A retrospective study of the ideal operation time for preterm biliary atresia patients

Biliary atresia in preterm infants: a single center experience and review of literature

Introduction

The diagnosis of biliary atresia (BA) remains challenging, and there is still uncertainty regarding the optimal time to perform a Kasai portoenterostomy (KPE). Little is known about the difficulties in the diagnosis and outcomes of BA in preterm infants (PBA). This study, which represents the first Italian report of preterm infants with BA, aims to describe a single-center experience of BA in preterm newborns.

Methods

We retrospectively reviewed all infants consecutively diagnosed with BA who underwent a Kasai procedure at the Bambino Gesù Children's Hospital between January 1998 and December 2021. Prematurity was defined as a gestational age (GA) of <37 weeks. Demographic, laboratory, and histology data were recorded, and the main outcomes considered were clearance of jaundice (COJ), native liver survival, and mortality.

Results

A total of 21 PBA were compared with 117 term BA controls (TBA). The median GA of PBA was 35.1 (32-36.1) weeks, with a mean birth weight of 2,100 (1,897-2,800) g. Age at first presentation was significantly lower in PBA patients: 46 (22-68) vs. 61 (44-72) days; p = 0.02. The median age at KPE was similar between the two groups: 70 days (33 corrected) for PBA vs. 67 in TBA; p = 0.8. At the time of surgery, median serum bilirubin was lower in the PBA group (7.7 vs. 8.6 mg/dl, p = 0.04). Similarly, the median APRi at the time of KPE was lower but not significant in the PBA group: 1.09 vs. 1.16; p = 0.8. No differences were found in terms of COJ between the PBA and TBA groups: n = 9 (43%) vs. 34 (35%); p = 0.2. Overall native liver survival was similar between the two groups: 8.6 (4.8-12.2) for the PBA group vs. 7.6 (5.6-9.5) years for the TBA group with no significant differences; p = 0.45. Post-KPE native liver survival was similar between the two groups: 38% vs. 52% at 5 years for the TBA and PBA groups, respectively;   p = 0.54.

Conclusion

The PBA and TBA groups appear to have similar outcomes in terms of COJ, overall native liver survival, and 5-year liver survival. Considering the corrected GA, early KPE is related to lower cholestatic damage. Further multicenter studies are required.

Application of Nonhuman Primate Models in the Studies of Pediatric Anesthesia Neurotoxicity

Numerous animal models have been used to study developmental neurotoxicity associated with short-term or prolonged exposure of common general anesthetics at clinically relevant concentrations. Pediatric anesthesia models using the nonhuman primate (NHP) may more accurately reflect the human condition because of their phylogenetic similarity to humans with regard to reproduction, development, neuroanatomy, and cognition. Although they are not as widely used as other animal models, the contribution of NHP models in the study of anesthetic-induced developmental neurotoxicity has been essential. In this review, we discuss how neonatal NHP animals have been used for modeling pediatric anesthetic exposure; how NHPs have addressed key data gaps and application of the NHP model for the studies of general anesthetic-induced developmental neurotoxicity. The appropriate application and evaluation of the NHP model in the study of general anesthetic-induced developmental neurotoxicity have played a key role in enhancing the understanding and awareness of the potential neurotoxicity associated with pediatric general anesthetics.

Variability in age at Kasai portoenterostomy for biliary atresia across US children's hospitals

BACKGROUND/PURPOSE

The purpose of this study was to assess variability in age at Kasai portoenterostomy (KP) in infants with biliary atresia (BA) across children's hospitals in the United States.

STUDY DESIGN

A multi-institutional retrospective study was performed examining infants with BA undergoing KP within 6 months of birth from 2016-2019, utilizing the Pediatric Health Information System (PHIS). Multivariable negative binomial mixed effects regression was performed for age at KP, and inter-hospital variability was examined.

RESULTS

Across 46 hospitals, 470 infants with BA underwent KP at a median age of 57 days (IQR 42-72), with 212 (45.1%) undergoing KP at ≥60 days of age. There was significant inter-hospital variability in age at KP ranging from 38 days (95% CI: 31d, 47d) to 76 days (95% CI: 63d, 91d) (p<0.0001). Factors associated with later KP were black or African-American race, urgent/emergent admission, and treatment at a hospital in the Pacific-West region. Predictors of earlier KP included later year, history of neonatal comorbidity, and admission to an intensive care service (all p<0.05).

CONCLUSION

There is significant variability in the age at KP in infants with BA across children's hospitals in the United States.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Biliary atresia in a preterm and extremely low birth weight infant: a case report and literature review

Background

Biliary atresia in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants is rarely reported, and the optimal timing of Kasai portoenterostomy (KPE) in these cases remains unclear.

Case presentation

We report a case of biliary atresia in a preterm female infant of 24 weeks of gestation who weighed 824 g. She underwent exploratory laparotomy and intraoperative cholangiography at 58 days of age (weight, 1336 g). Despite the diagnosis of biliary atresia with a type I cyst, we could only perform gallbladder drainage at that time due to the unstable intraoperative condition. While we waited for her body weight to increase, KPE was performed at 122 days of age (corrected age: 16 days), when the patient weighed 2296 g. Although she initially became jaundice-free, her liver function deteriorated due to cholangitis, and she developed decompensated cholestatic liver cirrhosis. Living donor liver transplantation was successfully performed at 117 days after KPE, and the postoperative course was uneventful. The timing of KPE is difficult to determine and a review of the relevant literature revealed that a poor prognosis in VLBW and ELBW infants with BA.

Conclusions

Early KPE and careful postoperative follow-up, including liver transplantation is important for the improvement of outcomes.

Diagnostic Value and Effectiveness of an Artificial Neural Network in Biliary Atresia

Objectives: Biliary atresia (BA) is a devastating pediatric liver disease. Early diagnosis is important for timely intervention and better prognosis. Using clinical parameters for non-invasive and efficient BA diagnosis, we aimed to establish an artificial neural network (ANN). Methods: A total of 2,384 obstructive jaundice patients from 2012 to 2017 and their 137 clinical parameters were screened for eligibility. A standard binary classification feed-forward ANN was employed. The network was trained and validated for accuracy. Gamma-glutamyl transpeptidase (GGT) level was used as an independent predictor and a comparison to assess the network effectiveness. Results: We included 46 parameters and 1,452 patients for ANN modeling. Total bilirubin, direct bilirubin, and GGT were the most significant indicators. The network consisted of an input layer, 3 hidden layers with 12 neurons each, and an output layer. The network showed good predictive property with a high area under curve (AUC) (0.967, sensitivity 97.2% and specificity 91.0%). Five-fold cross validation showed the mean accuracy for training data of 93.2% and for validation data of 88.6%. Conclusions: The high accuracy and efficiency demonstrated by the ANN model is promising in the noninvasive diagnosis of BA and could be considered as in a low-cost and independent expert diagnosis system.