Reappraisal of the role of the bilioenteric conduit in the pathogenesis of postoperative cholangitis

Cholangitis Definition and Treatment after Kasai Hepatoportoenterostomy for Biliary Atresia: A Delphi Process and International Expert Panel

(1) Background: Acute cholangitis during the first year after Kasai hepatoportoenterostomy (HPE) has a negative impact on patient and native liver survival. There are no consistent guidelines for the definition, treatment, and prophylaxis of cholangitis after HPE. The aim of this study was to develop definition, treatment, and prophylaxis guidelines to allow for expeditious management and for standardization in reporting. (2) Methods: the Delphi method, an extensive literature review, iterative rounds of surveys, and expert panel discussions were used to establish definition, treatment, and prophylaxis guidelines for cholangitis in the first year after HPE. (3) Results: Eight elements (pooled into two groups: clinical and laboratory/imaging) were identified to define cholangitis after HPE. The final proposed definitions for suspected and confirmed cholangitis are a combination of one element, respectively, two elements from each group; furthermore, the finding of a positive blood culture was added to the definition of confirmed cholangitis. The durations for prophylaxis and treatment of suspected and confirmed cholangitis were uniformly agreed upon by the experts. (4) Conclusions: for the first time, an international consensus was found for guidelines for definition, treatment, and prophylaxis for cholangitis during the first year after Kasai HPE. Applicability will need further prospective multicentered studies.

Gut Microbiome: A Potential Modifiable Risk Factor in Biliary Atresia

Biliary atresia (BA) is a fibro-obliterative condition of the biliary tree, presenting in infancy. The bilioenteric conduit formed at Kasai portoenterostomy (KPE), achieves restoration of bile flow in approximately 60% of infants. Even if the operation is successful, cirrhosis and its associated complications are, however, common. BA remains the leading cause for liver transplantation (LT) in children. Antibiotic, choleretic, and steroid therapy post-KPE have not convincingly reduced LT rates. Advances in molecular technology have enabled characterisation of the encoded genes of the gut microbiota (gut microbiome). The gut microbiome plays an important role in host metabolism, nutrition, and immune function, with alterations in its diversity and/or composition, known as dysbiosis, being described in disease states, including liver disease. Liver-gut microbiome exploration in adulthood largely focuses on nonalcoholic liver disease, cirrhosis (mainly alcohol- or viral-based aetiology) and cholestatic liver diseases (eg, primary sclerosing cholangitis), with microbial signatures correlating to disease severity. Investigation of the gut microbiota in BA had been limited to culture-based methodology, but molecular studies are emerging, and although in their infancy, highlight a potential pathogenic role for Enterobacteriaceae and Streptococcus, and a potential beneficial role for Bifidobacteria. Bacterial translocation, and the production of gut microbiome-derived metabolites, are key host-microbiome-mechanistic pathways in liver disease pathogenesis. Microbiome-targeted therapeutics for liver disease are in development, with faecal microbiota transplantation showing promise in cirrhosis. Could the gut microbiome be a novel modifiable risk factor in BA, reducing the need for LT?

Microbe Isolation from Blood, Central Venous Catheters, and Fluid Collections after Liver Resections

BACKGROUND

Our goal was to evaluate the microbe species responsible for bacteremia or infections related to central venous catheter (CVC) or fluid collections after liver resection.

PATIENTS AND METHODS

Data from 112 patients (68 males, 44 females) who underwent liver resection over a period of 63 months were reviewed. Patient and tumor characteristics, intra-operative and post-operative data, and the results from cultures of peripheral blood, CVC tips and drained intra-abdominal or intra-throracic fluid collections were collected.

RESULTS

There were positive blood cultures in 20 patients (17.9%). Coagulase-negative staphylococci (CoNS) and bacteria of enteric flora were the micro-organisms found most frequently and half of the cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis was an independent risk factor for microbe isolation in peripheral blood (odds ratio [OR]: 11, p = 0.01). Furthermore, there were positive cultures of the CVC tip in 14 patients (12.5%), with CoNS being the micro-organism found most frequently and most cases had only one isolated microbe species. No specific risk factor for catheter-related infections was detected. In addition, there were positive cultures of drained fluid collections in 19 patients (17%), with bacteria of enteric flora being the micro-organisms found most frequently and the majority of cases had multiple isolated microbe species. The construction of a bilioenteric anastomosis (OR: 23.5, p = 0.002) and the laparoscopic approach (OR: 4.7, p = 0.0496) were independent risk factors for microbe isolation in drained fluid collections. Finally, the presence of positive blood cultures was associated with the presence of positive culture of CVC tips (p = 0.018) and drained fluid collections (p = 0.001).

CONCLUSIONS

Post-operative bacteremia, colonization of CVCs, and contamination of fluid collections occur frequently after liver resections and various microbe species may be involved. Patients who undergo hepatectomy and a synchronous construction of a bilioenteric anastomosis are at increased risk of bacteremia development and contamination of fluid collections.

The application of vascularized stomach flap to repair postoperative biliary stricture

Hepaticojejunostomy, which is the "gold standard" procedure for repairing postoperative biliary strictures, predisposes patients to reflux cholangitis from loss of sphincter of Oddi. The aim of this study was to assess the sphincter-preserving biliary reconstruction approach to repair postoperative biliary stricture. An autologous vascularized stomach flap was prepared and used to repair biliary defect caused by postoperative biliary stricture. Patient clinical data were analyzed retrospectively and long-term prognosis was evaluated based on the Lillemoe standard. Twenty-eight patients who underwent surgery from 2002 to 2010 were enrolled for the study. The original surgical procedure that caused biliary stricture consisted of patients having cholecystectomy (n = 22), biliary duct exploration (n = 5), and hepatectomy (n = 1). Eighteen (64%) of the 28 patients had previous repair surgery before being admitted. Based on the Bismuth level, 7 were classified as type I, 15 as type II, and 6 as type III. The mean length of biliary defect determined preoperatively by magnetic resonance cholangiopancreatography was 1.5 cm. The surgical procedure was successfully performed for all patients with a mean operation time of 261 ± 47.8 minutes. The postoperative complication rate was 10.7%, including minor bile leak (n = 2) and pulmonary infection (n = 1). There was no perioperative deaths. Two patients were absent during follow-up, and the remaining 26 patients had a mean follow-up period of 7.5 years (61-155 months). Twenty-four patients remained healthy during the follow-up period, while 2 patients (7.7%) had sporadic recurrent cholangitis that eventually resolved spontaneously. The overall long-term outcome rate was 92.3%. None of the patients had recurrence of stricture during the follow-up period. These results suggest that biliary repair using vascularized stomach flap could reduce reflux cholangitis and offer a satisfactory long-term outcome. This procedure could be a reliable method to repair postoperative biliary stricture with limited biliary defect.

Long-term outlook in biliary atresia

The oldest survivors from the Kasai portoenterostomy originate in Sendai, Japan and are approaching their 60th birthday. These represent the tip of an expanding cohort of adults born with this previously fatal condition. Increasingly transition to adult-biased hepatologists and physicians will be the expectation of many with this condition. However unlike their usual patients with alcohol, drugs, virally mediated liver disease these are different with different expectations of health and quality of life. Cure is not on the cards for most of these and they survive still with impaired bile flow and increased liver fibrosis and cirrhosis with the threat of cholangitis and portal hypertension still apparent. We review the reported statistics on long-term survival essentially from Japan and Western Europe (such as the UK and France) and the range of complications that may still beset this group.

Infections in pediatric solid-organ transplant recipients

Solid-organ transplantation in pediatrics can be a life-saving procedure, but it cannot be accomplished without risk of infection-related morbidity and mortality. Evaluation of the recipient during candidacy and donor during evaluation can assist with identification of risk. Further, risk of infection from the surgical procedure can be mitigated through careful planning and attention to infection prevention processes. Finally, early recognition of infection posttransplant can limit the impact of these events.

Prophylactic Antibiotics for Prevention of Cholangitis in Patients With Biliary Atresia Status Post-Kasai Portoenterostomy: A Systematic Review

PURPOSE

To determine effectiveness of prophylactic antibiotics in preventing cholangitis, we conducted a systematic review comparing cholangitis occurrence in biliary atresia patients after Kasai portoenterostomy (KP) with and without antibiotics.

METHODS

We searched online bibliographic databases from April 1, 2013, using search terms "biliary atresia" OR "cholangitis" AND "antibiotics," selecting studies with control group data.

RESULTS

Four of 509 titles met inclusion criteria, yielding a total of 319 patients from 3 countries. Three studies were retrospective cohorts and one was a randomized clinical trial. Two cohort studies concluded that prophylactic antibiotics reduced incidence of cholangitis and one did not. The randomized clinical trial supported prophylaxis after comparing the prospective randomized groups to a historical control group.

CONCLUSION

Few published studies measure the effect of prophylactic antibiotics after Kasai portoenterostomy. We identified 4 studies and they presented contradictory results. Prospective research is needed.

Reappraise the effect of redo-Kasai for recurrent jaundice following Kasai operation for biliary atresia in the era of liver transplantation

PURPOSE

This study was conducted to reappraise the efficacy of redo-Kasai (or revision) in the era of liver transplantation as a treatment option in those patients with recurrent jaundice after initially successful Kasai procedure.

METHODS

We studied ten patients that received redo-Kasai, among a total of 102 patients diagnosed with biliary atresia after receiving Kasai operation from 1986 to 2011.

RESULTS

Kasai operation was done at a median age of 55 days and redo-Kasai at 150 days. The bilirubin levels returned to normal in six patients after the procedure. Four of six enjoyed jaundice-free survival with native liver till the time of last follow-up. Three patients died and three received liver transplantation (LT). Only one out of seven patients with three or more episodes of cholangitis survived with native liver, while all the three patients with 1 or 0 episode survived with native liver. The difference was significant (P = 0.033). Re-do Kasai did not result in more blood loss or operative time during LT.

CONCLUSION

Redo-Kasai is still valuable in the era of LT and the episodes of cholangitis are the decisive factors affecting the outcome of the procedure.

Hepatic portocholecystostomy (HPC) is ineffective in the treatment of biliary atresia with patent distal extrahepatic bile ducts

OBJECTIVE

To compare the effects of hepatic portocholecystostomy (HPC) and the Kasai procedure for the treatment of biliary atresia with patent distal extrahepatic bile ducts (BA with PDEBD) and to determine the reasons for the differences between the two procedures.

METHODS

The case files of 29 patients with BA with PDEBD were reviewed retrospectively. Twenty patients were treated with the Kasai procedure, and 9 patients were treated with HPC. We compared the rate of jaundice clearance, the incidence of cholangitis, survival rates of the native liver, and clinical outcomes between the two groups. Healthy gallbladders were collected for comparison with the pathologic specimens. Van-Gieson stains were used to detect the severity of fibrosis, and immunohistochemical methods were used to investigate the expression of CD68. Image analysis technology was used to quantitatively analyze the results.

RESULTS

Six months after surgery, the rate of jaundice clearance was 85% in the Kasai group and 33.3% in the HPC group (p = .01). The three-year survival rates of the two groups were 73.68% and 33.3%, respectively (p = .009). According to the criteria that define a cured state, there was an obvious difference between the two groups (p = .0056). The fibrosis and CD68(+) cell infiltration were more severe in the gallbladders of patients with BA than in controls (p < .05).

CONCLUSION

HPC was inferior to the Kasai procedure in the treatment of BA with PDEBD. This result may be due to the progressive inflammation and fibrosis of the extrahepatic bile duct.

Current concept about postoperative cholangitis in biliary atresia

BACKGROUND

Postoperative cholangitis characterized by fever and acholic stool and positive blood culture is a common and serious complication following Kasai's operation for biliary atresia. The aim of this review was to describe the pathogenesis, clinical manifestations, medical treatment and outcome of postoperative cholangitis.

DATA SOURCES

Articles on biliary atresia retrieved from Pubmed and MEDLINE in the recent 10 years were reviewed.

RESULTS

The pathogenesis of postoperative cholangitis is still controversial. Recent methods for the diagnosis of postoperative cholangitis include urinary sulfated bile acids (USBA) and magnetic resonance cholangio-pancreaticography (MRCP). High-dose steroids and oral antibiotics have been used to reduce the incidence of postoperative cholangitis, and recurrent cholangitis leads to a lower survival rate.

CONCLUSIONS

Cholangitis is one of the most important determinants of long-term survival after the Kasai's procedure. The knowledge on postoperative cholangitis has been increasing in the past 10 years, showing a lower incidence of the disease and better therapeutic results.

Late-presenting cholangitis and Roux loop obstruction after Kasai portoenterostomy for biliary atresia

BACKGROUND/PURPOSE

Late-onset cholangitis is an uncommon complication after the Kasai operation for biliary atresia. Experience with 3 recent patients illustrates appropriate management.

METHODS

Retrospective review of patients with late unexplained deterioration in liver function attributed to cholangitis. All underwent quantitative radioisotope hepatobiliary scans to identify the Roux loop obstruction and confirm postoperative resolution. The role of percutaneous transhepatic cholangiography and computed tomography scanning was reviewed.

RESULTS

Three patients aged 8, 13, and 17 years were identified. All 3 had had a successful Kasai portoenterostomy for type 3 biliary atresia and presented after several virtually trouble-free years with late-onset cholangitis. The radioisotope scans in all 3 patients showed poor tracer uptake by the liver and pooling of the radioisotope at the porta hepatis. Laparotomy confirmed a proximal Roux loop obstruction at the level of the mesocolic window in all. This required mobilization and adhesiolysis and, in 1, correction of an actual stenosis within the wall of the intestine at this level. All patients had normalization of their liver function postoperatively. All are now well and anicteric at a follow-up of 6 to 12 months.

CONCLUSIONS

Long-term survivors of the Kasai portoenterostomy for biliary atresia with immediate deterioration in liver function warrant investigation for possible Roux loop obstruction. Resolution of the obstruction allows preservation of their native liver.

Effective antibiotic regime for postoperative acute cholangitis in biliary atresia--an evolving scene

PURPOSE

The prompt use of empirical antibiotics is vital in managing post-Kasai cholangitis. The authors published findings of their clinical trial in 1991 and established the use of cefoperazone, with a response rate of 88.9%. Here its clinical use since its introduction is reviewed and the trend in its efficacy is assessed.

METHODS

A retrospective review was carried out between 1997 and 2003. All episodes of acute cholangitis in patients who underwent Kasai procedure were recorded. Cholangitis was defined as unexplained fever with derangement of liver enzymes. Cefoperazone was started empirically according to the established protocol, and the response to treatment was analyzed.

RESULTS

There were 19 patients with a total of 49 episodes of cholangitis. Cefoperazone was used as the first-line empirical antibiotic in 40 of these episodes. Only 30 showed successful response (75%). For the 10 unresponsive episodes, meropenem was used as second-line antibiotic with complete response in all.

CONCLUSIONS

The efficacy of cefoperazone in the treatment of post-Kasai cholangitis has decreased over the last years. This suggests a need for a more effective first-line empirical antibiotic. From this review, meropenem seems to be a suitable candidate, and a future prospective clinical trial is warranted.

The intussusception antireflux valve is ineffective for preventing cholangitis in biliary atresia: a prospective study

PURPOSE

Cholangitis after Kasai portoenterostomy for biliary atresia (BA) strongly influences outcome, and an intussusception antireflux valve (IAV) in the Roux-en-Y limb has been advocated for the prevention of cholangitis without definitive evidence. The authors report a prospective study to evaluate the effectiveness of IAV in BA.

METHODS

Twenty-one consecutive patients with uncorrectable-type BA were the subjects for this study. IAV was included based on informed parental request to give 2 groups: IAV- (n = 11) and IAV+ (n = 10). The incidence/duration of episodes of cholangitis (temperature > 38 degrees C, elevated serum bilirubin level, and leukocytosis) during the first 6 months after Kasai were statistically compared between the 2 groups (P >.05 was regarded as not significant).

RESULTS

Technical variations in surgical technique were minimized because the same surgeon supervised all procedures. There were no significant differences between the 2 groups for age and weight at the time of Kasai, mean size of bile ductules at the porta hepatis, and degree of liver cirrhosis present. Protocols for antibiotic and steroid therapy were the same for both groups. The total number of patients who had cholangitis in the IAV- group was 6 of 11 and 5 of 10 in the IAV+ group (P = NS). The total number of episodes of cholangitis was 16 in the IAV- group versus 17 in the IAV+ group (P value, not significant). The mean duration of an episode of cholangitis (number of days per number of episodes) was 12 +/- 6 days in the IAV- group versus 11 +/- 7 days in the IAV+ group (P value, not significant).

CONCLUSIONS

IAV does not make any significant impact on the incidence or duration of cholangitis in the early post-Kasai period.