DSRS (1974-1984) and EVS (since 1985) as primary or secondary treatment modalities.
- Assessment of shunt patency rates and perioperative mortality for DSRS.
Main Results:
- DSRS was the primary treatment from 1974-1984 (42 children), with shunt patency increasing from 71% to 95% over time and no perioperative mortality.
- Since 1985, EVS became the first-line therapy, with DSRS reserved for EVS failures (8 children).
- 107 children underwent EVS sessions for esophageal varices bleeding between 1985 and April 1993.
Conclusions:
- Endoscopic variceal sclerotherapy has largely replaced DSRS as the initial treatment for pediatric variceal bleeding.
- DSRS remains a viable option for refractory cases, demonstrating good shunt patency and safety.
- The management paradigm for pediatric portal hypertension has shifted towards less invasive endoscopic techniques.
Abstract:
The management of children with portal hypertension (PH) has substantially changed owing to the good results and broader application of both endoscopic sclerotherapy and orthotopic liver transplantation (OLT). Since the introduction of sclerotherapy for the treatment of bleeding esophageal varices, the number of surgical procedures has sharply decreased. Until the early 1980s, however, the treatment of choice of bleeding esophageal varices was based on different variations of two main types of open surgery: devacularization and transection operations and portosystemic shunts. The experience with nonshunt procedures is limited in the pediatric population. Literature reports from the last 25 years have emphasized a number of restrictions related to portosystemic shunts in small subjects. However, portosystemic shunts, selective or not, can be performed even in very young subjects with high rates of success. From 1974 to 1984 the distal splenorenal shunt (DSRS) was the procedure of choice for the treatment of children with variceal bleeding in our institution. Forty-two children underwent DSRS during this period. Since 1985, when endoscopic variceal sclerotherapy (EVS) replaced DSRS as the first therapeutic option in our service, this shunt has been performed in only 8 children in whom EVS has failed, none of them during the last 2 years. In this cohort of 50 cases of DSRS, the shunt patency has increased from 71% in the first 7 patients to 95% thereafter. There has been no perioperative mortality. From 1985 to April 1993, 107 children were submitted to EVS sessions for the treatment of esophageal varices bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)