Benjamin L Shneider1, Jean de Ville de Goyet2, Daniel H Leung1, Anshu Srivastava3, Simon C Ling4, Mathieu Duché5, Patrick McKiernan6, Riccardo Superina7, Robert H Squires8, Jaime Bosch9, Roberto Groszmann10, Shiv K Sarin11, Roberto de Franchis12, George V Mazariegos8. 1. Texas Children's Hospital and the Department of Pediatrics, Baylor College of Medicine, Houston, TX. 2. Bambino Gesu Children's Hospital and Tor Vergata Roma University, Rome, Italy. 3. Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. 4. Hospital for Sick Children and the Department of Paediatrics, University of Toronto, Toronto, Canada. 5. Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Radiologie Pédiatrique, Université Paris-Sud 11, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France. 6. Birmingham Children's Hospital, Birmingham, United Kingdom. 7. Lurie Children's Hospital, Chicago, IL. 8. Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA. 9. Hospital Clinic-IDIBAPS and CIBEREHD, Barcelona, Spain. 10. Yale University School of Medicine, New Haven, CT. 11. Institute of Liver and Biliary Sciences, New Delhi, India. 12. University of Milan, Milan, Italy.
Abstract
UNLABELLED: Approaches to the management of portal hypertension and variceal hemorrhage in pediatrics remain controversial, in large part because they are not well informed by rigorous clinical studies. Fundamental biological and clinical differences preclude automatic application of approaches used for adults to children. On April 11-12, 2015, experts in the field convened at the first Baveno Pediatric Satellite Meeting to discuss and explore current available evidence regarding indications for MesoRex bypass (MRB) in extrahepatic portal vein obstruction and the role of primary prophylaxis of variceal hemorrhage in children. Consensus was reached regarding MRB. The vast majority of children with extrahepatic portal vein obstruction will experience complications that can be prevented by successful MRB surgery. Therefore, children with extrahepatic portal vein obstruction should be offered MRB for primary and secondary prophylaxis of variceal bleeding and other complications, if appropriate surgical expertise is available, if preoperative and intraoperative evaluation demonstrates favorable anatomy, and if appropriate multidisciplinary care is available for postoperative evaluation and management of shunt thrombosis or stenosis. In contrast, consensus was not achieved regarding primary prophylaxis of varices. Although variceal hemorrhage is a concerning complication of portal hypertension in children, the first bleed appears to be only rarely fatal and the associated morbidity has not been well characterized. CONCLUSION: There are few pediatric data to indicate the efficacy and safety of pharmacologic or endoscopic therapies as primary prophylaxis or that prevention of a sentinel variceal bleed will ultimately improve survival; therefore, no recommendation for primary prophylaxis with endoscopic variceal ligation, sclerotherapy, or nonspecific beta-blockade in children was proposed.
UNLABELLED: Approaches to the management of portal hypertension and variceal hemorrhage in pediatrics remain controversial, in large part because they are not well informed by rigorous clinical studies. Fundamental biological and clinical differences preclude automatic application of approaches used for adults to children. On April 11-12, 2015, experts in the field convened at the first Baveno Pediatric Satellite Meeting to discuss and explore current available evidence regarding indications for MesoRex bypass (MRB) in extrahepatic portal vein obstruction and the role of primary prophylaxis of variceal hemorrhage in children. Consensus was reached regarding MRB. The vast majority of children with extrahepatic portal vein obstruction will experience complications that can be prevented by successful MRB surgery. Therefore, children with extrahepatic portal vein obstruction should be offered MRB for primary and secondary prophylaxis of variceal bleeding and other complications, if appropriate surgical expertise is available, if preoperative and intraoperative evaluation demonstrates favorable anatomy, and if appropriate multidisciplinary care is available for postoperative evaluation and management of shunt thrombosis or stenosis. In contrast, consensus was not achieved regarding primary prophylaxis of varices. Although variceal hemorrhage is a concerning complication of portal hypertension in children, the first bleed appears to be only rarely fatal and the associated morbidity has not been well characterized. CONCLUSION: There are few pediatric data to indicate the efficacy and safety of pharmacologic or endoscopic therapies as primary prophylaxis or that prevention of a sentinel variceal bleed will ultimately improve survival; therefore, no recommendation for primary prophylaxis with endoscopic variceal ligation, sclerotherapy, or nonspecific beta-blockade in children was proposed.
Authors: Lee M Bass; Benjamin L Shneider; Lisa Henn; Nathan P Goodrich; John C Magee Journal: J Pediatr Gastroenterol Nutr Date: 2019-06 Impact factor: 2.839