Associations between pediatric choledochal cysts, biliary atresia, and congenital cardiac anomalies

Liver transplantation for pediatric patients with congenital heart disease: A single-center study in mainland China

BACKGROUND

Liver transplantation (LT) is a serious cardiovascular stressor for patients with end-stage liver disease (ESLD). Data on the effects of cardiovascular diseases on pediatric LT is limited. No study on LT for pediatric patients with ESLD combined with congenital heart disease (CHD) has been reported from mainland China.

METHODS

A total of 1005 patients were included in this study. The Kaplan-Meier method with log-rank testing was used to evaluate survival outcomes between groups. Univariable and multivariable Cox regression models were used to determine the risk factors for patient and graft survival.

RESULTS

The most common indication for LT was biliary atresia (BA 90.3%). The prevalence of CHD was 3.8% (38). 42 CHD were found in 38 patients. The incidence of death and graft loss was more common in the CHD group than in the no-CHD group (13.2% vs. 5.0%, p = .045 and 15.8% vs. 6.2%, p = .019, respectively). The 5-year patient survival and graft survival in the CHD group versus the no-CHD group was 86.8% versus 94.7% (log-rank p = .022) and 84.2% versus 93.5% (log-rank p = .015), respectively. No significant differences were observed in re-transplantation, hepatic artery thrombosis (HAT), and portal vein thrombosis (PVT). After adjusting for age, BMI, etiology of LT, and other confounding factors, we can still find that the presence of CHD was associated with patient and graft survival after LT.

CONCLUSION

The presence of CHD was associated with higher mortality and lower graft survival after LT. If possible, the cardiac defects should be addressed prior to LT.

Cardiac-associated biliary atresia (CABA): a prognostic subgroup

OBJECTIVES

To describe the range of concurrent cardiac malformations in biliary atresia (BA) while providing a functional framework of risk.

METHODS

Demographic and variables were collected from a prospectively maintained single-centre database. Infants were grouped according to a cardiac functional framework (A=acyanotic, B=cyanotic and C=insignificant shunt). Primary outcome was set as clearance of jaundice (bilirubin ≤20 μmol/L) following Kasai portoenterostomy (KPE). Native liver survival and overall actuarial survival were compared with a date-matched control infant with BA (n=77). P value <0.05 was regarded as significant.

RESULTS

524 infants with histologically confirmed BA were treated between January 1999 and December 2018, 37 (7%) had a concurrent cardiac anomaly (A: n=23 (62%), B: n=10 (27%), C: n=4 (11%)). Infants with biliary atresia splenic malformation (BASM) or cat-eye syndrome (CES) contributed over half of the cases (21/37; 57%).Overall, 20 (54%) infants cleared jaundice (vs 50/77 (65%) controls; p=0.2), but with higher mortality compared with the non-cardiac controls (15/37 (40%) vs 3/77 (4%); HR 15.5 (95% CI 5.5 to 43.4); p<0.00001). Infants requiring cardiac intervention in the first year of life (n=15) were more likely to clear jaundice (6/7 vs 2/8; p=0.04) and had a trend towards higher survival (6/7 vs 3/8; p=0.1) when KPE followed cardiac surgery. Yet, the type of cardiac pathology did not impact clearance of jaundice or mortality.

CONCLUSION

We propose the term cardiac-associated biliary atresia (CABA) as a high-risk group. We believe that restorative cardiac surgery should precede KPE wherever possible to improve outcome.

Pediatric choledochal cysts: diagnosis and current management

Choledochal cysts are rare congenital disorders first described by Vater and Ezler in 1723. Their exact etiology remains incompletely understood; however, an anomalous pancreaticobiliary union (APBDU) and subsequent reflux of biliary contents into the biliary tree are thought to play a role. Accordingly, APBDU-associated choledochal cyst patients are significantly more likely to have evidence of hepatitis, cholangitis or pancreatitis and pathologically confirmed inflammation. In 1977, Todani and colleagues modified the original Alonso-Lej classification to include five types of CC. Type I and IV are the most common and most likely to be associated with malignancy. The majority of choledochal cysts are diagnosed in childhood. Clinical presentation varies and most often consists of nonspecific abdominal pain. Diagnosis is typically accomplished using multimodality imaging techniques including computed tomography, magnetic resonance imaging, ultrasound and MRCP. The use of diagnostic PTC and ERCP in CC has been largely replaced by MRCP. Appropriate management consists of prompt, complete cyst excision followed by restoration of biliary enteric continuity when necessary. Minimally invasive CC resection in the pediatric population has demonstrated acceptable outcomes. Prognosis is generally excellent; however, malignancy risk remains higher than the general population even after complete surgical excision.

Comorbidity in Adult Patients Hospitalized with Type 2 Diabetes in Northeast China: An Analysis of Hospital Discharge Data from 2002 to 2013

This study aims to evaluate the comorbidity burden and patterns among adult patients hospitalized with a diagnosis of type 2 diabetes mellitus (T2DM) in Northeast China using hospital discharge data derived from the electronic medical record database between 2002 and 2013. 12.8% of 4,400,892 inpatients aged ≥18 had a diagnosis of T2DM. Sex differences in prevalence varied among those aged <50, 50–59, and ≥60. Twenty-seven diseases were determined as major comorbidities of T2DM. Essential hypertension was the most common comorbidity of T2DM (absolute cooccurrence risk, 58.4%), while T2DM was also the most popular comorbidity of essential hypertension. Peripheral and visceral atherosclerosis showed the strongest association (relative cooccurrence risk, RCoR 4.206). For five leading comorbidities among patients aged ≥40, male patients had a stronger association with disorders of lipid metabolism than female patients (RCoR 2.779 versus 2.099), and female patients had a stronger association with chronic renal failure than male patients (RCoR 2.461 versus 2.155). Leading comorbidities, except chronic renal failure, had declining associations with T2DM with increased age. Collectively, hospital discharge data can be used to estimate disease prevalence and identify comorbidities. The findings provided comprehensive information on comorbidity patterns, helping policy makers and programs in public health domains to estimate and evaluate the epidemic of chronic diseases.

The prevalence of congenital heart defects in infants with cholestatic disorders of infancy: a single-centre study

BACKGROUND

There is deficiency of data about congenital heart defects (CHDs) in cholestatic disorders of infancy other than Alagille syndrome (AGS). We aimed to define the prevalence and types of CHDs in infants with various causes of cholestatic disorders of infancy.

METHODS

This cross-sectional study was conducted on 139 infants presenting with cholestasis whether surgical or non-surgical. The study was carried out at the Pediatric Hepatology Unit, Cairo University Children's Hospital, Egypt. Full examination and investigations were done in an attempt to reach an aetiologic diagnosis for cholestasis, in addition to a comprehensive echocardiographic study.

RESULTS

The age at the onset of cholestasis ranged from 1 day to 7 months. Males constituted 61.2%. Biliary atresia (BA) was diagnosed in 39 patients (28%), AGS in 16 patients (11.5%), 27 patients had miscellaneous diagnoses and 57 cases had indeterminate aetiology. CHDs were detected in 55 patients (39.5%). Shunt lesions were detected in 24 patients (43.6%), pulmonary stenosis in 18 patients (32.7%) and combined lesions in 9 patients (16.4%). Three patients (5.5%) had abnormal cardiac situs. Only seven patients had clinical presentation suggestive of CHD. CHDs were detected in 14 patients with BA (35.9%), 15 patients with AGS (93.7%) and 26 patients in the remaining group (30.9%).

CONCLUSION

CHDs are not uncommon among cholestatic infants and are mostly asymptomatic. Echocardiographic examination of cholestatic infants is recommended particularly for patients with BA before undergoing hepatic portoenterostomy as presence of CHD may impact the anaesthetic planning and affect the outcome of hepatobiliary surgery.

Treatment of choledochal cyst in a pediatric population. A single institution experience of 15-years. Case series

Background

Choledochal cyst (CC) is a rare congenital anomaly of the bile duct that approximately 75% of the patients are diagnosed in childhood. Without a standardized surgical procedure for the biliary reconstruction, we present our experience over the last 15 years and show the differences between the biliary reconstructions techniques in our population.

Methods

We did a retrospective hospital archive search for patients admitted to the pediatric surgery department with the diagnosis of a choledochal cyst from January 2000 to June 2015.

Results

We found 15 patients, of which, 1 was excluded because of missing data from the hospital record. Of the remaining 14, eight had hepaticojejunal (HY) anastomosis in Roux-en-Y, with a 25% rate of complications; six had hepatoduodenal (HD) anastomosis with a rate of complications of 16.6%. The average hospital length of stay in the group of HD vs. HY was 14 ± 1.6-days vs. 19 ± 8.2-days respectively.

Discussion

There are no standardized surgical reconstruction techniques of the biliary tract after the CC excision, there is literature that supports the biliary reconstruction with an HY and an HD without a distinct advantage over one or the other. Conclusion: In our series HD anastomosis represents a safe procedure with fewer complications than HY.

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Choledochal cyst is a rare disease either in pediatrics or adults.

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In the most common type of CC, the surgical excision is the gold standard.

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The reconstruction of the biliary tract in the case of CC is not standardized.

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We present the outcome of our series of patients that either HY or HD were performed.