Bile decompression in children with histopathological evidence of pre-existing liver cirrhosis.

Although it is agreed upon by most that adequate and timely bile decompression can preserve or even improve existing liver function much debate centers on whether pre-existing liver cirrhosis can also be reversed. To help answer this question we analyzed data on 47 children with choledochal cyst disease (CD) who underwent simultaneous liver biopsy during bile decompression surgery. We collected data on two groups of children with CD spanning two different time periods: January 1985 through November 1994 (Group A) and June 1995 through November 1999 (Group B). In Group A 37 children (16 boys and 21 girls ages 5 days to 10 years) underwent simultaneous liver biopsy during elective definitive surgery for CD. In Group B ten children (five boys and five girls age one month to 7 years) underwent liver biopsy twice: first during initial cyst decompression for acute obstruction and second during elective definitive surgery after resolution of acute disease. Degree of liver cirrhosis was based on a modified World Health Organization classification system (0-IV). In Group A 15/37 (40.5%) had significant liver cirrhosis at time of biopsy (III or IV) with altered liver function in all cases; eight of nine had normal liver function on follow-up, six were lost to follow-up. In Group B seven of ten (70%) had less liver cirrhosis on pathology at second operation with three unchanged; nine of ten (90%) regained normal liver function. We conclude that bile duct obstruction is the main cause of liver cirrhosis in children with CD. Adequate and timely bile decompression can restore normal liver function and even reverse severe cirrhosis.

Balloon catheter dilatation in children with congenital and acquired esophageal anomalies.

BACKGROUND/PURPOSE: Esophageal stricture requiring dilatation often is the sequelae in children with a history of congenital or acquired esophageal anomalies. Balloon catheter dilatation (BCD) for esophageal stricture is well established in adults, yet its role in children is less well described. The authors report their initial experience using BCD in children with esophageal stricture, assessing outcome. METHODS: Between January 1994, and December 1998, 20 children (age range, 17 days to 12 years) underwent BCD for esophageal strictures and were divided into 2 etiology groups (A and B). (A, n = 10) included congenital anomalies (esophageal atresia, 10), and (B, n = 10) included acquired anomalies (caustic ingestion, 7; tight fundoplication, 2; peptic stricture, 1). BCD was performed in all cases under conscious sedation with a balloon catheter (6 to 25 mm) with fluoroscopy. Outcome parameters included number of dilatations; complications, ie, perforation; and success or failure of procedure. Success was defined as increasing intervals of age-appropriate food tolerance between dilatations, and failure was defined as abandonment of dilatation in favor of surgical intervention. Follow-up for A and B ranged from 6 to 42 months. RESULTS: Seventeen of 20 (85.0%) underwent successful BCD. In A, 10 of 10 (100%) had complete resolution of symptoms with follow-up ranging from 6 to 42 months versus 7 of 10 (70.0%) in B with follow-up of 6.5 to 36 months. In A, number of dilatations ranged from 1 to 4 over an average period of 2 months. In B, number of dilatations ranged from 3 to 40 over periods ranging from 2 to 30 months. All 3 failures occurred in children with caustic ingestion, with 1 child suffering perforation requiring urgent surgical intervention. CONCLUSIONS: Balloon catheter dilatation can be applied safely and effectively to children in whom esophageal strictures develop after repair of esophageal atresia. However, its use in children with acquired esophageal anomalies, notably caustic injury, is associated with higher complication and failure rates, necessitating greater caution and lower expectations.