Contemporary surgery of biliary atresia

Biliary atresia: evaluation on two distinct periods at a reference pediatric service

CONTEXT

Biliary atresia is a progressive, idiopathic, fibro-obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction exclusively in the neonatal period.

OBJECTIVES

To assess the differences regarding age at referral, age at surgery, duration of propaedeutics and waiting time for surgery between two groups of infants in different periods.

METHODS

Retrospective study of infants diagnosed with biliary atresia on two periods: 1983-1993 and 1998-2011.

RESULTS

Biliary atresia was diagnosed in 129 infants, being 48 in casuistic I and 81 in casuistic II. The median age at admission was 94 and 60 days, respectively (P = 0.0001). On evaluating patients who had undergone portoenterostomy before 120 days of age, no difference was observed regarding the duration of propaedeutics or waiting time for surgery (P = 0.15), but difference was found when comparing the age at surgery (P = 0.002). Among those infants with no biliary flow and without liver transplantation or death after 18 post-operative months, the estimated probability of survival was 44.6% and 38.7% in casuistics I and II, respectively. In casuistic I, all infants who showed biliary flow were alive during the observation period and, in casuistic II, 80.3% were alive after 7 years of follow-up.

CONCLUSIONS

Even though patients were admitted and treated earlier, it is clear that surgery could be done sooner. Delay in referral and timely propaedeutics were the main contributors.

CT and MRI of hepatic pseudotumor in long-standing biliary atresia

Two patients who developed a hepatic pseudotumor in long-standing biliary atresia treated by hepatoportoenterostomy are presented. Both masses were detected during routine imaging surveillance prior to liver transplantation. The CT, MR, and pathologic appearances are described. Accurate radiologic identification of this entity is important for appropriate clinical management.

Chronic cholestasis of infancy

This article focuses on the few disorders that produce chronic cholestasis in infants and children. Cholestasis is defined, and a framework for thinking about pathophysiology is provided. Medical management is discussed in the context of the consequences and complications of chronic cholestasis. The limited differential for chronic cholestasis is discussed, and approaches to diagnosis and management of specific disorders are provided.

Neonatal cholestasis. New approaches to diagnostic evaluation and therapy

Neonatal cholestasis remains a major diagnostic challenge despite increasing knowledge regarding its pathogenesis. The time constraint and urgency in the investigational process is underscored by the age-dependent success rate of the surgical corrective procedures for EHBA. Appropriate interpretation of imaging and pathologic studies requires a pediatric center familiar with the entities causing neonatal cholestasis. When liver failure or progressive hepatic dysfunction is likely to occur, early referral to a liver transplant center is recommended. Despite the increasing experience and excellent results of pediatric liver transplantation, at this point, surgical corrective procedures such as the Kasai procedure remain the first line of treatment for most patients with EHBA.

Extrahepatic biliary atresia and associated anomalies: etiologic heterogeneity suggested by distinctive patterns of associations

Fifty-one cases of extrahepatic biliary atresia (EHBA) with associated anomalies were found in a study of EHBA (251 cases). Analysis of segregation patterns of these anomalies in individual patients suggested the existence of 2 major groups: (1) 15 cases (29.4%) with various combinations of anomalies within the laterality sequence, and (2) 30 cases (58.8%) with one or 2 anomalies mostly involving the cardiac, gastrointestinal, and urinary systems. These latter anomalies did not follow any recognizable pattern. The third group of 6 cases all had intestinal malrotation, some with preduodenal portal vein; these cases show some similarity to the laterality sequence group and may represent a more confined phenotypic result of faulty situs determination. This previously unattempted classification of patients with EHBA and associated anomalies might enable a more targeted approach towards identification of causes in this heterogeneous disorder. EHBA within the laterality sequence might prove a suitable candidate for a major gene mutation. Teratogenic, infectious and polygenic multifactorial causes might play a more significant role in EHBA associated with "nonsyndromic" organ system anomalies.

Optimal therapy for patients with biliary atresia: portoenterostomy ("Kasai" procedures) versus primary transplantation

As the results with liver transplantation have improved, a controversy has arisen regarding the precise role of a portoenterostomy in the treatment of infants with biliary atresia. The controversy centers around three issues: (1) the short- and long-term survival rates achieved with both procedures, (2) the influence of a portoenterostomy on a subsequent transplant, and (3) the shortage of suitable liver donors for very small infants. To address these questions, we retrospectively reviewed the charts of 48 children with biliary atresia who underwent liver transplantation and compared these results with 35 children transplanted for other liver diseases. As a group, the biliary atresia patients had significantly lower mean body weights and ages and spent a significantly longer time on the waiting list. In addition, significantly more of the biliary atresia patients had undergone prior abdominal surgery when compared with the non-biliary atresia group. There was no difference in the intraoperative variables of mean anesthesia time, mean operative time, mean anesthesia preparation time, nor the mean amount of blood transfused intraoperatively between the two groups. However, when the biliary atresia patients who had undergone a portoenterostomy with a stoma were compared with either the biliary atresia patients who did not have a stoma created as part of their portoenterostomy or the non-biliary atresia patients, significant differences were noted in mean total anesthesia time, mean operative time, and the mean amount of blood transfused intraoperatively. The survival rate of the biliary atresia patients was significantly greater than the non-biliary atresia patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholangitis after the Kasai operation for biliary atresia

One hundred seventy-nine episodes of cholangitis in 28 consecutive patients having a Kasai operation for biliary atresia during the past 3 1/2 years were analyzed. The diagnosis was made primarily on the basis of unexplained fever (greater than 38.0 degrees C). An increase in serum bilirubin or a decrease in bile volume and in bile bilirubin concentration were often confirmatory, but other laboratory data including serum hepatic enzymes and blood and bile culture data were of little or inconsistent value. All patients were treated with systemic antibiotics. The best results were obtained with third-generation cephalosporins or imipenemcilastatin with the addition of aminoglycosides in recalcitrant cases. Antibiotic therapy was modified if defervescence did not occur within the first 24 hours. Cholangitis refractory to antibiotics was aggressively treated with pulse steroid therapy, and in some cases, operative intervention, both with good clinical success (60% and 73%, respectively).

Biliary appendico-duodenostomy: a nonrefluxing conduit for biliary reconstruction

Biliary conduits constructed during operations for choledochal cysts or biliary atresia are frequently complicated by reflux of gastrointestinal contents, stasis, and obstruction with resulting cholangitis. We have used the appendix as a biliary conduit for cases of biliary atresia and choledochal cyst, adapting the urologic technique of a tunneled, nonrefluxing anastomosis for reconstruction of the biliary tree--biliary appendico-duodenostomy (BAD). From our preliminary experience with this technique, it appears promising.

Post-operative abdominal CT scanning in extrahepatic biliary atresia

A retrospective review of the abdominal CT scans of 26 children with extrahepatic biliary atresia was performed, and the results were correlated with available surgical and pathologic data. Associated congenital anomalies or acquired abnormalities were identified in these patients. Congenital anomalies included polysplenia, venous anomalies and bowel stenosis. Acquired abnormalities developed secondary to cirrhosis, portal hypertension, intrahepatic biliary duct dilatation, and hepatic ischemia. Despite frequent episodes of ascending cholangitis in these children, no hepatic abscesses were identified by CT or by pathologic examination. In conclusion, abdominal CT scanning of children with extrahepatic biliary atresia can define congenital and acquired abnormalities and provide important anatomic data for the surgeons before liver transplantation.