Evaluation of the endoscopic and surgical methods of prehepatic portal hypertension treatment in children
DOI:
https://doi.org/10.15574/PS.2020.67.29Keywords:
portal hypertension, esophageal varices, variceal bleeding, porto-systemic shunting, endoscopic variceal band ligationAbstract
Surgical methods of treating portal hypertension (PH) in children make give the opportunity to achieve a lasting effect in the variceal bleeding prevention and reducing pressure in the portal system. The question, regarding the possibility of combining the endoscopic and surgical treatment methods in order to increase the effectiveness of variceal bleeding prophylaxis, remains debatable in children with PH.
Aim. To determine the optimal tactics for the prophylactic treatment of variceal bleeding in children with prehepatic PH.
Materials and methods. The study design is a retrospective cohort. The data of 84 patients with PH, who were examined and treated during 2016–2019 at the National Children’s Specialized Hospital «OKHMATDYT», were analyzed. The study included patients under the age of 18 years with prehepatic PH and the presence of esophageal and stomach varices with the high risk of variceal bleeding. According to the chosen prophylactic method, two groups were formed – surgical and endoscopic treatment. The main study variables were the variceal eradication and the rebreeding number.
Results. Data from 21 patients from the endoscopic prophylactic treatment group and 36 from the surgical group were analyzed. A significant difference (p=0.02) of esophageal varices grade was found between the study groups. However, no significant difference between the groups was found for indicators of the gastric varices degree, the red marks presence and the portal gastropathy severity (p>0.05). The complications incidence was significantly higher in the surgical treatment group (p<0.001). Eesophageal varices eradication was achieved in 17 (81%) patients in the endoscopic group and in 15 (41.7%) in the surgical treatment group. It was found that esophageal varices eradication was more commonly achieved in patients with endoscopic treatment (p=0.01). Bleeding after treatment occurred in 4 (19%) patients from the endoscopic group and 14 (38.9%) from the surgical treatment group. No significant difference in the bleeding rates (p=0.15) depending on the treatment type selected was found. Also no significant difference was found for esophageal varices recurrence rates (p=0.35) depending on the selected prophylactic treatment type.
Conclusions. Endoscopic prophylactic treatment compared to surgical treatment may be more effective in esophageal varices eradication (p=0.005). Endoscopic treatment has a lower postoperative complications incidence and severity compared to surgical treatment (p<0.001). The optimal prophylactic treatment tactic is a combination of endoscopic and surgical methods to achieve treatment completeness in children with prehepatic PH.
The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institution. The informed consent of the patient was obtained for conducting the studies.
References
Voroniak DI, Godik OS, Kolomoiets IV, Dubrovin OG. (2019). Efficacy of the staged endoscopic ligature of the varicose veins in children, suffering portal hypertension. Klinichna khirurgiia.86(10): 24-27. https://doi.org/10.26779/2522-1396.2019.10.24
Dubrovin ОG, Godik ОS, Soruchan VP. (2016). Choice of variants of mesocaval shunting, depending on peculiarities of the splenomesenterial confluence structure in children, suffering from portal hypertension. Klinichna khirurgiia. 10(891): 55-57. PMID: 30479116
Bass LM, Shneider BL, Nathan P. Goodrich LH, Magee JC. (2019). Clinically Evident Portal Hypertension: An Operational Research Definition for Future Investigations in the Pediatric Population. J Pediatr Gastroenterol Nutr. 6(68): 763-767. https://doi.org/10.1097/MPG.0000000000002333; PMid:30908382 PMCid:PMC6534459
Beng Hui Ng N, Karthik SV, Aw MM, Quak SH. (2016). Endoscopic Evaluation in Children With End-Stage Liver Disease–Associated Portal Hypertension Awaiting Liver Transplant. J Pediatr Gastroenterol Nutr. 63: 365-369. https://doi.org/10.1097/MPG.0000000000001160; PMid:26863384
D’Antiga L, Betalli P, De Angelis P, Davenport M et al. (2015). Interobserver Agreement on Endoscopic Classification of Oesophageal Varices in Children: A Multicenter Study. J Pediatr Gastroenterol Nutr. 61: 176-181 https://doi.org/10.1097/MPG.0000000000000822; PMid:25883057
De Franchis R, Dell’Era A. (2014). Invasive and non-invasive methods to diagnose portal hypertension and esophageal varices. Clinics in Liver Disease. 18: 293-302. https://doi.org/10.1016/j.jhep.2010.06.004; PMid:20638742
De Franchis R. (2010). Revising consensus in portal hypertension: report of the Baveno V Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 53: 762-768. https://doi.org/10.1016/j.jhep.2010.06.004; PMid:20638742
Di Francesco F, Grimaldi C, de Ville de Goyet J. (2014). Meso-Rex bypass – a procedure to cure prehepatic portal hypertension: the insight and the inside. J Am Coll Surg.218: e23–e36. https://doi.org/10.1016/j.jamcollsurg.2013.10.024; PMid:24326080
Dindo D, Demartines N, Clavien PA. (2004). Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 240(2): 205-213. https://doi.org/10.1097/01.sla.0000133083.54934.ae; PMid:15273542 PMCid:PMC1360123
Duche M, Ducot B, Ackermann O, Guerin F et al. (2017). Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding. J of Hepatol. 66: 320-327. https://doi.org/10.1016/j.jhep.2016.09.006; PMid:27663417
Giouleme O, Theocharidou E. (2013). Management of Portal Hypertension in Children with Portal Vein Thrombosis. J Pediatric Gastroenterology Nutr. 57: 419-25. https://doi.org/10.1097/MPG.0b013e3182a1cd7f; PMid:23820400
Gjeorgjievski М, Cappell MS. (2016). Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy. World J Hepatol.8(4): 231-262. https://doi.org/10.4254/wjh.v8.i4.231; PMid:26855694 PMCid:PMC4733466
Itha S, Yachha SK. (2006). Endoscopic outcome beyond esophageal variceal eradication in children with extrahepatic portal venous obstruction. J Pediatr Gastroenterol Nutr. 42: 196-200 https://doi.org/10.1097/01.mpg.0000189351.55666.45; PMid:16456415
Iwakiri Y. (2014). Pathophysiology of portal hypertension. Clinics in Liver Disease; 18: 281-291 https://doi.org/10.1016/j.cld.2013.12.001; PMid:24679494 PMCid:PMC3971388
Kang KS, Yang HR, Ko JS, Seo JK. (2013). Long-term Outcomes of Endoscopic Variceal Ligation to Prevent Rebleeding in Children with Esophageal Varices. J Korean Med Sci. 28: 1657-1660. https://doi.org/10.3346/jkms.2013.28.11.1657; PMid:24265531 PMCid:PMC3835510
Khanna R, Sarin SK. (2014). Non-cirrhotic portal hypertension – diagnosis and management. Journal of Hepatology. 60(2): 421-441. https://doi.org/10.1016/j.jhep.2013.08.013; PMid:23978714
Ling SC. (2012). Advances in the evaluation and management of children with portal hypertension. Seminars in Liver Disease. 32: 288-297 https://doi.org/10.1055/s-0032-1329897; PMid:23397529
Maksoud-Filho JG, Goncalves MEP, Cardoso SR et al. (2009). Long term follow up of children with extrahepatic portal vein obstruction: impact of an endoscopic sclerotherapy program on bleeding episodes, hepatic function, hypersplenism, and mortality. J Pediatr Surg. 44: 1877-83. https://doi.org/10.1016/j.jpedsurg.2009.02.074; PMid:19853741
McCormack TT, Sims J, Eyre-Brook I, Kennedy H et al. (1985). Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy? Gut. 26: 1226-1232 https://doi.org/10.1136/gut.26.11.1226; PMid:3877665 PMCid:PMC1432906
Sarin SK, Kumar A. (1989). Gastric varices: profile, classification, and management. Am J Gastroenterol. 84(10): 1244-1249. PMID: 2679046
Sarin SK, Sollano JD, Chawla YK et al. (2006). Members of the APASL Working Party on Portal Hypertension. Consensus on extrahepatic portal vein obstruction. Liver Int.26: 512-9 https://doi.org/10.1111/j.1478-3231.2006.01269.x; PMid:16761994
Shneider BL, Bosch J, de Franchis R, Emre SH et al. (2012). Expert Panel of the Children’s Hospital of Pittsburgh of UPMC. Portal hypertension in children: expert pediatric opinion on the report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. Pediatr Transplant.16(5): 426-37. https://doi.org/10.1111/j.1399-3046.2012.01652.x; PMid:22409296
Thomas V, Jose T, Kumar S. (2009). Natural history of bleeding after esophageal variceal eradication in patients with extrahepatic portal venous obstruction: a 20 year follow up. Indian J Gastroenterol. 28: 206-11 https://doi.org/10.1007/s12664-009-0086-0; PMid:20425640
Thomson M, Tringali A, Dumonceau JM, Tavares M et al. (2017). Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines. Pediatr Gastroenerol Hepatol Nutr. 64: 133-53. https://doi.org/10.1097/MPG.0000000000001408; PMid:27622898
Vittorio J, Orellana K, Martinez M, Ovchinsky N et al. (2019). Partial Splenic Embolization Is a Safe and Effective Alternative in the Management of Portal Hypertension in Children. J Pediatr Gastroenterol Nutr. 6(68): 793-798. https://doi.org/10.1097/MPG.0000000000002332; PMid:30908386
Zargar SA, Javid G, Khan BA, Shah OJ et al. (2005). Endoscopic ligation versus sclerotherapy in adults with extrahepatic portal venous obstruction: a prospective randomized study. Gastrointest Endosc. 61(1): 58-66. PMID: 15672057, https://doi.org/10.1016/S0016-5107(04)02455-1
Zargar SA, Yattoo GN, Javid G et al. (2004). Fifteen-year follow up of endoscopic injection sclerotherapy in children with extrahepatic portal venous obstruction. J Gastroenterol Hepatol.19: 139-45. https://doi.org/10.1111/j.1440-1746.2004.03224.x; PMid:14731122
Downloads
Published
Issue
Section
License
The policy of the Journal “PAEDIATRIC SURGERY. UKRAINE” is compatible with the vast majority of funders' of open access and self-archiving policies. The journal provides immediate open access route being convinced that everyone – not only scientists - can benefit from research results, and publishes articles exclusively under open access distribution, with a Creative Commons Attribution-Noncommercial 4.0 international license(СС BY-NC).
Authors transfer the copyright to the Journal “PAEDIATRIC SURGERY.UKRAINE” when the manuscript is accepted for publication. Authors declare that this manuscript has not been published nor is under simultaneous consideration for publication elsewhere. After publication, the articles become freely available on-line to the public.
Readers have the right to use, distribute, and reproduce articles in any medium, provided the articles and the journal are properly cited.
The use of published materials for commercial purposes is strongly prohibited.