Price M R, Sartorelli K H, Karrer F M, Narkewicz M R, Sokol R J, Lilly J R
Department of Surgery, University of Colorado School of Medicine, Children's Hospital, Denver 80218, USA.
J Pediatr Surg. 1996 Aug;31(8):1056-9. doi: 10.1016/s0022-3468(96)90086-x.
Endoscopic variceal sclerotherapy (EVS) has been considered the mainstay of therapy for bleeding esophageal varices in adults. However, recent data have shown that endoscopic variceal ligation (EVL) is just as efficacious and has fewer complications than EVS. Although there are many reports concerning EVL in adults, only a few studies have been done in children. This report describes experience with EVL in 22 children with esophageal variceal hemorrhage. Eighty-seven EVL procedures were performed during a 9-year period in 22 children. The causes of portal hypertension were biliary atresia (10), portal vein thrombosis (8), chronic active hepatitis (1), cirrhosis secondary to cystic fibrosis (2), and primary sclerosing cholangitis (1). The age range at the onset of variceal bleeding was 8 months to 19 years. Twelve patients had EVS before EVL treatment was begun. Distal esophageal varices (one to four per session) were mechanically ligated using an elastic band ligature device attached to a flexible endoscope. The aim of therapy was obliteration of distal esophageal varices by EVL, every 2 to 4 weeks, until eradication. Subsequent EVL was dictated by the status of the varices. Outcome was assessed with respect to survival, rebleeding, status of varices, and complications. The patients underwent a mean of four sessions of EVL (range, one to eight). Four patients subsequently underwent liver transplantation. Of the 18 patients remaining (average follow-up period, 5.3 years), 12 had their varices eradicated (average of four EVL sessions), four are still in treatment, one has not been evaluated in the past 4 years, and one died of liver failure. Complications included bleeding between sessions (6 patients), cervical esophageal perforation (1 patient), and transient fever (2 patients). No child has experienced symptoms of esophageal stenosis or gastroesophageal reflux. Two patients died of liver disease, unrelated to bleeding from portal hypertension. EVL is effective in controlling variceal hemorrhage in children with portal hypertension, regardless of etiology. The complication rate is low, and EVL is an acceptable and perhaps preferable alternative to EVS in children with esophageal varices.
内镜下静脉曲张硬化疗法（EVS）一直被视为治疗成人食管静脉曲张出血的主要方法。然而，最近的数据表明，内镜下静脉曲张套扎术（EVL）同样有效，且并发症比EVS少。尽管有许多关于成人EVL的报道，但针对儿童的研究却很少。本报告描述了对22例食管静脉曲张出血儿童进行EVL的经验。在9年期间，对22例儿童进行了87次EVL手术。门静脉高压的病因包括胆道闭锁（10例）、门静脉血栓形成（8例）、慢性活动性肝炎（1例）、囊性纤维化继发肝硬化（2例）和原发性硬化性胆管炎（1例）。静脉曲张出血开始时的年龄范围为8个月至19岁。12例患者在开始EVL治疗前接受过EVS。使用连接在柔性内镜上的弹性带结扎装置对远端食管静脉曲张（每次1至4个）进行机械结扎。治疗目的是每2至4周通过EVL消除远端食管静脉曲张，直至根除。后续的EVL根据静脉曲张的情况而定。从生存、再出血、静脉曲张状态和并发症方面评估结果。患者平均接受了4次EVL手术（范围为1至8次）。4例患者随后接受了肝移植。在其余18例患者中（平均随访期5.3年），12例患者的静脉曲张被根除（平均进行了4次EVL手术），4例仍在接受治疗，1例在过去4年中未接受评估，1例死于肝功能衰竭。并发症包括两次手术之间的出血（6例患者）、颈部食管穿孔（1例患者）和短暂发热（2例患者）。没有儿童出现食管狭窄或胃食管反流症状。2例患者死于肝病，与门静脉高压出血无关。无论病因如何，EVL对于控制门静脉高压儿童的静脉曲张出血均有效。并发症发生率低，对于患有食管静脉曲张的儿童，EVL是一种可接受的、甚至可能更可取的替代EVS的方法。
