Many adult RCTs have tried to compare variceal band ligation and injection sclerotherapy to control esophageal variceal bleeding [14
]. These previous data indicate that band ligation is no less effective than sclerotherapy, while producing fewer occurrences of procedure-related complications such as procedure related perforation, bleeding, ulceration, and stricture formation at the injection site. A detailed review of the complications of endoscopic management is described elsewhere [16
]. For children, those findings are inconclusive owing to the lack of appropriate RCTs and the inadequacy of the sample sizes for robust statistical analysis [7
]. Notwithstanding the limitations of these studies to guide the treatment of pediatric patients, it is generally accepted that octreotide effectively controls variceal bleeding in a significant number of patients and that endoscopic therapy with band ligation or injection sclerotherapy is suitable for children with variceal bleeding [17
In our present study, we performed band ligation in 39 children and injection sclerotherapy in 16 children as an initial form of therapy. We observed that both esophageal band ligation and injection sclerotherapy were equally effective in controlling active variceal bleeding and preventing rebleeding during the first year after treatment (), although this observation incorporates a selection bias because of two main limitations. First, band ligation was preferred over injection sclerotherapy as an initial form of treatment for variceal bleeding. This preference is based on a pediatric RCT study on secondary prophylaxis, in which band ligation was found to be more efficient than injection sclerotherapy [7
]. In addition to its superior effectiveness, band ligation also showed fewer complications than injection sclerotherapy [18
]. Second, for small children (whose etiology is mainly biliary atresia), it is difficult to insert the device-attached endoscopic probe into their small esophageal lumen in an attempt to control variceal bleeding by band ligation, whereas injection sclerotherapy is feasible even for small infants. Therefore, although band ligation is the best treatment methods for children with liver cirrhosis, injection sclerotherapy is recommended if band ligation is not feasible [8
]. In our present study, the significantly lower mean age of patients that underwent injection sclerotherapy compared with those that underwent band ligation was attributed to the small esophageal lumen of younger children who were unable to accept band ligation probes. Notwithstanding these two limitations, both band ligation and injection sclerotherapy were shown to be highly successful in controlling variceal bleedings. There was no difference in complications between the band ligation and injection sclerotherapy groups. The most commonly encountered complications were short-term fever and abdominal pain. One of our patients who underwent band ligation developed subcutaneous emphysema caused by a tearing of the mucosa. Hazardous complications, such as esopageal stricture and perforation and bacteremia did not occur in our injection sclerotherapy group even in infants.
To date, our center has not investigated either primary or secondary prophylaxis extensively, owing to our belief that endoscopic intervention cannot change the long-term outcome of children with portal hypertension. Two important facts support this belief. First, a recent study in the United States of the long term outcome of biliary atresia showed that only one-third of children who underwent endoscopic intervention were able to preserve their naive liver function until the age of 20 [20
]. Despite measures that included the Kasai operation and endoscopic interventions, many of these children died or underwent liver transplantation. Liver transplantation is the best treatment for children with end-stage liver disease [21
], with surgical intervention, such as the Rex shunt, a further possibility for children with EHPVO [5
]. Second, there is no evidence that endoscopic intervention can prevent hepatopulmonary syndrome or portopulmonary hypertension [22
]. Hepatopulmonary syndrome and portopulmonary hypertension are more critical complications that even make the attempt of liver transplantation unfeasible [23
]. In addition, given that these complications are found at late stages, clinicians usually make their diagnosis at a clinically advanced stage, when the issue can be detected using contrast echocardiography. In such instances, repeated endoscopic interventions might be unwise for children with irreversible hepatopulmonary syndrome or portopulmonary hypertension.
In conclusion, band ligation and injection sclerotherapy are both efficient and safe for the control of acute variceal bleeding and the prevention of rebleeding in children. Although endoscopic intervention is not accepted as the preferred modality for the treatment of variceal bleeding, the high success rates shown in the present study suggest that esophageal varices in children with portal hypertension can initially be managed by endoscopic approaches.