Correspondence

Abstract

We read with interest the case report and literature review of inflammatory pseudotumors (IPTs) of the porta hepatis published by Swinney et al [ [1] Swinney R. Sadri R. Muenchow S. Nonresectable inflammatory pseudotumor of the porta hepatis. J Pediatr Surg. 2006; 41: E21-E23 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ]. However, the article contains some inaccuracies, and we do not consider the conclusions to be justified. 1.The reported case was not an IPT at the porta hepatis. The porta hepatis is the area of the inferior surface of the liver between the quadrate lobe (segment 4) anteriorly and the caudate lobe (segment 1) posteriorly through which the portal vein, hepatic artery, bile ducts, lymphatics, and neural tissue enter and exit the liver parenchyma [ [2] Standring S. Gray's anatomy 39th edition, 2005. Google Scholar ]. Had the IPT been centered on this area as stated, then cholecystojejunal bypass would not have been effective in relieving jaundice. The 2 images in the report suggest a more distal origin of the IPT from the common bile duct. 2.There are at least 2 other patients with a hilar IPT not cited in the article, both of whom underwent orthotopic liver transplantation: Tepetes et al [ [3] Tepetes K. Selby R. Webb M. et al. Orthotopic liver transplantation for benign hepatic neoplasms. Arch Surg. 1995; 130: 153-156 Crossref PubMed Scopus (92) Google Scholar ] reported on the case of an 8-year-old girl, and we reported on a 7-year-old boy with obstructive jaundice and portal vein involvement who required orthotopic liver transplantation after an unsuccessful attempt at radical resection [ [4] Dasgupta D. Guthrie A. McClean P. et al. Liver transplantation for a hilar inflammatory myofibroblastic tumor. Pediatr Transplantation. 2004; 8: 517-521 Crossref PubMed Scopus (11) Google Scholar ]. Our patient remains well 3.5 years later. Swinney et al [ [1] Swinney R. Sadri R. Muenchow S. Nonresectable inflammatory pseudotumor of the porta hepatis. J Pediatr Surg. 2006; 41: E21-E23 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ] stated that only 2 cases of IPT at the porta hepatis have been documented in the pediatric literature (both in patients older than 30 years!); however, this is at odds both with Table 1 and with our review published in 2004, which documented 8 cases. 3.We question the evidence base for the statement that “...nonoperative treatments seem to be the most promising primary therapy” for IPTs arising at the porta hepatis. The patient in the report by Swinney et al [ [1] Swinney R. Sadri R. Muenchow S. Nonresectable inflammatory pseudotumor of the porta hepatis. J Pediatr Surg. 2006; 41: E21-E23 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ] was lost to follow-up after discharge from the hospital. As the authors stated, hilar IPTs present with obstructive jaundice and may cause portal hypertension, biliary cirrhosis, and liver failure. Although a short period of observation or medical therapy [ [5] Applebaum H. Kieran M.W. Cripe T.P. et al. The rationale for nonsteroidal anti-inflammatory drug therapy for inflammatory myofibroblastic tumors: a Children's Oncology Group study. J Pediatr Surg. 2005; 40: 999-1003 Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar ] or temporary intervention with biliary stenting may be justified in the hope of observing tumor arrest or even regression, the chances of a successful conservative approach with an IPT at the hepatic hilum (in contrast to an IPT within the liver parenchyma) are very small. Of the 9 previously reported IPTs at the hepatic hilum, 8 required either major hepatic resection (n = 4) or transplantation (n = 4), 2 after failure to respond to medical therapy [ [4] Dasgupta D. Guthrie A. McClean P. et al. Liver transplantation for a hilar inflammatory myofibroblastic tumor. Pediatr Transplantation. 2004; 8: 517-521 Crossref PubMed Scopus (11) Google Scholar ]. The authors described the single case reported by Hertzer et al [ [6] Hertzer N.R. Hawk W.A. Hermann R.E. Inflammatory lesions of the liver which simulate tumour: report of two cases in children. Surgery. 1971; 69: 839-846 PubMed Google Scholar ] as being successfully treated with steroids with a good outcome, but this child developed progressive hepatosplenomegaly and portal vein thrombosis resulting in chronic symptomatic portal hypertension.