The intussusception antireflux valve is ineffective in preventing cholangitis in biliary atresia.

Cholangitis is the most common complication after portoenterostomy for biliary atresia. The construction of an intussusception valve in the Roux-en-Y limb of the portoenterostomy has been advocated as a means to ameliorate this complication. The authors reviewed the records of children who underwent portoenterostomy to assess the incidence and severity of cholangitis, as well as outcome. The children were divided into two groups according to whether they did not have (group I) or did have (group II) an antireflux valve in the Roux limb of the bilioenteric conduit. There were 19 children in each group. There were no significant differences between the groups with respect to age at time of portoenterostomy or length of follow-up (Table 1). Nine group I patients are alive and well; five died and five have had or are awaiting transplantation. In group II, 10 patients are alive and well, eight have had transplantation, and one is awaiting transplantation. Outcome with respect to death or the need for liver transplantation because of progressive hepatic failure is not different between the groups (P = 1.0, Fisher's 2 x 2). The incidence of cholangitis was evaluated by comparing the average number of episodes of cholangitis during the follow-up period, the number of episodes per year, and the number of episodes in the first postoperative year (when this complication is most prevalent). Analysis of the data showed no difference in incidence between those with valved and nonvalved biliary conduits. The severity of cholangitis, judged by total length of antibiotic treatment, did not differ between the groups. It appears that the presence of an intussusception valve in the Roux-en-Y biliary conduit does not affect the incidence of cholangitis or the outcome after portoenterostomy, over short-term follow-up.

Portal vein thrombosis: treatment of variceal hemorrhage by endoscopic variceal ligation.

Thirty-one endoscopic variceal ligation (EVL) procedures have been done in seven consecutively treated children who had esophageal varices resulting from portal vein thrombosis. Using an elastic band ligature device attached to a standard flexible endoscope, the varices in the distal 5 cm of the esophagus were mechanically strangulated. Typically, one to three varices were banded at each session. The children were between 8 months and 19 years of age at the onset of variceal bleeding. Treatment initially required frequent procedures (every 2 to 4 weeks), but the interval was gradually extended to biannual or annual. Treatment was assessed by survival, complications, incidence of rebleeding, and obliteration of varices. Each patient had from 3 to 9 EVL sessions. There were no deaths related to EVL. There were no complications. Only one patient had rebleeding in the interval between sessions. The follow-up period is 3 to 12 years. In three of the six surviving patients, the varices have been completely eradicated. The remaining three are completing treatment. Endoscopic variceal ligation is safe efficacious treatment for control of variceal bleeding caused by portal vein thrombosis. In our experience, the technique has eliminated the need for portosystemic shunting in this patient population.

Childhood injury: a current perspective.

The majority of childhood injuries requiring admission are due to traffic-related injury, falls, and burns. Many of these injuries are preventable. In the case of the unpreventable, unintentional injury, the natural history of the injury and outcome can be altered by adherence to established safety standards. New standards also need to be set. There is definitely room for improvement in vehicular restraint systems for the smaller and younger passengers. It is known that wearing bicycle helmets, using safety belts, securing firearms in the home, and controlling hot water heater temperature levels will prevent or lessen injury in children. This information is being promulgated to communities by activities such as the National SAFE KIDS Campaign, a program of Children's National Medical Center sponsored by Johnson & Johnson Family of Companies and the National Safety Council. This campaign emphasizes important aspects of childhood injury: scope, causes, and prevention. Questions about the most devastating of childhood injuries, child abuse and assault related to violent crime, are more complex and the answers elusive. The study of patterns of injury in children highlights the need to implement new strategies aimed at prevention. At the same time, valuable information is obtained about specific injuries and responses seen in children that set them apart from adults.