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Degtyareva A, Isaeva M, Tumanova E, Filippova E, Sugak A, Razumovsky A, Kulikova N, Albegova M, Rebrikov D. Combined Predictors of Long-Term Outcomes of Kasai Surgery in Infants with Biliary Atresia. Pediatr Gastroenterol Hepatol Nutr 2024; 27:224-235. [PMID: 39035404 PMCID: PMC11254651 DOI: 10.5223/pghn.2024.27.4.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/09/2024] [Accepted: 04/21/2024] [Indexed: 07/23/2024] Open
Abstract
Purpose Biliary atresia (BA) is the leading cause of neonatal cholestasis (25-45%). The primary treatment is hepatic portoenterostomy (Kasai procedure), but only 20-40% provide long-term benefits. This study aimed to develop a predictive model for surgical efficacy by comparing preoperative and early postoperative indicators in infants with different outcomes. Methods We enrolled 166 infants with BA (93 girls, 73 boys) who underwent the Kasai procedure between September 2002 and December 2021, dividing them into favorable or adverse outcome groups. Over 40 parameters were measured, and the diagnostic significance of the prognostic model was evaluated. Results Kasai surgery was efficacious in 69 patients (42%) and non-efficacious in 97 (58%). Our model assesses efficacy by day 14 after surgery, improving on the <34 µmol/L direct bilirubin threshold established for 3-6 months after the procedure. Including the Desmet fibrosis score refined the model. Conclusion Blood cholesterol below 5.41 mmol/L, direct bilirubin below 56.3 µmol/L on postoperative days 14±3, and a low Desmet score indicate a high probability of efficacious Kasai surgery in infants with BA.
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Affiliation(s)
- Anna Degtyareva
- Department of Pediatric, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
- Department of Neonatology, Sechenov University, Moscow, Russia
| | - Medan Isaeva
- Department of Research, NPF DNA-Technology LLC., Moscow, Russia
| | - Elena Tumanova
- Department of Pathological Anatomy and Clinical Pathological Anatomy, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Elena Filippova
- Department of Ultrasound Diagnostics in Neonatology and Pediatrics, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - Anna Sugak
- Department of Ultrasound Diagnostics in Neonatology and Pediatrics, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - Alexander Razumovsky
- Division of Thoracic Surgery, Department of Moscow Healthcare, Filatov Children’s City Clinical Hospital, Moscow, Russia
- Department of Pediatric Surgery Named after Academician Y. F. Isakov, Faculty of Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Nadezhda Kulikova
- Division of Thoracic Surgery, Department of Moscow Healthcare, Filatov Children’s City Clinical Hospital, Moscow, Russia
| | - Marina Albegova
- Department of Pediatric, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - Denis Rebrikov
- Institute of Translational Medicine, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
- Vice-Rector for Scientific Research, Pirogov Russian National Research Medical University, Moscow, Russia
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Vutukuru S, Solanki S, Kanojia RP. Delphi Method Analysis and Consensus of Prevalent Distinctive Practices for Biliary Atresia Management after Kasai Portoenterostomy. J Indian Assoc Pediatr Surg 2024; 29:271-276. [PMID: 38912031 PMCID: PMC11192269 DOI: 10.4103/jiaps.jiaps_250_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 06/25/2024] Open
Abstract
Background Extrahepatic biliary atresia (BA) is seen in infants, with an incidence of 1 in 15,000 live births. The presentation is progressive jaundice, dark-colored urine, and clay-colored stools. Kasai portoenterostomy (KPE) is the commonly performed surgical procedure in these patients. Postoperatively, phenobarbitone, ursodeoxycholic acid (UDCA), steroids, and other drugs are given to improve bile drainage and prevent inflammation and fibrosis. However, a definitive protocol regarding the need for different drugs, dosage, and duration varies across individual surgeons and centers. No universally accepted protocol exists for postoperative management after KPE. Aim The aim of this study was to know the prevailing postoperative management of BA by subject experts and use the Delphi process to know if the experts want to change their practice based on the results from the survey. Material and Methods A questionnaire was made after discussing with two experts in the field of BA. The questionnaire was mailed to 25 subject experts. The first survey data were analyzed and shared with all responders. In the second survey, change in the management based on the results from the first survey was assessed. Results The Delphi questionnaire was answered by 17 experts. Postoperatively, prophylactic antibiotics are prescribed for 6-12 weeks by around 40% and >12 weeks by 30% of respondents. Phenobarbitone is prescribed for <3 months by nearly 50%. UDCA is prescribed for <3 months, ≤6 months, and 6 months-1 year by 47.1%, 23.5%, and 23.5% responders, respectively. Nearly 50% prescribe steroids (mostly prednisolone), and among them, two-thirds prescribe it for 6-12 weeks. Approximately 60% give antiviral drugs to children who are cytomegalovirus immunoglobulin M positive. In our survey, 50% of experts perform 5-10 KPE per year, and 25% each perform 10-15 and >15 KPE per year. The second survey noted that a significant percentage of responders want to change their practice according to consensus. Conclusion From our Delphi survey, an overview of the postoperative management of BA could be made. However, multicentric studies are required for uniform protocol on the postoperative management of BA.
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Affiliation(s)
- Sravanthi Vutukuru
- Department of Pediatric Surgery, Siddhartha Medical College, Vijayawada, Andhra Pradesh, India
| | - Shailesh Solanki
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravi Prakash Kanojia
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Matcovici M, Davenport M. Response to Letter RE: What Makes A "Successful" Kasai Portoenterostomy "Unsuccessful?". J Pediatr Gastroenterol Nutr 2023; 77:e70-e71. [PMID: 37417831 DOI: 10.1097/mpg.0000000000003881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Affiliation(s)
- Melania Matcovici
- From the Department of Paediatric Surgery, Kings College Hospital, London, UK
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Alatas FS, Lazarus G, Junaidi MC, Oswari H. Prophylactic Antibiotics to Prevent Cholangitis in Children with Biliary Atresia After Kasai Portoenterostomy: A Meta-Analysis. J Pediatr Gastroenterol Nutr 2023; 77:648-654. [PMID: 37705401 DOI: 10.1097/mpg.0000000000003935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVES A connection between the bowel and bile ducts after the Kasai hepatoportoenterostomy (HPE) procedure poses a risk of ascending cholangitis. There were only a few evidence-based consensuses on the benefits of prophylactic antibiotics. This study aims to assess the value of prophylactic antibiotics in reducing the risk of cholangitis following the Kasai HPE procedure. METHODS Meta-analysis is performed using random-effects model from the search result of 5 online databases (PubMed, Google Scholar, EBSCO MEDLINE, ClinicalTrials.gov , and EuropePMC) from inception to October 27, 2021. The keywords used were "antibiotic," "antimicrobial," "Kasai," "portoenterostomy," "biliary atresia," and "bile duct atresia." Cochrane Risk of Bias tool and Newcastle-Ottawa Scale is used to assess the risk of bias. The outcomes are incidence of cholangitis and native liver survival. RESULTS Six studies consisting of 4 cohorts and 2 cross-sectional studies were extracted. A total of 714 patients reported different cholangitis incidence after prophylactic antibiotics administration post-Kasai HPE. The incidence of cholangitis following Kasai HPE was not statistically significant among participants. There is conflicting evidence on the efficacy of antibiotics in prolonging native liver survival. CONCLUSIONS The existing evidence does not support the administration of prophylactic antibiotics in preventing cholangitis after Kasai HPE among biliary atresia patients. Additionally, their roles in native liver survival are still inconclusive. The fact that there were heterogeneous method and antibiotic usage between existing studies must also be highlighted for better design in future studies.
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Affiliation(s)
- Fatima Safira Alatas
- From the Department of Child Health, Gastrohepatology Division, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Rachmani E, Davenport M. Letter to the Editor: Comment on Wickramasekara N, Ignatius J, Lamahewage A. Prognostic factors and outcomes of Kasai portoenterostomy (KPE): nine-year experience from a lower-middle income country. Pediatr Surg Int. 2023; 39(1):142. doi: 10.1007/s00383-023-05,424-y. Pediatr Surg Int 2023; 39:197. [PMID: 37166540 DOI: 10.1007/s00383-023-05482-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Evangelia Rachmani
- Department of Paediatric Surgery, Kings College Hospital, London, SE5 9RS, UK
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London, SE5 9RS, UK.
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Zhang M, Cao G, Li X, Zhang X, Li Y, Chi S, Rong L, Tang ST. Robotic-assisted Kasai portoenterostomy for biliary atresia. Surg Endosc 2023; 37:3540-3547. [PMID: 36602550 DOI: 10.1007/s00464-022-09855-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Robotic-assisted Kasai portoenterostomy (RAKPE) has been utilized to treat biliary atresia (BA). However, RAKPE is not widely performed and its efficacy remains unknown. We summarized the experience of RAKPE for BA and determined its efficacy. MATERIALS AND METHODS We retrospectively analyzed 25 consecutive infants with non-syndromic type III BA who received RAKPE in our center from January 2020 to July 2021. RAKPE is a three-arm setup and four-trocar operation. Bipolar coagulation was used to dissect the small blood vessels at the hepatic portal. The fibrous cone was shallowly transected with bending electric scissors, followed by gelatin sponge compression to staunch the hemorrhage. Finally, a wide anastomosis was accurately constructed. Demographics and outcomes were recorded. RESULTS The mean operative time was 211.64 ± 18.93 min. No conversion to laparotomy or intraoperative complications occurred. The mean estimated blood loss was 7.64 ± 2.43 mL. Enteral feeding was resumed after 3.44 ± 1.23 days. All patients achieved bile excretion postoperatively, and dark green bile-stained stools were passed 1.50 days (range 1.00-3.00 days) after surgery. The average postoperative length of hospital stay was 10.32 ± 2.59 days. The jaundice clearance (JC) rate was 76.00% within 6 months after surgery and the incidence of cholangitis was 48.00% within 1 year following surgery. The survival with native liver (SNL) rate was 80.00% at 1 year and 66.67% at 2 years. CONCLUSION RAKPE can be regarded as a treatment option for patients with BA due to the good outcomes reported. However, long-term studies comparing open or laparoscopic approaches are needed.
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Affiliation(s)
- Mengxin Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Guoqing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Xiangyang Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Yibo Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Shuiqing Chi
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Liying Rong
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Shao-Tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
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Wang Y, Jia LQ, Hu YX, Xin Y, Yang X, Wang XM. Development and Validation of a Nomogram Incorporating Ultrasonic and Elastic Findings for the Preoperative Diagnosis of Biliary Atresia. Acad Radiol 2021; 28 Suppl 1:S55-S63. [PMID: 32972841 DOI: 10.1016/j.acra.2020.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE AND OBJECTIVES To develop and validate a nomogram that incorporates the gallbladder morphology, hepatic elasticity, and demographic information for the prediction of biliary atresia (BA) in children. MATERIALS AND METHODS A total of 294 consecutive patients under the age of 70 days with cholestasis and suspected symptoms of BA were enrolled in this study, who were divided into a training cohort (150 patients) and a validation cohort (144 patients). Ultrasonography and two-dimensional shear wave elastography were performed for each patient prior to knowing the final diagnosis. Multivariate logistic regression was used to analyze the gallbladder morphologic feature in the sonogram (absence of gallbladder, small gallbladder, lower postprandial gallbladder contractibility, or abnormal gallbladder wall), hepatic elasticity and clinical data from the training cohort, and a diagnostic nomogram for BA was subsequently developed. The performance of the nomogram was respectively evaluated with respect to the discrimination and calibration in every cohort. RESULTS The multivariate analysis showed that the factors of age (p = 0.009), gallbladder morphology (p = 0.001) and hepatic elasticity (p < 0.001) could serve as independent predictive factors to differentiate between BA and other causes of cholestasis. The nomogram incorporating these three parameters showed good discrimination and satisfactory calibration, indicating a better performance compared to using only the gallbladder morphologic features and hepatic elasticity. The observed area under the receiver operator characteristic curve in the training cohort and validation cohort was 0.939 (p < 0.001) and 0.942 (p < 0.001), respectively, with a sensitivity of 95.5% and a specificity of 83.4% in the combined cohort. CONCLUSION The established nomogram shows a favored and improved predictive value for the diagnosis of BA.
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Affiliation(s)
- Yu Wang
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China
| | - Li Qun Jia
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China
| | - Yan Xiu Hu
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China
| | - Yue Xin
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China
| | - Xi Yang
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China
| | - Xiao Man Wang
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China.
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Khayat A, Alamri AM, Saadah OI. Outcomes of late Kasai portoenterostomy in biliary atresia: a single-center experience. J Int Med Res 2021; 49:3000605211012596. [PMID: 33947263 PMCID: PMC8113946 DOI: 10.1177/03000605211012596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To describe the clinical, histopathologic, and outcomes data for a cohort of patients with biliary atresia (BA), and to identify the factors affecting survival. METHODS This was a cross-sectional study of all BA patients diagnosed between 1999 and 2017. Clinical, biochemical, imaging, and histopathologic data were analyzed, and Kaplan-Meier survival rates were compared to identify potential prognostic factors. RESULTS We evaluated 23 patients. The median age at the Kasai procedure was 77 ± 34 days, and the median overall survival was 12.5 ± 65 months. Thirteen (56%) patients survived with their native livers, 3 (13%) received a transplant, and 6 died (26%) while awaiting a transplant. Cholangitis and the use of ursodeoxycholic acid were associated with longer survival, while impaired synthetic function was associated with shorter survival. CONCLUSIONS Most patients presented late for the Kasai procedure. The survival rate with the native liver was comparable to other cohorts. Therefore, clinicians are encouraged to refer for the Kasai procedure even with late presentation (between 60 and 90 days), provided there is no hepatic decompensation.
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Affiliation(s)
- Ammar Khayat
- Department of Pediatrics, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.,Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Aisha M Alamri
- Department of Pediatrics, East Jeddah General Hospital, Jeddah, Saudi Arabia
| | - Omar I Saadah
- Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.,Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Abstract
Several patient and treatment related factors significantly modify outcomes of biliary atresia. The extremely variable prognosis mandates intensive postoperative monitoring following portoenterostomy. Accurate prediction of outcome and progression of liver injury would enable individualized treatment and follow-up protocols, patient counseling and meaningful stratification of patients into clinical trials. While results on most biomarkers of cholestasis, hepatocyte function, fibrosis and inflammation studied so far are inconsistent or have not been validated in independent patient cohorts, postoperative serum bilirubin level 3 months after portoenterostomy remains the most accurate clinically feasible predictor of native liver survival. Although liver stiffness and a novel marker of cholangiocyte integrity, serum matrix metalloproteinase-7, correlate with liver fibrosis and may discriminate biliary atresia from other causes of neonatal cholestasis, further information on their ability to predict portoenterostomy outcomes is needed. Recent gene expression profiling has shown promise in overcoming the sampling error associated with histological quantification of liver fibrosis, and provides an important possibility to stratify patients for clinical trials according to the prognosis of native liver survival already preoperatively. As activity and extent of ductular reaction is linked with progression of liver fibrosis in cholangiopathies, further research is also warranted to evaluate predictive value of ductular reaction, matrix metalloproteinase-7 and the underlying gene expression signatures in relation to circulating bile acids in biliary atresia. Discovery of accurate predictive tools will ultimately increase our understanding of the unpredictable response to surgery and pathophysiology of progressive liver injury in biliary atresia.
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Abstract
Biliary atresia is a progressive fibrosing obstructive cholangiopathy of the intrahepatic and extrahepatic biliary system, resulting in obstruction of bile flow and neonatal jaundice. Histopathological findings in liver biopsies include the expansion of the portal tracts, with edematous fibroplasia and bile ductular proliferation, with bile plugs in duct lumen. Lobular morphological features may include variable multinucleate giant cells, bilirubinostasis and hemopoiesis. The etiopathogenesis of biliary atresia is multifactorial and multiple pathomechanisms have been proposed. Experimental and clinical studies have suggested that viral infection initiates biliary epithelium destruction and release of antigens that trigger a Th1 immune response, which leads to further injury of the bile duct, resulting in inflammation and obstructive scarring of the biliary tree. It has also been postulated that biliary atresia is caused by a defect in the normal remodelling process. Genetic predisposition has also been proposed as a factor for the development of biliary atresia.
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