Advances in treatment of biliary atresia

Biochemical Evaluation of Laparoscopic Portoenterostomy for Treating Biliary Atresia and Redo for Failed Portoenterostomy

Background: Postoperative outcomes of portoenterostomy (PE) and redo-PE were evaluated using selected biochemical markers (SBM) and biochemical status categories (BSC). Methods: Subjects were 70 consecutive PE performed for biliary atresia. SBM were aspartate aminotransferase (AST)/alanine aminotransferase (ALT), cholinesterase (ChE), and platelet count (PLT) assessed at 1, 2, 3, 6, and 12 months, and thence, annually for a maximum of 10 years. BSC were as follows: all SBM normal (N-SBM), normal AST/ALT (N-SLT), normal ChE (N-ChE), normal PC (N-PLT), all abnormal (A-SBM), abnormal AST/ALT (A-SLT), abnormal ChE (A-ChE), and abnormal PC (A-PLT). Subjects achieving jaundice clearance (JC) and surviving with native livers (SNL) also had gamma glutamyl transpeptidase assessed. Redo-PE indicated for failed PE was assessed postoperatively using the same SBM/BSC protocol. Results: PE were laparoscopic (LPE; n = 40) or open (OPE; n = 30). Mean age/weight at PE and duration of follow-up were similar. For JC, LPE = 34/40 (85.0%) and OPE = 22/30 (73.3%); P = .23. For SNL, LPE = 29/40 (72.5%) and OPE = 16/30 (53.3%); P = .10. LPE and OPE were similar for SBM/BSC, except for a single significant increase in ALT in OPE at 6 months. Redo-PE was performed 17-180 days (mean 67.1 days) after primary PE. AST was significantly increased at the last preredo assessment 3 months after primary PE; P < .05. After redo, AST decreased and SBM/BSC results were equivalent to nonredo subjects. Conclusion: Postoperative biochemical data for all PE cases were comparable; redo-PE would appear to be viable for restoring SBM, and AST could be valuable as a single marker of deterioration in redo cases.

Relationships Between Histopathological Findings in the Liver and Prognosis in Patients With Biliary Atresia

BACKGROUND

Biliary atresia (BA) is a progressive obstructive hepatic disease that requires early diagnosis and the prompt initiation of treatment. Although portoenterostomy (PES) is usually performed as the initial surgical procedure, the liver damage may subsequently progress, such that liver transplantation (LTx) may be required. In this study, we comprehensively evaluated the histopathology of liver samples collected during PES and retrospectively evaluated its relationship with prognosis.

METHODS

Forty-seven patients with BA who underwent PES between 2002 and 2021 were included. Their biopsy samples were semi-quantitatively graded according to the severity of liver fibrosis, bile duct proliferation, cholestasis, ductal plate malformation, and inflammatory cell infiltration; and the expression of cluster of differentiation (CD)3, CD20, human leukocyte antigen II-DR, and α-smooth muscle actin (α-SMA). The relationships of each with the prevalence of survival with native liver (SNL) were evaluated to identify prognostic markers.

RESULTS

The median postoperative duration of follow-up was 11.8 years (maximum, 18.0 years; minimum, 3.5 years). There were no deaths during this period, but LTx was performed in 31 patients and the final prevalence of SNL was 34.0% (16/47). There were negative correlations of liver fibrosis and α-SMA with SNL, and a positive correlation between CD20 and SNL. Multivariate analysis using a proportional hazards regression model showed that only CD20 expression was significant.

CONCLUSIONS

Comprehensive histopathological analysis of liver biopsy samples obtained at the time of PES showed a positive correlation between CD20 expression and SNL, suggesting that this may represent a useful prognostic marker.

LEVEL OF EVIDENCE

III.

Diagnostic Performance of Transient Elastography in Biliary Atresia Among Infants With Cholestasis

Biliary atresia (BA) is a challenging liver disease in infancy. Early diagnosis of BA is important for timely hepatoportoenterostomy. We evaluated the age-specific diagnostic performance of transient elastography (TE) with a liver stiffness measurement (LSM) greater than 7.7 kPa in BA among infants with cholestasis. A total of 61 infants with cholestasis (5-121 days of age) were enrolled in this prospective follow-up study; 15 infants were BA. Four age groups were defined (≤30, 31-60, 61-90, and 91-180 days). Picrosirius red staining was performed to quantify the percentage of collagen fibers in liver specimens. The utility of an LSM greater than 7.7 kPa for diagnosis of BA among infants with cholestasis was compared among age groups. In all four groups, TE showed high diagnostic power for BA using the criterion of an LSM greater than 7.7 kPa. Positive predictive values were 100%, 100%, and 100% in the groups aged 30 days or younger, 31 to 60 days, and 61 to 90 days, respectively. Respective negative predictive values were 90.9%, 94.7%, and 100%, and respective diagnostic accuracies were 92.9%, 95.2%, and 100%. The positive predictive value, negative predictive value, and diagnostic accuracy were 100%, 100%, and 100%, respectively, for LSM greater than 8.8 kPa in the group aged 91 to 180 days. The LSM was positively correlated with the percentage of collagen fibers stained by picrosirius red (P = 0.03). Conclusion: In this prospective follow-up study, TE had good diagnostic accuracy for differentiation of BA from non-BA cholestasis in infants with cholestasis who were 90 days of age or younger. The LSM was significantly positive correlated with the liver fibrosis status stained by picrosirius red in infants with cholestasis.

Hepatic expression of HGF/C-met and native liver survival in biliary atresia

BACKGROUND

The prognosis of biliary atresia (BA) remains difficult to predict. This study evaluated the roles of hepatocyte growth factor (HGF) and its receptor (C-met) towards clinical outcome and native liver survival.

METHODS

Hepatic HGF and C-met expression were determined using immunohistochemistry from liver biopsies of 41 BA patients during Kasai operation, and 17 non-cholestatic patients. The HGF and C-met expression was visually scored as per its intensity and percentage of stained area. BA patients were classified as high- and low-HGF and C-met receptor status. Native liver survival was compared between the two groups at 3-year follow-up. Data are shown as median and range.

MAIN RESULTS

Median age of BA patients was 2 (1-6) months. Hepatic HGF and C-met staining scores of BA patients were higher than those of non-cholestatic patients (P < 0.0001). There was a correlation between HGF and C-met staining scores (spearman r = 0.77, P < 0.0001). However, there was no association between their expression and early outcome at 6 months post-op. Mean follow-up time was 68.6 months. Survival analysis revealed that native liver survival at 1 year and 3 years were 88% and 77%, respectively. Additionally, 82.6% (19/23) of patients in the low-HGF group survived with native liver, compared with 66.7% (10/15) of those in high-HGF group (P = 0.436). For C-met expression, 78.6% (22/28) of low-score and 70% (7/10) of high score groups survived with native liver (P = 0.673).

CONCLUSIONS

Strong expression of hepatic HGF and its receptor in BA patients was demonstrated. However, the expression was not associated with the early outcome and native liver survival. These results suggest that HGF involved in the liver pathology of BA but its expression cannot be used as a prognostic indicator. Small sample size of patients was a main limitation. Further studies are warranted to validate our findings.

Hepatoportoenterostomy surgery technique

Biliary atresia (BA) is a pathology that causes jaundice in children because of an obstruction of the obliterated biliary tract. Despite being considered a rare disease, the incidence can reach 1/2400 live births in the Pacific region. The etiology is unknown. If untreated, it will lead to cirrhosis and death. Early operation (within 60 days after birth) is the most important prognostic factor. The objective of this article is to present the technical description step by step of a hepatoportoenterostomy operation in a female 61 days of age with BA.

Quantification of Serum Matrix Metallopeptide 7 Levels May Assist in the Diagnosis and Predict the Outcome for Patients with Biliary Atresia

OBJECTIVE

To assess the diagnostic and prognostic usefulness of the serum matrix metallopeptidase-7 (MMP-7) level for biliary atresia in infants with cholestasis after hepatoportoenterostomy.

STUDY DESIGN

We enrolled 100 infants with cholestasis (age, 43.56 ± 1.97 days; 62 males) with a direct bilirubin level of >1 mg/dL, of whom 36 (36%) were diagnosed with biliary atresisa. The MMP-7 levels in serum samples collected during the cholestasis workup and 6 months after hepatoportoenterostomy were assessed by enzyme-linked immunosorbent assay. We quantified liver fibrosis by Picro Sirius red staining of collagen in specimens from the 81 infants with cholestasis.

RESULTS

Infants with biliary atresisa had a significantly higher serum MMP-7 level than that of non-biliary atresisa infants with cholestasis of equivalent age (P < .0001). Receiver operating characteristic analysis showed that a serum MMP-7 level of >1.43 ng/mL was predictive of biliary atresisa in infants with cholestasis (diagnostic accuracy, 88%). There was a positive correlation between the serum MMP-7 level and the severity of liver fibrosis (P = .0002). Survival analysis showed that the frequency of liver transplantation was significantly higher in infants with biliary atresisa with a serum MMP-7 level of >10.30 ng/mL compared with a serum MMP-7 level of ≤10.30 ng/mL after hepatoportoenterostomy (hazard ratio, 4.22; P = .02).

CONCLUSIONS

The serum MMP-7 level, which reflects the severity of liver fibrosis and can be determined noninvasively, may facilitate the diagnosis of biliary atresisa among infants with cholestasis. Moreover, the serum MMP-7 level after hepatoportoenterostomy is associated with a need for liver transplantation in infants with biliary atresisa.

Transient elastography is useful in diagnosing biliary atresia and predicting prognosis after hepatoportoenterostomy

We investigated the utility of transient elastography (TE) for diagnosing biliary atresia (BA) in cholestatic infants and predicting the outcome of BA. Forty-eight cholestatic infants (9-87 days of age) with direct bilirubin level >1 mg/dL were enrolled. Liver stiffness measurement (LSM) by TE was performed during the cholestasis workup, and 15 subjects were diagnosed as BA. We assessed liver histology using liver biopsies from 36 subjects and graded fibrosis status using the METAVIR score. BA infants had significantly higher LSM values and METAVIR scores than non-BA cholestatic infants. A receiver operating characteristic (ROC) curve analysis showed that an LSM >7.7 kPa was predictive of BA among cholestatic infants (sensitivity = 80%; specificity = 97%; area under the curve [AUC] = 85.3%; P = 0.0001). Cholestatic infants with an LSM >7.7 kPa were more likely to be diagnosed with BA (odds ratio [OR] = 128; P < 0.001). Very early measurement of LSM after hepatoportoenterostomy (HPE) is associated with occurrence of thrombocytopenia, splenomegaly, and esophageal varices 6 months post-HPE. Five of the BA subjects were awaiting or had received liver transplantation (LT), and they had a significantly higher LSM measured 1 week post-HPE than that in the other BA subjects (26.0 vs. 10.8 kPa; P = 0.006). A Cox proportional analysis demonstrated that the need for LT was significantly higher in BA subjects with LSM >16 kPa measured 1 week post-HPE than other BA subjects (hazard ratio [HR] = 10.16; P = 0.04).

CONCLUSION

LSM assessment during the workup of cholestatic infants may facilitate the diagnosis of BA. LSM post-HPE may predict complications and the need for early LT in infants with BA. (Hepatology 2018).

Prognostic values of serum bilirubin at 7th day post-Kasai for survival with native livers in patients with biliary atresia

BACKGROUND

Biliary atresia (BA) is a serious liver disease with uncertain prognosis. The objective of this study was to investigate prognostic values of the >20 % decrease in serum total bilirubin (TB) at 7th day post-op regarding early outcome and 5-year survival with native liver in BA.

METHODS

Biliary atresia patients undergoing Kasai operation between 2000 and 2014 were reviewed. The ratio of serum TB at 7th day post-op to pre-op TB levels (TB7/TB0) was calculated for every patient. TB7/TB0 ratio of <0.8 indicated the >20 % decrease in serum TB. At 6th month following Kasai operation, outcome of BA patients were categorized into good outcome (TB < 2 mg % or clinically jaundice free) and poor outcome (TB > 2 mg % or clinically jaundice). For outcome analysis, logistic regression was used. For survival analysis, Cox regression was applied.

RESULTS

There were 133 BA patients (M:F = 68:65) undergoing Kasai operation. Median age at surgery was 79 days. BA patients with TB7/TB0 ratio of <0.8 were found in 38 %. Outcome at 6-month post-op could be evaluated in 126 patients (good: poor = 68:58). The 1-, 3- and 5-year survival rates with native livers were 85, 70 and 65 %, respectively. The median overall survival with native livers was 164 months. Median follow-up time was 87 months. Logistic regression showed that gender and age at operation were not significant factors impacting on early outcome (p > 0.05). However, TB7/TB0 ratio of <0.8 was an independent factor for good outcome (Odds ratio = 3.0, p = 0.006). Cox regression analysis demonstrated that 5-year survival rate was significantly correlated with TB7/TB0 ratio of <0.8 (HR = 0.46, 95 % CI 0.23-0.91, p = 0.025) and outcome at 6th month post-op (HR = 0.05, 95 % CI 0.01-0.15, p < 0.001).

CONCLUSIONS

The >20 % decrease in serum TB at 7th day post-Kasai is a predictor for good outcome. BA patients with TB7/TB0 of <0.8 had 5-year survival with native livers significantly higher than those with the ratio of >0.8.

APRi predicts native liver survival by reflecting portal fibrogenesis and hepatic neovascularization at the time of portoenterostomy in biliary atresia

BACKGROUND

Aspartate aminotransferase-to-platelet ratio index (APRi) may be useful noninvasive prognostic tool in biliary atresia (BA). We studied whether APRi predicts native liver survival and parallels biochemical and immunohistological signs of liver injury and fibrogenesis at the time of Kasai portoenterostomy (PE).

METHODS

Serum and liver specimens were obtained at PE from 29 BA patients for liver biochemistry including APRi, histology and immunohistochemical analysis of collagen 1, α-SMA and CD34. APRi values were related to native liver survival and other clinical data as well as serum liver biochemistry, liver histology and immunohistochemistry at PE.

RESULTS

Median age at PE was 63 (range 7-141) days and median APRi was 0.92 (0.13-6.39). APRi had strong positive correlations with patient age (r=0.684, p<0.001) and biochemical signs of hepatocyte injury and cholestasis. APRi showed no significant correlations with Metavir (r=0.336, p=0.223) or Ishak (r=0.289, p=0.262) global fibrosis scores nor with liver collagen 1 expression (r=0.260, p=0.222). In contrast, portal fibrosis score (r=0.515, p=0.013), predominantly portal α-SMA expression (r=0.519, p=0.015) and amount CD34-positive microvessels in the centrizonal region (r=0.604, p=0.004) correlated positively with APRi. Patients (n=10) who underwent liver transplantation had significantly higher APRi at presentation (1.34 vs. 0.77, p=0.017) compared to those who survived with native liver (n=19).

CONCLUSIONS

APRi correlates with portal fibrosis, expression of α-SMA and the amount of CD34-positive microvessels, suggesting that APRi predicts native liver survival by reflecting portal myofibroblastic cell activation, fibrogenesis and associated neovascularization.

Kasai hepatoportoenterostomy in South Australia: a case for 'centralized decentralization'

BACKGROUND

Recent follow-up studies have demonstrated significant improvement in overall survival as well as survival with native liver following geographic centralization of services to three centres in the UK. However, this model has not been replicated in countries with relatively low population density such as Australia and Canada.

METHODS

Retrospective evaluation of all patients born with biliary atresia (BA) in South Australia from 1989 to 2010 was performed. Thirty-one patients with BA were discovered. Two patients were excluded because the initial Kasai procedure (KP) was performed interstate. Outcome parameters measured were (i) clearance of jaundice (bilirubin of less than 20 μmol/L, by 6 months); (ii) survival with native liver; and (iii) overall survival. Kaplan-Meier survival curves were plotted for both survival with native liver and overall survival.

RESULTS

The incidence of BA in South Australia between 1989 and 2010 was 7.48 per 100,000 live births. Following KP, clearance of jaundice was achieved in 42.9% of patients. Five-year actuarial survival with native liver was 55.2%, and overall 5-year actuarial survival was 89.3%.

CONCLUSIONS

The results of KP performed at Women's and Children's Hospital from 1989 to 2010 can be considered comparable with international benchmarks. Based on these results, we propose the creation of a 'centralized' pool of surgeons in Australia to help continue providing 'decentralized' care of BA.

A high serum interleukin-12p40 level prior to Kasai surgery predict a favourable outcome in children with biliary atresia

BACKGROUND

Biliary atresia (BA) is a paediatric cholestatic disease characterized by a progressive fibro-inflammation of the biliary tree. Current treatment of choice is to establish good bile flow via the Kasai operation.

AIMS

We aimed to identify outcome-predictive serum biomarkers in BA infant.

METHODS

Thirty-three BA children recruited from 1986 to 2007 served as the baseline-study group. An additional 11 children recruited from 2008 to 2011 served as the validation group. Serum samples were collected immediately before and 6 months after the Kasai operation for the assessment of serum cytokines, including tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), interferon-γ (IFN-γ), interleukin-2 (IL-2), IL-10, IL-12p40 and IL-12p70 as the candidate biomarkers.

RESULTS

Increased serum TGF-β levels indicated a lower Knodell hepatitis activity index at Kasai operation. The serum TGF-β levels declined after the operation. Serum IL-12p40 levels before the Kasai operation were higher in the subjects with a 3-month jaundice-free status than in others (P = 0.001). A serum pre-operative IL-12p40 level of 33 pg/ml was predictive of a 3-month jaundice-free status after surgery (positive predictive value=81.0%; negative predictive value=83.3%). This biomarker was also predictive of a better outcome, in terms of 3-year survival with native liver (risk ratio [RR = 4.00]; P < 0.001), and 3-year jaundice-free survival with native liver (RR = 12.00; P < 0.001). We confirmed the predictive power of a high pre-operative IL-12p40 level on 3-month jaundice-free status in the validation group.

CONCLUSIONS

The pre-operative IL-12p40 level was a good predictive biomarker of clinical outcome in children with BA undergoing the Kasai operation.

The anatomic pattern of biliary atresia identified at time of Kasai hepatoportoenterostomy and early postoperative clearance of jaundice are significant predictors of transplant-free survival

OBJECTIVE

The goals of this study were to describe the clinical and anatomic features of infants undergoing Kasai portoenterostomy (KPE) for biliary atresia (BA) and to examine associations between these parameters and outcomes.

METHODS

Infants enrolled in the prospective Childhood Liver Disease Research and Education Network, who underwent KPE were studied. Patients enrolled in a blinded, interventional trial were excluded from survival analysis. Primary endpoints were successful surgical drainage (total bilirubin less than 2 mg/dL within the first 3 months), transplant-free survival (Kaplan-Meier), and time to transplant/death (Cox regression).

RESULTS

KPE was performed in 244 infants (54% female; mean age: 65 ± 29 days). Transplant-free survival was 53.7% and 46.7% at 1 and 2 years post-KPE. The risk of transplant/death was significantly lower in the 45.6% of patients who achieved successful bile drainage within 3 months post-KPE (HR: 0.08, P < 0.001). The risk of transplant/death was increased in patients with porta hepatis atresia (Ohi type II and III vs type I; HR: 2.03, P = 0.030), nonpatent common bile duct (Ohi subtype: b, c, and d vs a; HR: 4.31, P = 0.022), BA splenic malformation syndrome (HR: 1.92, P = 0.025), ascites > 20 mL (HR: = 1.90, P = 0.0230), nodular liver appearance compared to firm (HR: = 1.61, P = 0.008), and age at KPE ≥ 75 days (HR: 1.73, P < 0.002). Outcome was not associated with gestational age, gender, race, ethnicity, or extent of porta hepatis dissection.

CONCLUSION

Anatomic pattern of BA, BASM, presence of ascites and nodular liver appearance at KPE, and early postoperative jaundice clearance are significant predictors of transplant-free survival.

Pseudo gallbladder sign in biliary atresia--an imaging pitfall

BACKGROUND

Ultrasound (US) is used to identify causes of neonatal cholestasis. We describe a potential sonographic pitfall, the "pseudo gallbladder," in biliary atresia (BA).

OBJECTIVE

To describe the Pseudo Gallbladder sign (PsGB sign).

MATERIALS AND METHODS

Sonograms/clinical records of 20 confirmed BA infants and 20 non-BA cases were reviewed retrospectively. For the BA group, preoperative sonography and surgical and pathological findings were examined. For the non-BA group, sonographic features and pathological findings were examined. The PsGB sign is defined as a fluid-filled structure, located in the expected region of the gallbladder, measuring ≤ 15 mm in length but without a well-defined or normal-appearing gallbladder wall.

RESULTS

A recognizable gallbladder and normal gallbladder wall were present in all non-BA infants. However, none of the BA infants had a sonographically normal gallbladder. Seventy-three percent of BA patients had a PsGB, and in 27% no gallbladder or gallbladder-like structure was detected.

CONCLUSION

A gallbladder-like structure in BA is common and can be misinterpreted as a normal gallbladder, delaying diagnosis and therapy. Recognition of this imaging pitfall, described here as the pseudo gallbladder sign, will help avoid this error.

Trends in age for hepatoportoenterostomy in the United States

BACKGROUND

Biliary atresia is a rare but devastating disease for which hepatoportoenterostomy remains the primary intervention. Increased age at the time of hepatoportoenterostomy is associated with unfavorable outcomes. In this study, we examined trends in age at the time of hepatoportoenterostomy and explored hospital and patient factors associated with more timely diagnosis and treatment.

METHODS

Median ages of patients undergoing hepatoportoenterostomy for biliary atresia were compared using the Kids' Inpatients Database from 1997, 2000, 2003, and 2006. The patient and hospital factors associated with later treatment were compared.

RESULTS

Of 192 patients, 13.5% had surgery in 1997, 13.5% in 2000, 36.5% in 2003, and 36.5% in 2006. The overall median age was 65.5 days; the median age was 64 days in 1997, 57.5 days in 2000, 69 days in 2003, and 64 days in 2006 (P = .80). Overall, 71% of patients were treated at nonchildren's hospitals, and although the proportion has increased over time, the trend did not reach significance (P = .12). Hispanic and African American patients were more likely to undergo hepatoportoenterostomy after 60 days of life compared with white patients (Hispanic patients: odds ratio, 3.6; 95% confidence interval, 1.1-12.5; P = .04; African American patients: odds ratio, 2.2; 95% confidence interval, 0.8-6.3; P = .14). Compared with specialized children's centers, treatment at nonchildren's hospitals was associated with delayed hepatoportoenterostomy (odds ratio, 3.5; 95% confidence interval, 1.2-9.8; P = .02).

CONCLUSION

Although early hepatoportoenterostomy is associated with improved outcomes for children with biliary atresia, our study shows the median age at surgery has not significantly changed over 2 decades. Both hospital and socioeconomic factors play a role in the early treatment of biliary atresia.

Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop

Biliary atresia is the most common cause of end-stage liver disease in the infant and is the leading pediatric indication for liver transplantation in the United States. Earlier diagnosis (<30-45 days of life) is associated with improved outcomes following the Kasai portoenterostomy and longer survival with the native liver. However, establishing this diagnosis is problematic because of its rarity, the much more common indirect hyperbilirubinemia that occurs in the newborn period, and the schedule for routine infant health care visits in the United States. The pathogenesis of biliary atresia appears to involve immune-mediated fibro-obliteration of the extrahepatic and intrahepatic biliary tree in most patients and defective morphogenesis of the biliary system in the remainder. The determinants of the outcome of portoenterostomy include the age at surgery, the center's experience, the presence of associated congenital anomalies, and the postoperative occurrence of cholangitis. A number of screening strategies in infants have been studied. The most promising are early measurements of serum conjugated bilirubin and a stool color card given to new parents that alerts them and their primary care provider to alcholic stools. This report summarizes a National Institutes of Health workshop held on September 12 and 13, 2006, in Bethesda, MD, that addressed the issues of outcomes, screening, and pathogenesis of biliary atresia.

Orthotopic Liver Transplantation for Biliary Atresia

Biliary atresia (BA) represents the most frequent indication for liver transplantation (OLTX) in the pediatric population. The aim of this paper was to present a series collected over the last 7 years from October 1997 through July 2004, including 260 pediatric OLTX in 231 patients. BA was the indication in 137 patients. There were 69 boys and 68 girls of mean weight 10.68 kg and median age 0.9 years. As a primary transplant, 99 patients received a LLS graft; 27 a whole graft; four a I+IV-VIII segment, and two a I-IV segment. Mean follow up was 1047 days (range, 1-2496 day). Infections were diagnosed in 45 patients, vascular complications in 27 patients. Surgical complications that required reintervention occurred in 25 patients. In 41 cases biliary complications occurred, 11 requiring reintervention. 16 patients were retransplanted. In two cases another re-OLTx was performed. Currently 126 patients are alive, showing an actuarial 1 year survival of 92% and 5 year 91%, with actuarial graft survivals of 85% at 1 year and 82% at 3 and 5 years. Our results confirm the effectiveness of OLTx for the treatment of children with BA and a failed Kasai procedure. Split liver grafts represent an excellent organ supply for these patients, achieving optimal results with no mortality on the waiting list.

Pediatric liver transplantation for biliary atresia: results of primary grafts in 328 recipients

PURPOSE

The purpose of this study was to assess the overall results of recipients undergoing transplantation for biliary atresia (BA), according to age, surgical techniques, and transplant eras, and to identify the prognostic factors affecting outcome.

METHODS

Between 1984 and 2000, 328 pediatric recipients with BA who underwent orthotopic liver transplantation (OLT) were reviewed. Median age at OLT was 1.5 years (range, 0.4-14.5 years). Kasai hepatoportoenterostomy (KHPE) had been previously performed in 285 (87%) children. Regarding surgical techniques, 125 (38%) children received a whole-liver graft, 128 (39%) received a reduced-size graft, 16 (5%) received a split-liver graft, and 59 (18%) received a living-related (LR) donor graft.

RESULTS

Overall actuarial patient survivals were 87%, 83%, and 81% at 1, 5, and 10 years, respectively. One-year patient survivals in children undergoing transplantation at the different age ranges were 85% (under 1 year), 86% (1-3 years), 83% (3-6 years), 100% (6-10 years), and 100% (beyond 10 years) (not significant). One-year patient survivals for the different transplant eras were 75% (1984-1988), 85% (1989-1992), 93% (1993-1996), and 98% (1997-2000) (P=0.0001). Multivariate analysis demonstrated that pretransplant recipient weight (P=0.004), indication for OLT (P=0.083), and age at OLT (P=0.024) predicted patient survival. The type of baseline calcineurin inhibitor (tacrolimus) and the age at OLT (beyond 6 years) were significantly associated with a better graft survival.

CONCLUSIONS

Best results in children undergoing transplantation beyond 6 years indicate the importance of performing a KHPE as the first therapeutic step in BA; innovative surgical techniques, particularly LR donor graft, allowed successful transplantation in infants with early failure of KHPE.

E-cadherin, alpha-catenin and beta-catenin in biliary atresia: correlation with apoptosis and cell cycle

Biliary atresia (BA) is the most common cause of obstructive jaundice in infancy. Although the etiology of BA remains unknown, the ductal plate malformation has been considered to play an important role in the development of BA. Cell-cell adhesion has long been recognized as one of the most important processes in organogenesis. E-cadherin is involved in cell-cell adhesion, together with the catenins. Abnormalities of E-cadherin and associated catenins have not been examined in detail in the liver with BA. We therefore examined immunolocalization of E-cadherin and alpha- and beta-catenins in the BA liver (n = 45) and compared the findings with those in non-BA (n = 11) and fetal liver (n = 21). We semiquantitatively evaluated the findings using H score, which were generated according to the percentage of immunopositive cells and their immunointensity. We also examined mRNA localization of E-cadherin using mRNA in situ hybridization. We then studied the correlation of E-cadherin immunoreactivity with apoptotic cells, and cyclin-dependent kinase inhibitor p27Kip1 immunolocalization of bile duct cells in BA liver (n = 10) and fetal liver (n = 10). In fetal liver, H score of E-cadherin, but not of alpha- and beta-catenins, was significantly lower in the remodeling stage than in the ductal plate (P = 0.0034) and remodeled stages (P = 0.0024). In addition, the H score of E-cadherin, but not alpha- and beta-catenin, in bile duct cells was significantly lower in BA liver than in non-BA liver (P = 0.0132). E-cadherin mRNA hybridization signals were relatively conserved in bile duct cells of BA liver, but decreased in remodeling ductal plate cells of fetal liver. An inverse correlation was detected between the H score of E-cadherin and the TUNEL labeling index (LI) in both fetal and BA liver. In contrast, a positive correlation was detected between the H score of E-cadherin and p27 LI in both fetal and BA liver. These findings suggest that impaired expression of E-cadherin in bile ducts may play an important role in the biological features of BA, possibly associated with cell cycle and apoptosis.

Kasai portoenterostomy: differences related to race

PURPOSE

The aim of this study was to evaluate the Kasai portoenterostomy in African-American and white children with respect to differences in presentation and outcome.

METHODS

A retrospective review of all children with biliary atresia who underwent a portoenterostomy at our institution over the last 15 years (n = 63) was performed. Sex, age at the time of Kasai, preoperative laboratory tests, success rates (defined as postoperative total serum bilirubin < or = 2.0 mg/dL), and survival rate were recorded. Differences between African-American (AA; n = 30) and white (W; n = 33) children were analyzed. Long-term follow-up was available on 59 of 63 patients.

RESULTS

Sixty-three percent of all patients (40 of 65) were girls, and 48% were AA (30 of 63). A higher percentage of AA children (73%) were girls than were white children (55%), although this difference did not achieve statistical significance. African-Americans underwent portoenterostomy at a later age, had higher alkaline phosphatase levels, and higher AST. These differences were statistically significant. Preoperative ALT, total bilirubin level, and GGTP levels all were greater in African-Americans, although these differences did not achieve statistical significance. There was a trend toward decreased success and survival rate, although these results also were not statistically significant.

CONCLUSIONS

African-Americans underwent primary therapeutic intervention for biliary atresia at an older age than white children with a trend toward less favorable results. These differences related to race may be attributed to greater difficulty in diagnosing jaundice or poorer access to health care in this patient population. Increased effort at identifying biliary atresia in AA children may lead to earlier diagnosis and treatment and improved outcomes.

Cytokeratin subtypes in biliary atresia: immunohistochemical study

The etiology of biliary atresia (BA) remains unknown, but ductal-plate malformation and insufficient ductal-plate remodeling have been suggested to play important roles, so it is beneficial to examine the maturation and differentiation of bile ducts in BA. Different epithelial types are characterized by the expression of specific cytokeratin (CK) subtypes. CK can therefore serve as a 'lineage marker' of epithelial cells. CK subtypes have not been previously examined in BA. In this study, we examined the maturation of bile-duct cells in BA (n = 45) using immunohistochemistry of CK subtypes, with mouse monoclonal antibodies to CAM5.2, and CK subtypes 7, 8, 13, 14, 17, 19 and 20. We then compared these findings with pediatric non-BA (n = 11) and fetal (n = 21) liver. We semiquantitatively evaluated the findings using a H score method. In the fetal liver, immunoreactivity for CAM5.2, CK-7, CK-8 and CK-19 was detected in bile-duct cells, and CAM5.2 and CK-8 immunoreactivity was also detected in hepatocytes. The distribution of these CK subtypes was the same in fetal, pediatric non-BA and BA liver. However, CK-7 immunoreactivity was markedly weaker in bile ducts of fetal (H scores: ductal plate 0 +/- 0; remodeling 9.5 +/- 40.3; remodeled 37.3 +/- 60.8) and BA (H score: 200.9 +/- 55.3) liver compared to non-BA liver (H score: 251.1 +/- 33.5). In addition, CK-20 was detected in the bile ducts of the fetal and BA liver, but not in non-BA liver. These findings suggest that the expression patterns of CK subtypes in bile-duct cells in BA are similar to that in developing bile-duct cells, which is indicative of bile-duct cell immaturity.

Apoptosis and cell proliferation in biliary atresia

Biliary atresia (BA), which is thought to result from progressive destruction of the bile ducts by a necroinflammatory process, is the most common cause of obstructive jaundice in infancy. Abnormalities in the cell turnover of remodelling ductal plates are considered one of the important aetiological factors in this disorder, but little work has been done on this topic. Programmed cell death or apoptosis was therefore examined by TdT-mediated dUTP biotin nick end labelling (TUNEL) and cell proliferation by Ki67 immunostaining in 34 cases of BA. The results were compared with normal control liver (five cases) and congenital dilatation of the bile ducts (CDB, five cases) in order to study the cell turnover or tissue dynamics of BA. The TUNEL labelling index (LI) in bile ducts (48.9 +/- 13.2 per cent) was significantly higher than that of the control normal liver (3.6 +/- 2.8 per cent) and of CDB (2.5 +/- 5.1 per cent). The Ki67 LI in the bile ducts of BA (15.0 +/- 5.57 per cent) was also significantly higher than that of CDB (8.6 +/- 5.4 per cent). No significant differences of the TUNEL and Ki67 LIs in hepatocytes were, however, observed between BA, CDB, and normal liver. The TUNEL LI was significantly higher than the Ki67 LI in the bile ducts of BA. BA is therefore associated with increased and disorganized cell turnover of the bile ducts, which is related to malformation of the ductal plate or abnormal bile duct development.

Proliferation of intrahepatic bile-duct epithelium in biliary atresia : A useful predictor of clinical outcome

Proliferating cell nuclear antigen (PCNA) and transforming growth factor α (TGFα) are considered as markers of cell proliferation. The expression of PCNA and TGFα was evaluated immunohistochemically using anti-PCNA antibody and TGFα in 31 patients with biliary atresia (BA) (15 jaundice-free and 16 with persistent jaundice) and 6 control infants. The labeling indices (LI) for PCNA- and TGFα-positive bile-duct epithelium in BA were 14.1±14.0% and 51.4±33.7%, respectively, which was significantly higher than in the controls (P <0.01). In BA, the number of PCNA-immunoreactive cells was higher in the peripheral bile ductules than in the central bile ducts of the portal tract (P <0.01). LI was not related to patient age at the time of hepatic portoenterostomy in two groups divided at the age of 60 days. Patients in the persistent jaundice group had greater expression of PCNA and TGFα (21.7±16.0% and 76.9±20.7%, respectively) compared to those in the jaundice-free group (6.0±2.7% and 24.3±20.9%, P <0.001). PCNA and TGFα expression in the bile-duct epithelium of the portal tract was closely related to prognosis in BA patients, and thus could be useful as a prognostic marker.

Immunohistochemical study of proliferating cell nuclear antigen in hepatocytes of biliary atresia: a parameter to predict clinical outcome

The hepatic lobulus was studied histologically and immunohistochemically using the monoclonal antibody for proliferating cell nuclear antigen (PCNA/Cyclin, a cell-cycle-related nuclear protein) in 27 patients with biliary atresia (BA) and six normal infants. The study showed that the labeling index (LI) for PCNA-positive hepatocytes was 37.21 +/- 17.75% in the patients with BA and 3.14 +/- 1.5% in the normal infants (P < .0001). LI for PCNA-positive cells was higher in the periportal area than the pericentral area (P < .01). LI was not related to the patients' age at the time of hepatic portoenterostomy. LI was 20.80 +/- 7.03% for patients whose jaundice cleared postoperatively and 48.49 +/- 13.43% for patients who had persistent jaundice (P < .001). Conventional histological studies of the same specimens showed common findings of BA, such as hepatocellular degeneration, necrosis, inflammatory cell infiltration, and giant cell transformation. Most patients with BA had 8.94 +/- 13.55% giant cell transformation among 1,000 hepatocytes. Patients who exhibited high giant cell transformation had an unfavorable outcome. Only 0.42% of giant cells were immunoreactive for PCNA. In conclusion, the PCNA expression of hepatocytes is closely related to the prognosis of patients with BA, and thus could be used as a prognostic indicator.

A new clinical prognostic predictor for patients with biliary atresia

The excretion of D-glucaric acid (DGA), a metabolite of the cytochrome P-450 pathway, is considered a marker of the viability of hepatocytes. Twelve cases of biliary atresia (BA) have been investigated, correlating the level of DGA, degree of histological alteration of liver parenchyma, and clinical outcome. Urine was collected in the preoperative period. Five patients had good bile flow after the Kasai operation and demonstrated mild liver fibrosis. The urine excretion level of DGA in this group was 17.2 +/- 3.1 mumol/d (control, 15.2 + 2.2 [67od] mmol/d). Seven patients had partial bile drainage or prolonged jaundice. They also had altered liver parenchyma and a very low level of DGA in the urine preoperatively (4.2 + 2.2 mumol/d). Urine excretion of DGA reflected the degree of alteration of liver parenchyma and closely correlated with clinical outcome. Measurement of DGA before the Kasai operation provides information concerning the present hepatic function and the postoperative prognosis. Once the activity of hepatocytes deteriorates, this test is quicker than the other liver function tests. It is noninvasive and is a useful clinical prognostic predictor in BA.

Use of near infrared reflectance spectroscopy in the screening for biliary atresia

Early diagnosis is crucial for treatment and prognosis of biliary atresia (BA). We used near infrared reflectance spectroscopy (NIRS) for screening of BA. Fecal samples were collected from 200 healthy infants and 16 infants for whom either BA or neonatal hepatitis was diagnosed. Diagnoses were made retrospectively by other diagnostic methods, including laparotomy. The samples (0.5 g each) were manually homogenized. Reflected light from the surface of feces was measured by NIRS. Absorbance peak spectra for fecal fat and conjugated bilirubin were determined before the study, and proved to be 730, 1158, and 1210 nm, respectively. Two cutoff points were set in the second-derivative spectrum: the first (> -0.005) at 730 nm for conjugated bilirubin, and the second (< 1.0) at 1,158:1,210 nm for fat (to include all patients with BA). The sensitivity of NIRS in the diagnosis of BA was 100%, and the specificity was 95.2%. The authors conclude that NIRS is a simple, rapid, noninvasive, and precise technique for the early diagnosis of BA.

A long-term experience with biliary atresia. Reassessment of prognostic factors

Thirty-four infants with biliary atresia were primarily treated at our institution between 1974 and 1987. The mean age at diagnosis was 8.8 weeks. The Kasai portoenterostomy was used in 11 patients (32%) and the Sawaguchi modification in 23 infants (68%). Overall survival was 47% (16/34), with a mean follow-up of 45 months. Fifteen survivors (94%) are jaundice free, with two having undergone liver transplantation. Survival was not influenced by earlier age at operation, size of ductal remnants, or the use of an external biliary vent. Good bile flow was predictive of a favorable outcome. The incidence of cholangitis was increased in the Kasai (87%) versus the Sawaguchi groups (45%) (p less than 0.05), but 1-year survival rates were similar (55% vs 64%). The authors conclude that portoenterostomy offers a reasonable chance for success and should be the initial procedure for biliary atresia.

Late referral for biliary atresia--missed opportunities for effective surgery

To assess whether clinicopathological features other than the age at operation influence prognosis after surgery for extrahepatic biliary atresia (EHBA) and to determine whether the age at referral has fallen since a previous survey, 50 consecutive cases with EHBA referred between February, 1985, and December, 1987, were reviewed. Liver or spleen size, liver function tests, or histological appearance of liver biopsy specimen before surgery were not predictive of outcome. The jaundice cleared up in 12 of 14 children operated on by age 8 weeks, but in only 13 of 36 operated on later. In 41 referral was delayed. All 25 children in whom surgery was successful are alive and well, while 13 of 25 with unsuccessful surgery have died, at a median age of 1 year. To improve the prognosis of infants with EHBA parents and health staff need a better awareness of the early clinical features of EHBA and of the necessity for prompt referral. Liver disease should be suspected in any infant jaundiced after 14 days of age.

Stoma-related variceal bleeding: an under-recognized complication of biliary atresia

The medical records of 52 children with biliary atresia treated by portoenterostomy and evaluated for liver transplantation were reviewed to determine the frequency of stoma variceal bleeding and the optimal strategies for prevention and treatment. Eighteen patients had had prior stoma closure, four by preperitoneal closure without takedown from the abdominal wall. Three of the four developed occult variceal bleeding from the stoma closure site. Twenty-two patients had a stoma present at evaluation. All 22 patients with stomas (100%) had at least one bleeding episode requiring transfusion. Treatment included transfusion and local pressure (9), suture ligation of the bleeding site (5), and stoma closure and/or takedown (11). Local treatment led to recurrences in eight of 14 (57%) of the cases. To reduce the high mortality in patients with biliary atresia awaiting liver transplantation, multiple variceal bleeding episodes should be prevented. To eliminate one source, stoma variceal bleeding, the stoma, whether functioning or nonfunctioning should be taken down and closed. Preperitoneal closure alone does not prevent stoma bleeding.

Ten minute radiopharmaceutical test in biliary atresia

To provide an objective rapid means of excluding extrahepatic biliary atresia (atresia), a hepatic index was devised from the ratio of the net hepatic to cardiac distribution of 99mTc diisopropyl iminodiacetic acid or methylbrom iminodiacetic acid between 2.5 and 10 minutes after injection. The hepatic index was compared with subjective assessment of abdominal scintigraphy performed repeatedly over 24 hours. In 22 infants with hepatitis the hepatic index ranged from 5.03 to 14.9, one having no excretion on scintiscan. In 26 infants with atresia the index ranged from 0.49 to 4.26 and in two with paucity of intralobular bile ducts it was 1.85 and 3.69. None of these infants had excretion apparent on scintiscans. Similarly, low hepatic indices occurred in four infants with liver dysfunction but pigmented stools, three of whom had no excretion apparent on scintiscans. These preliminary studies suggest that a hepatic index of greater than 5 is much more rapid and as specific in excluding atresia as repeated abdominal scintigraphy.

Biliary scintigraphy with DISIDA. A simpler way of showing bile duct patency in suspected biliary atresia

99mTC-diisopropyl iminodiacetic acid (DISIDA) scintigraphy after oral phenobarbitone treatment accurately indicated bile duct patency or obstruction in 28 of 32 (87%) infants, aged less than 12 weeks, with suspected biliary atresia. This investigation is more rapid than and as accurate as the 131I Rose-Bengal faecal excretion test.

Short term histological liver changes in extrahepatic biliary atresia with good postoperative bile drainage

Short term histological liver changes were studied in 13 patients with congenital biliary atresia, who showed good bile drainage after radical operation. Biopsies obtained at the time of the corrective surgery and at the second operation to convert from external total to partial bile drainage (undertaken once the bilirubin concentration was less than 30.8 mumol/l) were compared. A significant correlation was found between histological findings and the clinical course. In particular, at the second biopsy an increase in hepatic fibrosis and cell infiltration was observed mainly in patients whose bilirubin concentration decreased slowly or who had cholangitis, or both. Hepatic fibrosis and cell infiltration had decreased, however, in an appreciable number of patients whose postoperative course had been characterised by a rapid reduction in the bilirubin concentration and no cholangitis.

Hepatitis syndrome in infancy--an epidemiological survey with 10 year follow up

Fifty four infants with hepatobiliary disease and conjugated hyperbilirubinaemia of more than two weeks' duration were identified in a defined area of south east England in a prospective study between January 1971 and December 1973. The overall incidence was one case per 2500 live births. The cases were regularly reviewed and all survivors except one were assessed at age 10 years. Nine of 11 with extrahepatic biliary atresia died from liver disease by 2 years of age, one died at 5 years, and the survivor has cirrhosis with portal hypertension. Four out of seven with alpha 1 antitrypsin deficiency died aged 1 to 3 years from liver disease and one of the survivors has cirrhosis. All three infants with intrauterine infection and one with chromosomal abnormality died in infancy. Three children with other associated factors, choledochal cyst, galactosaemia, and rhesus isoimmunisation, recovered completely with no persisting liver disease. Two of 29 with cryptogenic hepatitis died, but only a further two have signs of persisting liver disease. Perinatal complications were more common in this group. Four of the 27 children surviving to the age of 10 years are educationally subnormal. Prognosis for infants with intrahepatic liver disease in the absence of known associated factors is good and every effort should be made to minimise the short term effects of cholestasis.

Results of surgical treatment for extrahepatic biliary atresia in United Kingdom 1980-2. Survey conducted on behalf of the British Paediatric Association Gastroenterology Group and the British Association of Paediatric Surgeons

A postal survey identified 114 infants with biliary atresia (roughly one in 21 000 live births). Biliary operations were performed on 107. Of the 105 infants who were followed up, 35 were free of jaundice at 10 months to 3 1/2 years. Good results occurred most often in those operated on by 12 weeks and were also related to the number of cases operated on in each centre. Only two of 18 infants treated in centres dealing with one case a year were free of jaundice compared with 11 of 38 at centres treating two to five cases a year and 22 of 49 in a centre treating more than five cases a year. Jaundice in an infant of more than 2 weeks associated with yellow urine or pale stools is never physiological and requires urgent investigation to identify causes for which effective treatment may be possible. Identification of suspected cases by 4 weeks of age and a greater concentration of investigative and surgical skills should improve the short term results of surgery and the long term prognosis of biliary atresia.

Analysis of patients with biliary atresia coming to liver transplantation

Seventy-two patients with end-stage liver disease underwent liver transplantation between March 1981 and March 1984; 35 (49%) with biliary atresia, the remainder with other disorders. This provided us with a unique opportunity to analyze factors leading to liver failure in patients who had undergone biliary drainage procedures for "uncorrectable" biliary atresia. Four patients in the biliary atresia group were excluded (no corrective procedure done, 3; "correctable" biliary atresia, 1), leaving 31 patients for study. Transplantation survival was 84% for the study group and 73% in children with other primary liver disorders. Most patients were less than 3 months old at the time of initial surgery, had minimal liver disease, and had accepted corrective operations by experienced surgeons. Despite these "favorable" factors, bile drainage was rarely achieved. All patients with continued bile drainage at the time of transplantation had repeated episodes of cholangitis, and cholangitis was associated with cessation of bile drainage in half of those with transient function. Findings at hepatectomy suggested that in four cases where bile drainage was never achieved, reexploration may have been successful. Complications included those associated with hepatic failure and portal hypertension. Of note were a high incidence of bone disease and a 43% incidence of stomal hemorrhage in patients with stomas. The short-term survival after transplantation was comparable in the biliary atresia group and the children with other disorders. This suggests that while the presence of a previous biliary drainage procedure may increase the technical difficulty of transplantation, it does not decrease survival.