Surgical experience in children with biliary atresia treated with portoenterostomy

Diagnosis of liver cirrhosis with two-dimensional shear wave elastography in biliary atresia before Kasai portoenterostomy

PURPOSE

To evaluate the application value of two-dimensional shear wave elastography (2D-SWE) for non-invasive diagnosis of liver cirrhosis (LC) in patients with biliary atresia (BA) before Kasai portoenterostomy (KP), and the cutoff value of liver stiffness measurement (LSM) for diagnosing LC.

METHODS

The clinical data of 51 patients with BA who were diagnosed via surgery and pathological results from May 2017 to December 2018 in the department of general surgery, Beijing Children's Hospital, Capital Medical University, were retrospectively analyzed. The liver tissue specimens obtained during KP were evaluated according to the METAVIR criteria. The LSM was obtained using the 2D-SWE technique before KP.

RESULTS

There was a grade positive correlation between LSM and METAVIR staging, and the Spearman correlation coefficient was 0.432 (P = 0.002). The AUC for 2D-SWE diagnosing LC (METAVIR score S = 4) in patients with BA before KP was 0.843 (95% confidence interval 0.736 ~ 0.950). The best cutoff value was 16.05 kPa, and the corresponding sensitivity was 75.0%, specificity was 83.7%, positive predictive value (PPV) was 46.1%, negative predictive value (NPV) was 94.7%, and the accuracy was 82.4%.

CONCLUSION

2D-SWE can be used to noninvasively diagnose LC in patients with BA before KP, and the cutoff value is 16.05 kPa.

Diagnostic and Prognostic Significance of Various Histopathological Features in Extrahepatic Biliary Atresia

INTRODUCTION

Extrahepatic biliary atresia is a progressive disorder characterised by fibroinflammatory obliteration or stenosis of the extrahepatic biliary tree leading to obstruction of bile flow and cholestatic jaundice. It is the most common cause for cholestasis in newborn. Histopathological criteria for diagnosing biliary atresia from liver biopsy have not been clearly defined.

AIM

This study was undertaken to analyse the significance of the various histopathological features in diagnosis and prognosis of extrahepatic biliary atresia from liver biopsy specimens.

MATERIALS AND METHODS

This was a retrospective study of 43 cases of extra-hepatic biliary atresia diagnosed and treated at a tertiary care hospital between January 2010 to December 2014. Formalin fixed paraffin embedded liver biopsy tissues were processed by standard technique and the slides were stained with haematoxylin and eosin. All the slides were reviewed and graded by a semi-quantitative scoring system. Features such as increased age at kasai's portoenterostomy, portal fibrosis, bile duct proliferation, cholestasis, portal inflammation and duct plate malformation were studied. Statistical analysis was worked out using SPSS 17.0 (statistical package for the social science software). Chi-square test was used to find association between various parameters with respect to mortality and Kaplan-Meier estimator was used for survival analysis of the population under study.

RESULTS

In this study comprising of 43 cases, only 6 cases (13.95%) were alive at the end of 6 months follow-up. Twenty patients who died and the 17 cases with poor survival had greater degrees of fibrosis, bile duct proliferation and cholestasis. Majority of the cases with duct plate malformation expired inspite of earlier surgical intervention. Thus proving the association of fibrosis, bile duct proliferation, cholestasis and duct plate malformation with the survival and prognosis of biliary atresia cases. Age at surgery did not show any correlation with prognosis as cases operated even at <60 days had poor survival.

CONCLUSION

From this study it can be concluded that in extrahepatic biliary atresia patients, presence of duct plate malformation, greater degrees of fibrosis, bile duct proliferation and cholestasis were strongly associated with poor prognosis.

Anaesthesia for biliary atresia and hepatectomy in paediatrics

The scope of this article precludes an 'in depth' description of all liver problems and I will limit this review to anaesthesia for biliary atresia - a common hepatic problem in the very young - and partial hepatectomy in older children. I will not be discussing the problems of anaesthetising children with hepatitis, cirrhosis, congenital storage diseases or liver failure. Extrahepatic biliary obstruction is an obliterative cholangiopathy of infancy which is fatal if untreated. Diagnosis involves exclusion of other causes of neonatal jaundice and treatment involves a hepatico portoenterostomy carried out at the earliest. This is a review of current concepts in anaesthesia and postoperative management of neonates with extrahepatic biliary atresia. Anaesthesia for hepatic resection has seen great changes in recent times with the improvement in surgical techniques, technology and a better understanding of the underlying physiology. These are reviewed along with the problems of postoperative pain management.

Liver and portal histopathological correlation with age and survival in extra hepatic biliary atresia

AIM

To grade histopathological parameters in biliary atresia (BA) and correlate it with advancing age and outcome.

METHOD

Liver and porta hepatis biopsies of 18 BA cases were graded for cholestasis (C), hepatocellular degeneration (HD), bile duct proliferation (BDP), bile duct fibrosis (BDF), bile duct inflammation (BDI), portal edema (PE), portal inflammation (PI) and portal fibrosis (PF) with a total histopathological score (THS) of 25. Confidence intervals were calculated. Image analysis at porta hepatis for largest subhepatic bile ductule diameter (BDD) and area was correlated with liver histopathology. Patients were followed up to at least 1 year after surgery. Four cases of neonatal autopsies were taken as control.

RESULTS

Mean age at Kasai was 95.5 + 32.03 (51-172) days. Mean THS was 16.83 + 2.57 (13-23) with no significant difference in relation to age <90; >90 days (p = 0.4410) or age <60; 61-90; 91-120; >121 days (p = 0.6549). There was no significant difference with relation to age in grading of parameters; C (p = 1.000) HD (p = 0.638), BDP (p = 0.530), BDF (p = 0.342), BDI (p = 0.395), PE (p = 0.476), PI (p = 0.342), PF (p = 0.530), BDD (p = 0.1097) and area (p = 0.1097). There was no significant difference between survival and age at operation (p = 0.4178) or THS (p = 0.3025).

CONCLUSION

Advanced histopathological findings even at younger age suggests the need to consider BA as an emergency.