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Tam PKH, Wells RG, Tang CSM, Lui VCH, Hukkinen M, Luque CD, De Coppi P, Mack CL, Pakarinen M, Davenport M. Biliary atresia. Nat Rev Dis Primers 2024; 10:47. [PMID: 38992031 DOI: 10.1038/s41572-024-00533-x] [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] [Accepted: 06/10/2024] [Indexed: 07/13/2024]
Abstract
Biliary atresia (BA) is a progressive inflammatory fibrosclerosing disease of the biliary system and a major cause of neonatal cholestasis. It affects 1:5,000-20,000 live births, with the highest incidence in Asia. The pathogenesis is still unknown, but emerging research suggests a role for ciliary dysfunction, redox stress and hypoxia. The study of the underlying mechanisms can be conceptualized along the likely prenatal timing of an initial insult and the distinction between the injury and prenatal and postnatal responses to injury. Although still speculative, these emerging concepts, new diagnostic tools and early diagnosis might enable neoadjuvant therapy (possibly aimed at oxidative stress) before a Kasai portoenterostomy (KPE). This is particularly important, as timely KPE restores bile flow in only 50-75% of patients of whom many subsequently develop cholangitis, portal hypertension and progressive fibrosis; 60-75% of patients require liver transplantation by the age of 18 years. Early diagnosis, multidisciplinary management, centralization of surgery and optimized interventions for complications after KPE lead to better survival. Postoperative corticosteroid use has shown benefits, whereas the role of other adjuvant therapies remains to be evaluated. Continued research to better understand disease mechanisms is necessary to develop innovative treatments, including adjuvant therapies targeting the immune response, regenerative medicine approaches and new clinical tests to improve patient outcomes.
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Affiliation(s)
- Paul K H Tam
- Medical Sciences Division, Macau University of Science and Technology, Macau, China.
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Rebecca G Wells
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Clara S M Tang
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong, Hong Kong SAR, China
| | - Vincent C H Lui
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong, Hong Kong SAR, China
| | - Maria Hukkinen
- Section of Paediatric Surgery, Paediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Carlos D Luque
- Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Paolo De Coppi
- NIHR Biomedical Research Centre, Great Ormond Street Hospital for Children NHS Foundation Trust and Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Cara L Mack
- Department of Paediatrics, Division of Paediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Mikko Pakarinen
- Section of Paediatric Surgery, Paediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
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Söderström L, Gunnarsdottir A, Oddsberg J, Svensson PJ, Wester T, Granström AL. National Centralization of Hirschsprung's Disease in Sweden:A Comparison of Preoperative Management and Outcomes. J Pediatr Surg 2024:S0022-3468(24)00308-7. [PMID: 38871619 DOI: 10.1016/j.jpedsurg.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Surgical treatment of Hirschsprung's disease (HSCR) in Sweden was centralized to two tertiary pediatric surgery centers 1st of July 2018. Although complex surgical care in adults seems to benefit from centralization there is little evidence to support centralization of pediatric surgical care. The aim of this study was to assess centralization of HSCR in Sweden, with special consideration to preoperative management and outcomes in this group of patients. METHODS This study retrospectively analyzed data of patients with HSCR that had undergone or were planned to undergo pull-through at our center, from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 were compared with patients managed from 1st of July 2018 to 30th of June 2023 regarding diagnostic procedures, preoperative treatment, complications and time to definitive surgery. RESULTS Thirty-six patients were managed during the first five-year period compared to 57 during the second period. There was an increased number of patients referred from other Swedish regions to our center following the centralization. Time from diagnosis to pull-through increased from 33 to 55 days after centralization. There were no significant differences in pre-operative management or complications, general or related to stoma. CONCLUSIONS Despite increasing patient volumes and longer time from diagnosis to pull through, centralization of care for HSCR does not seem to change the preoperative management and risk of complications. With access to support from the specialist center, transanal irrigations remain a safe mode of at home management until surgery, regardless of distance to index hospital. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Linnea Söderström
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
| | - Anna Gunnarsdottir
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jenny Oddsberg
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Pär-Johan Svensson
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Wester
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Löf Granström
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
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Goldstein MA, Karlik J, Kamat PP, Lo DJ, Liu K, Gilbertson LE. Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes. Pediatr Transplant 2024; 28:e14722. [PMID: 38553820 DOI: 10.1111/petr.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/29/2024] [Accepted: 02/08/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.
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Affiliation(s)
- Matthew A Goldstein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joelle Karlik
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pradip P Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Denise J Lo
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katie Liu
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura E Gilbertson
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
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Kim H, Yoo SY, Kim JH, Kim MJ, Lee S, Jeon TY. Preoperative imaging findings to predict 2-year native liver survival after the Kasai procedure in patients with biliary atresia. Eur Radiol 2024; 34:1493-1501. [PMID: 37646810 DOI: 10.1007/s00330-023-10055-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/14/2023] [Accepted: 06/25/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVES To investigate the feasibility of using preoperative imaging indices to predict 2-year native liver survival after the Kasai procedure in patients with biliary atresia (BA). MATERIALS AND METHODS The retrospective review included 190 BA patients who underwent the Kasai procedure between 2000 and 2020, with preoperative US and/or MRI, excluding cases with less than 2-year follow-up period. Multivariable logistic regression analysis was performed to identify imaging indices to predict 2-year native liver survival. Kasai failure was defined as the need for liver transplantation or death within 2 years of the Kasai procedure. RESULTS Of the 90 patients included, all had preoperative US, and 61 also had MRI. Kasai failure occurred in 52% (47/90). Preoperative US identified gallbladder length (OR 0.40, 95% CI 0.17-0.95, p = 0.039; cutoff 1.6 cm, AUC 67.66) and biliary cysts (OR 24.64, 95% CI 1.97-308.08, p = 0.013) as significant Kasai failure predictors, with a combined accuracy of 73% (60/82). For patients having both preoperative US and MRI, significant predictors were hepatic artery diameter (OR 6.75, 95% CI 1.31-34.88, p = 0.023; cutoff 2 mm, AUC 73.83) and biliary cysts (OR 23.89, 95% CI 1.43-398.82, p = 0.027) on US, and gallbladder length (OR 0.25, 95% CI 0.08-0.76, p = 0.014; cutoff 1.2 cm, AUC 74.72) and spleen size (OR 2.53, 95% CI 1.02-6.29, p = 0.045; cutoff 6.9 cm, AUC 73.72) on MRI, with a combined accuracy of 85% (52/61). CONCLUSION Preoperative US and/or MRI enhance the 2-year native liver survival prediction in BA patients after the Kasai procedure. CLINICAL RELEVANCE STATEMENT BA patients with hepatic artery diameter > 2 mm (US), gallbladder length < 1.6 cm (US) or < 1.2 cm (MRI), spleen size > 6.9 cm (MRI), and absence of biliary cysts (US/MRI) have a decreased likelihood of 2-year native liver survival. KEY POINTS • Preoperative US and/or MRI can predict the probability of achieving 2-year native liver survival following the Kasai procedure. • Combining US and MRI improved the accuracy to 85% for predicting 2-year native liver survival in BA patients. • The hepatic artery diameter > 2 mm (US), gallbladder length < 1.6 cm (US) or < 1.2 cm (MRI), spleen size > 6.9 cm (MRI), and no biliary cysts (US/MRI) are significant predictors of Kasai failure in patients with biliary atresia.
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Affiliation(s)
- Harim Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - So-Young Yoo
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Min-Ji Kim
- Biomedical Statistics Center and Research Institute for Future Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Alhebbi H, El-Edreesi M, Abanemai M, Saadah O, Alhatlani M, Halabi H, Bader R, Sarkhy AA, Aladsani A, Wali S, Alguofi T, Alkhathran N, NasserAllah A, Bashir MS, Al-Hussaini A. Clinical and laboratory features of biliary atresia and patterns of management practices: Saudi national study (2000-2018). Saudi J Gastroenterol 2024; 30:89-95. [PMID: 37706420 PMCID: PMC10980299 DOI: 10.4103/sjg.sjg_151_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND We utilized the data from the Saudi national biliary atresia (BA) study (2000-2018) to describe the clinical, biochemical, imaging, and histopathological features of BA and the perioperative clinical practices among local pediatric gastroenterologists. METHODS This is a retrospective, multicenter, nationwide study that included 10 tertiary care governmental hospitals including the four liver transplant (LT) centers in different regions across Saudi Arabia. RESULTS BA was diagnosed in 204 infants (106 females; 10% preterm). The median age at referral was 65 days. Congenital anomalies were present in 68 patients (33%); 22 were splenic malformation (10.8%). The medians of laboratory investigations were total bilirubin (189 μmol/l), direct bilirubin (139 μmol/l), ALT (164 u/l), and GGT (472 u/l). The level of serum GGT was normal in 26 cases (12.7%). The ultrasound findings included hypoplastic or atrophic gall bladder (GB) (65%), normal GB (30%), and cord sign (5%). A HIDA scan was performed in 99 cases (48.52%). Magnetic resonance cholangiopancreatography (MRCP) was performed in 27 cases (13%). A total of 179 liver biopsies (88%) were obtained. The most common histopathologic findings were bile duct proliferation (92%), canalicular cholestasis (96%), bile plugs (84%), and portal fibrosis (95%). Cholangiography was performed in 139 cases (68%): operative in 122 (60%) and percutaneous in 17 (8%). A total of 143 children (70%) underwent Kasai portoenterostomy (KPE) at a median age of 70 days. After KPE, steroid was used in 37% of the cases and 100 cases (70%) were prescribed prophylactic antibiotics for variable duration (ranging between 3 and 12 months). CONCLUSION Our data show marked variation in the diagnostic evaluation and perioperative management of BA cases among the different tertiary centers. There is a need to establish a national BA registry in Saudi Arabia aiming to standardize pre- and postoperative clinical practices. Additionally, normal serum GGT level, normal GB size on ultrasound, and being a premature baby should not preclude the diagnostic workup for BA.
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Affiliation(s)
- Homoud Alhebbi
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed El-Edreesi
- Division of Pediatric Gastroenterology, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Mohammed Abanemai
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Omar Saadah
- Division of Pediatric Gastroenterology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maher Alhatlani
- Al Imam Abdulrahman Bin Faisal Hospital, Ministry of National Guard Health Affairs, Dammam, Saudi Arabia
| | - Hana Halabi
- Maternity and Children’s Hospital, Makkah, Saudi Arabia
| | - Razan Bader
- Multi-organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed Al Sarkhy
- Department of Pediatrics, Gastroenterology Division, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Aladsani
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sami Wali
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Talal Alguofi
- Organ Transplant Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nawaf Alkhathran
- Division of Pediatric Gastroenterology, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Muhammed Salman Bashir
- Department of Biostatistics, Research Services Administration, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Al-Hussaini
- Division of Pediatric Gastroenterology, Children’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Prince Abdullah Bin Khaled Celiac Disease Research Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
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Sadiq J, Lloyd C, Hodson J, Trapero Marugan M, Ferguson J, Sharif K, Mirza DF, Hirschfield G, Kelly D. Long-term clinical and socioeconomic outcomes of children with biliary atresia. JGH Open 2023; 7:841-847. [PMID: 38162865 PMCID: PMC10757476 DOI: 10.1002/jgh3.12980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 08/28/2023] [Accepted: 10/02/2023] [Indexed: 01/03/2024]
Abstract
Background Biliary atresia (BA) is rare liver disease of unknown etiology, and is a major indication for liver transplant (LT). Previous data indicate improved outcomes with early referral for Kasai portoenterostomy (KPE). Objective Evaluate the long-term outcomes in BA, with particular focus on those transitioned to adult care with native livers. Subjects and Methods Patients with BA treated between1980 and 2012 were identified. Data were collected from the time of referral, transition to adult care, and the most recent clinic notes, from which patient and native liver survival were calculated. Results Four hundred and fifty-four patients with BA were identified, who were followed up for median of 16.4 years from birth; 74 died (41 of whom had a LT), giving a 20-year survival rate of 83.6%. Two hundred and seventy-two patients received an LT, with the median native liver survival being 35 months. Of patients who transitioned to adult care, 54 of 180 (30.0%) retained their native liver. Of these, 72% (39 of 54) had evidence of chronic liver disease at transition, of whom 8 were subsequently lost to follow-up, 9 were transplanted, and 22 remained stable with compensated liver disease. Of the 15 of 54 patients (28%) with no evidence of chronic disease in their native liver disease at transition, 3 were subsequently lost to follow-up; none received transplants, although 3 patients developed new-onset liver disease. All patients transitioned to adult care completed secondary school education (N = 180), with 49% having attended college/university and 87% being in employment or education at the last follow-up. Of female patients, 34% had at least one pregnancy (27 children in 21 women), while 22% of males had fathered a child. Conclusion Long-term outcomes in BA are good, with patients surviving into adult life. Progression of chronic liver disease and associated morbidity is common in those who retained their native livers, suggesting that these patients require monitoring of liver disease throughout adult life, and early recognition of the need for LT.
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Affiliation(s)
- Javaid Sadiq
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
| | - Carla Lloyd
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
| | - James Hodson
- Institute of Translational MedicineUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
- Research Development and InnovationUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Maria Trapero Marugan
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - James Ferguson
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - Khalid Sharif
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
| | - Darius F Mirza
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - Gideon Hirschfield
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
| | - Deirdre Kelly
- Birmingham Women's & Children's Hospital& University Hospital BirminghamBirminghamUK
- Centre for Liver ResearchNIHR Biomedical Research Unit, University of BirminghamBirminghamUK
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Poddar U, Samanta A, Sarma MS, Kumar B, Lal R, Srivastava A, Upadhyaya VD, Yachha SK, Mandelia A. How to suspect the presence of high-risk esophageal varices and when to start endoscopic surveillance in children with biliary atresia? J Gastroenterol Hepatol 2023; 38:1610-1617. [PMID: 37407246 DOI: 10.1111/jgh.16267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND AIM Portal hypertension determines the outcome of children with biliary atresia (BA) and is common even after a successful Kasai portoenterostomy (KPE). However, there are no clear-cut guidelines on the age of starting surveillance and the modality (endoscopy vs non-invasive tests [NITs]). In this cohort study, we analyzed our database to find out the utility of NITs in detecting high-risk esophageal varices in BA. METHODS From June 2010 to May 2022, consecutive children of BA who underwent upper gastrointestinal (UGI) endoscopy were included. Esophageal varices were classified as high-risk (grade II with red-color signs or grade III or IV irrespective of red-color signs. NITs such as splenomegaly (clinical and USG), platelet count, aspartate transaminase to platelet ratio index (APRI), and platelet-to-spleen diameter ratio were compared between cases with high-risk and low-risk varices. RESULTS A total of 110 children, 75 boys (66 successful KPE and 44 failed/KPE not performed) were enrolled. The median age at KPE was 85 days (IQR 63-98). Thirteen (11.8%) children presented with UGI bleeding. The first endoscopy revealed gastroesophageal varices in 75.4% of cases, and 32% of them had high-risk varices. Multivariate analysis revealed failed KPE, history of UGI bleeding, bigger spleen size (> 3.5 cm), lower platelet count (< 150 000), and higher APRI (> 2) are independent predictors of the presence of high-risk esophageal varices. CONCLUSION Endoscopy is the best in predicting the presence of high-risk varices that might bleed; hence, early surveillance endoscopy should be started in children with splenomegaly, thrombocytopenia, and high APRI score to prevent variceal bleeding.
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Affiliation(s)
- Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Basant Kumar
- Pediatric Surgical Specialty, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Richa Lal
- Pediatric Surgical Specialty, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Vijay Datta Upadhyaya
- Pediatric Surgical Specialty, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Ankur Mandelia
- Pediatric Surgical Specialty, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Bustorff-Silva J, Miranda ML, Rosendo A, Gerk A, Oliveira-Filho AG. Evaluation of the regional distribution of the pediatric surgery workforce and surgical load in Brazil. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000522. [PMID: 37215247 PMCID: PMC10193071 DOI: 10.1136/wjps-2022-000522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/20/2023] [Indexed: 05/24/2023] Open
Abstract
Objective The purpose of this study is to examine the regional distribution of the pediatric surgery workforce and the expected local demand for pediatric surgical procedures in Brazil. Methods We collected data on the pediatric surgical workforce, surgical volume, Gross Domestic Product per capita, and mortality for gastrointestinal tract malformations (MGITM) across the different regions of Brazil for 2019. Results Data from the Federal Medical Council reported 1515 pediatric surgery registries in Brazil, corresponding to 1414 pediatric surgeons (some pediatric surgeons are registered in more than one state), or 2.4 pediatric surgeons per 100 000 children 14 years of age and younger. There were 828 men and 586 women. The mean age was 51.5±12.8 years, and the mean time from graduation was 3.4±5.7 years. There is a higher concentration of pediatric surgeons in the wealthier Central-West, South, and Southeast regions. Individual surgical volume ranged from 88 to 245 operations/year (average 146 operations/year) depending on the region. Of these, only nine (6.1%) were high-complexity (including neonatal) operations. MGITM tended to be higher in the poorer North and Northeast regions than in other regions of Brazil. Conclusions Our findings suggest significant disparities in the surgical workforce and workload across Brazil related to socioeconomic status. Regions with an increased surgical workforce were associated with lower MGITM. The average number of complex operations performed annually by each pediatric surgeon was considerably low. Strategic investment and well-defined health policies are imperative to enhance the quality of surgical care in the different regions of Brazil. Level of evidence Retrospective review; level IV.
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Affiliation(s)
| | - Marcio Lopes Miranda
- Pediatric Surgery, State University of Campinas Medical School, Campinas, Brazil
| | - Amanda Rosendo
- Pediatric Surgery, State University of Campinas Medical School, Campinas, Brazil
| | - Ayla Gerk
- Pediatric Surgery, State University of Campinas Medical School, Campinas, Brazil
- Medicine, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
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Nyholm I, Hukkinen M, Pihlajoki M, Davidson JR, Tyraskis A, Lohi J, Heikkilä P, Hänninen S, Andersson N, Eloranta K, Carpén O, Heikinheimo M, Davenport M, Pakarinen MP. Serum FGF19 predicts outcomes of Kasai portoenterostomy in biliary atresia. Hepatology 2023; 77:1263-1273. [PMID: 36692476 PMCID: PMC10026978 DOI: 10.1097/hep.0000000000000048] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Outcomes after Kasai portoenterostomy (KPE) for biliary atresia remain highly variable for unclear reasons. As reliable early biomarkers predicting KPE outcomes are lacking, we studied the prognostic value of FGF19. APPROACH AND RESULTS Serum and liver specimens, obtained from biliary atresia patients (N=87) at KPE or age-matched cholestatic controls (N=26) were included. Serum concentration of FGF19 and bile acids, liver mRNA expression of FGF19 , and key regulators of bile acid synthesis were related to KPE outcomes and liver histopathology. Immunohistochemistry and in situ hybridization were used for the localization of liver FGF19 expression. Serum levels (223 vs. 61 pg/mL, p <0.001) and liver mRNA expression of FGF19 were significantly increased in biliary atresia. Patients with unsuccessful KPE (419 vs. 145 pg/mL, p =0.047), and those subsequently underwent liver transplantation (410 vs. 99 pg/mL, p =0.007) had significantly increased serum, but not liver, FGF19, which localized mainly in hepatocytes. In Cox hazard modeling serum FGF19 <109 pg/mL predicted native liver survival (HR: 4.31, p <0.001) also among patients operated <60 days of age (HR: 8.77, p =0.004) or after successful KPE (HR: 6.76, p =0.01). Serum FGF19 correlated positively with increased serum primary bile acids ( R =0.41, p =0.004) and ductular reaction ( R =0.39, p =0.004). CONCLUSIONS Increased serum FGF19 at KPE predicted inferior long-term native liver survival in biliary atresia and was associated with unsuccessful KPE, elevated serum primary bile acids, and ductular reaction.
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Affiliation(s)
- Iiris Nyholm
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Hukkinen
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Joseph R. Davidson
- Department of Pediatric Surgery, GOS-UCL Institute of Child Health, London, UK
- Department of Pediatric Surgery, King’s College Hospital, London, UK
| | | | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Heikkilä
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Satu Hänninen
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Noora Andersson
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Katja Eloranta
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Carpén
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Mark Davenport
- Department of Pediatric Surgery, King’s College Hospital, London, UK
| | - Mikko P. Pakarinen
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
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10
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Harpavat S, Hawthorne K, Setchell KDR, Rivas MN, Henn L, Beil CA, Karpen SJ, Ng VL, Alonso EM, Bezerra JA, Guthery SL, Horslen S, Loomes KM, McKiernan P, Magee JC, Merion RM, Molleston JP, Rosenthal P, Thompson RJ, Wang KS, Sokol RJ, Shneider BL. Serum bile acids as a prognostic biomarker in biliary atresia following Kasai portoenterostomy. Hepatology 2023; 77:862-873. [PMID: 36131538 PMCID: PMC9936974 DOI: 10.1002/hep.32800] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/22/2022] [Accepted: 09/04/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS In biliary atresia, serum bilirubin is commonly used to predict outcomes after Kasai portoenterostomy (KP). Infants with persistently high levels invariably need liver transplant, but those achieving normalized levels have a less certain disease course. We hypothesized that serum bile acid levels could help predict outcomes in the latter group. APPROACH AND RESULTS Participants with biliary atresia from the Childhood Liver Disease Research Network were included if they had normalized bilirubin levels 6 months after KP and stored serum samples from the 6-month post-KP clinic visit ( n = 137). Bile acids were measured from the stored serum samples and used to divide participants into ≤40 μmol/L ( n = 43) or >40 μmol/L ( n = 94) groups. At 2 years of age, the ≤40 μmol/L compared with >40 μmol/L group had significantly lower total bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase, bile acids, and spleen size, as well as significantly higher albumin and platelet counts. Furthermore, during 734 person-years of follow-up, those in the ≤40 μmol/L group were significantly less likely to develop splenomegaly, ascites, gastrointestinal bleeding, or clinically evident portal hypertension. The ≤40 μmol/L group had a 10-year cumulative incidence of liver transplant/death of 8.5% (95% CI: 1.1%-26.1%), compared with 42.9% (95% CI: 28.6%-56.4%) for the >40 μmol/L group ( p = 0.001). CONCLUSIONS Serum bile acid levels may be a useful prognostic biomarker for infants achieving normalized bilirubin levels after KP.
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Affiliation(s)
- Sanjiv Harpavat
- Division of Gastroenterology, Department of Pediatrics , Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital , Houston , Texas , USA
| | - Kieran Hawthorne
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Kenneth D R Setchell
- Division of Pathology and Laboratory Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Monica Narvaez Rivas
- Division of Pathology and Laboratory Medicine , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Lisa Henn
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Charlotte A Beil
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Saul J Karpen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Emory University School of Medicine , Atlanta , Georgia , USA
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children and University of Toronto , Toronto , Ontario , Canada
| | - Estella M Alonso
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Ann and Robert H. Lurie Children's Hospital of Chicago , Chicago , Illinois , USA
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , Ohio , USA
| | - Stephen L Guthery
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Utah , Salt Lake City , Utah , USA
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, Department of Pediatrics , University of Washington Medical Center and Seattle Children's , Seattle , Washington , USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - Kathy M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia , Philadelphia , Pennsylvania , USA
| | - Patrick McKiernan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh , Pittsburgh , Pennsylvania , USA
| | - John C Magee
- Department of Surgery, Section of Transplant Surgery , University of Michigan Medical School , Ann Arbor , Michigan , USA
| | - Robert M Merion
- Arbor Research Collaborative for Health , Ann Arbor , Michigan , USA
| | - Jean P Molleston
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , Indiana University School of Medicine and Riley Hospital for Children , Indianapolis , Indiana , USA
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics , University of California San Francisco , San Francisco , California , USA
| | | | - Kasper S Wang
- Division of Pediatric Surgery, Department of Surgery , Children's Hospital of Los Angeles, University of Southern California , Los Angeles , California , USA
| | - Ronald J Sokol
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition , University of Colorado School of Medicine and Children's Hospital Colorado , Aurora , Colorado , USA
| | - Benjamin L Shneider
- Division of Gastroenterology, Department of Pediatrics , Hepatology and Nutrition, Baylor College of Medicine and Texas Children's Hospital , Houston , Texas , USA
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11
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Fusco J, Williams R, Malek M, Avansino JR, Hirose S, Perkins JA, Farmer D, Gow KW. Centers of Excellence: If We Build It, Will They Come? J Pediatr Surg 2023; 58:1048-1052. [PMID: 36925401 DOI: 10.1016/j.jpedsurg.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 02/19/2023]
Abstract
Pediatric surgeons have been pursuing high quality, affordable care or value-based care for over 50 years. One approach to streamlining the clinical care for a complex problem was the development of a center of excellence (COE). The concept of COE focuses on a shared vision of providing high quality care through a multidisciplinary approach. The goal is to improve diagnostic accuracy as well as therapeutic outcomes using focused expertise within a group. COEs are often resource intensive before becoming fiscally viable and therefore require initial support from hospital leadership. This review discusses the key steps to consider before building a COE, strategies to help build one, and how to keep one successful as defined by quality, accessibility, equity, training, and maintaining teams within the group.
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Affiliation(s)
- Joseph Fusco
- Monroe Carrel Jr Children's Hospital at Vanderbilt, Nashville, TN, 37232, USA
| | | | - Marcus Malek
- University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jeffery R Avansino
- Seattle Children's Hospital and the University of Washington, Seattle, WA, 98105, USA
| | | | - Jonathan A Perkins
- Seattle Children's Hospital and the University of Washington, Seattle, WA, 98105, USA
| | | | - Kenneth W Gow
- Seattle Children's Hospital and the University of Washington, Seattle, WA, 98105, USA.
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12
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Patkowski D. Thoracoscopic approach for oesophageal atresia: A real game changer? J Pediatr Surg 2023; 58:204-208. [PMID: 36402593 DOI: 10.1016/j.jpedsurg.2022.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
Almost 23 years have passed since the first thoracoscopic procedure was done. However, according to the recent study in USA, only 16% of newborns with oesophageal atresia and distal tracheooesophageal fistula are managed by thoracoscopic approach with a very high 53% conversion rate. The aim of presentation based on experience of one paediatric surgery centre is to prove that thoracoscopic approach for this malformation is a powerful tool with a potential to change the current results. It requires considerable experience that comes only from the high number of operated cases. The technique is one amongst the many others means which taken together may really help to improve the results. Thus, the question of centralisation for special rare congenital malformations comes back to mind. Is it rational to operate on only 2 or 3 cases a year in a single centre, or is it the time for centralisation and close co-operation, as has been done with biliary atresia treatment in the UK? LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Dariusz Patkowski
- Pediatric Surgery and Urology Department, Wroclaw Medical University, Borowska 213, Wroclaw 50-556, Poland.
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13
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Matcovici M, Stoica I, Smith K, Davenport M. What Makes A "Successful" Kasai Portoenterostomy "Unsuccessful"? J Pediatr Gastroenterol Nutr 2023; 76:66-71. [PMID: 36574004 DOI: 10.1097/mpg.0000000000003638] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Clearance of jaundice (CoJ) is the first key objective of Kasai portoenterostomy (KPE) for biliary atresia (BA) and its achievement is by far the best index of long-term prognosis. We sought to identify the reasons for failure [subsequent liver transplant (LT)] in this cohort. METHODS Review of single-center prospective BA database. Successful KPE was defined by achieving a postoperative bilirubin of ≤20 µmol/L. Pre-KPE and post-KPE variables were identified together with a multivariate logistic regression model to identify those observable at 3 months post-KPE. Data are quoted as median (range). A P value of ≤0.05 was significant. RESULTS One hundred thirty-five infants underwent KPE between January 2012 and December 2018, of which 90 (67%) achieved CoJ. From these 20 (22%) (Cohort A) underwent LT with the remainder continuing with native liver (Cohort B) (median follow-up of 4.15 years). There was no difference in age at KPE ( P = 0.41), APRi (aspartate aminotransferase-to-platelet ratio) ( P = 0.07), associated anomalies ( P = 0.7), and cytomegalovirus status ( P = 0.7) between the 2 groups. Postoperatively, both cholangitis [any episode, 18/20 (90%) vs 15/70 (21%); P < 0.0001] and portal hypertension (PHT) [gastrointestinal (GI) bleed, 10/20 (50%) vs 2/70 (2.8%); P < 0.0001] were significantly more common in cohort A. Univariate analysis showed that the most significant predictive values at 3 months for LT by 2 years were high APRi, bilirubin, international normalized ratio, and ultrasound (US)-detected ascites with multivariate logistic modeling confirming these variables with predictive values of r2 = 0.79, AUROC = 0.98. CONCLUSIONS Failure is not preordained at KPE but due to recurrent cholangitis and/or symptoms of PHT.
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Affiliation(s)
- Melania Matcovici
- From the Department of Paediatric Surgery, Kings College Hospital, London, United Kingdom
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14
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Le M, Reinshagen K, Tomuschat C. Systematic review: The quality of life of patients with biliary atresia. J Pediatr Surg 2022; 57:934-946. [PMID: 35428492 DOI: 10.1016/j.jpedsurg.2022.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The quality of life of patients with Biliary Atresia (BA) have not been systematically examined. The goal of this meta-analysis is to determine patients' postoperative health-related Quality of life (HrQoL) with native or transplanted livers. METHODS From 2000 to August 2021, a literature-based search for relevant cohorts was conducted using Pubmed/Medline, the Cochrane Library, and Embase. Original research on BA, Hepatoportoenterostomy (HPE), portoenterostomy, Kasai, Liver transplantation and HrQoL was included. Using RevMan, a forest plot analysis of HrQoL after surgical treatment after BA was calculated (version 5.4). Using MetaXL, a pooled prevalence for cholangitis, secondary liver transplantation, or related malformations was computed (version 5.3). RESULTS Nine studies compared individuals with BA to an age-matched healthy control group. 4/9 (n = 352) of these studies found poorer scores for BA patients, while 5/9 (n = 81) found equivalent health status. Factors associated with HrQoL: older age at the time of the survey was linked to greater HrQoL; whereas females, higher total bilirubin and the amount of immunosuppressive medicines were associated with lower HrQoL in BA patients. CONCLUSION The current study emphasises the critical need to improve the many parameters influencing HrQoL in BA patients, as well as the methods utilized to assess those factors. This includes immunosuppression, withdrawal from polydrug regimes and recognizing the differences in disease burden between males and females. TYPE OF STUDY Systematic review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Melanie Le
- Department of Pediatric Surgery, Kinder-UKE Campus Ost 45, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, Kinder-UKE Campus Ost 45, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Christian Tomuschat
- Department of Pediatric Surgery, Kinder-UKE Campus Ost 45, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany.
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15
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Lemoine CP, Melin-Aldana H, Brandt KA, Superina R. Identification of Early Clinical and Histological Factors Predictive of Kasai Portoenterostomy Failure. J Clin Med 2022; 11:jcm11216523. [PMID: 36362751 PMCID: PMC9654517 DOI: 10.3390/jcm11216523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
Abstract
Background: It is impossible to predict which patients with biliary atresia (BA) will fail after Kasai portoenterostomy (KPE). We evaluated the predictive nature of pre-KPE clinical and histological factors on transplant-free survival (TFS) and jaundice clearance. Methods: A retrospective review of patients who received a KPE at our institution (1997−2018) was performed. Primary outcomes were two-year TFS, five-year TFS, and jaundice clearance 3 months after KPE. p < 0.05 was considered significant. Results: Fifty-four patients were included in this study. The two-year TFS was 35.1%, five-year TFS was 24.5%, and 37% patients reached a direct bilirubin (DB) ≤ 2.0 mg/dL 3 months post KPE. The median age at biopsy was younger in the five-year TFS (39.0 (24.5−55.5) vs. 56.0 days (51.0−67.0), p = 0.011). Patients with DB ≤ 1.0 mg/dL 3 months after KPE were statistically younger at biopsy (DB ≤ 1.0 44.0 (26.0−56.0) vs. DB > 1.0 56.0 days (51.0−69.0), p = 0.016). Ductal plate malformation was less frequent in the five-year TFS (16/17, 94.1%, vs. 1/17, 5.9%, p = 0.037). Portal fibrosis (19/23, 82.6%, vs. 4/23, 17.4%, p = 0.028) and acute cholangitis (6/7, 85.7%, vs. 1/7, 14.3%, p = 0.047) occurred less frequently in two-year TFS. Conclusion: Older age at biopsy, acute cholangitis, portal fibrosis, and ductal plate malformation were associated with lower native liver survival. Evaluation in a larger study population is needed to validate these results.
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Affiliation(s)
- Caroline P. Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Hector Melin-Aldana
- Department of Pathology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Katherine A. Brandt
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Riccardo Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Correspondence: ; Tel.: +312-227-4040; Fax: +312-227-9387
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16
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Weng Z, Zhou W, Wu Q, Ma H, Fang Y, Dang T, Ling W, Liu M, Zhou L. Gamma-Glutamyl Transferase Combined With Conventional Ultrasound Features in Diagnosing Biliary Atresia: A Two-Center Retrospective Analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:2805-2817. [PMID: 35229893 DOI: 10.1002/jum.15968] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 02/12/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To develop and validate a biliary atresia (BA) diagnostic score based on serum gamma-glutamyl transferase (GGT) levels and conventional ultrasound features for discriminating BA in patients with jaundice from two centers. METHODS A total of 958 patients from one hospital were classified as the derivation cohort, and 725 patients from another hospital were classified as the validation cohort. The optimal GGT cutoff value for diagnosing BA was calculated in the derivation cohort and subsequently verified in the validation cohort. Gallbladder abnormalities and the triangular cord (TC) sign were evaluated in all patients. A BA diagnostic score was developed for diagnosing BA using the GGT levels, gallbladder abnormalities and the TC sign based on the data from the derivation cohort followed by external validation. RESULTS Based on the optimal cutoff value 350.0 U/L, GGT yielded a sensitivity of 59.3% and specificity of 85.4% in diagnosing BA. The area under the receiver operating characteristic curve (AUC 0.724) was inferior to that of the gallbladder (AUC 0.911, P < .001) and comparable to that of the TC sign (AUC 0.771, P = .128). The combination of GGT and ultrasound diagnosis could help to reduce the misdiagnosis of 9 infants with BA. The BA diagnostic score yielded a sensitivity of 93.3% and specificity of 95.0% with the highest AUC in this study (0.941). CONCLUSIONS GGT can add diagnostic value to ultrasound examination when diagnosing BA. The BA diagnostic score based on GGT, gallbladder abnormalities and the TC sign shows satisfactory discrimination abilities in BA.
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Affiliation(s)
- Zongjie Weng
- Department of Medical Ultrasonics, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Wenying Zhou
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qiumei Wu
- Department of Medical Ultrasonics, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Hong Ma
- Department of Pathology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Yifan Fang
- Department of Pediatric Surgery, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Tingting Dang
- Department of Medical Ultrasonics, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Wen Ling
- Department of Medical Ultrasonics, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Min Liu
- Department of Medical Ultrasonics, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou City, China
| | - Luyao Zhou
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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17
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Betalli P, Cheli M, Colusso MM, Casotti V, Alberti D, Ferrari A, Starita G, Lucianetti A, Pinelli D, Colledan M, D'Antiga L. Association between Kasai portoenterostomy at low caseload centres and transplant complications in children with biliary atresia. J Pediatr Surg 2022; 57:223-228. [PMID: 35063251 DOI: 10.1016/j.jpedsurg.2021.12.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/09/2021] [Accepted: 12/29/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Kasai portoenterostomy (KPE) is the preferred treatment for biliary atresia (BA) patients. It has been shown that the center caseload of KPE impacts on native liver survival. We aimed to define the impact of KPE caseload on complications at the time of liver transplantation (LT). METHODS Retrospective data collection of LT for BA performed in our tertiary center between 2010 and 2018. The patients were grouped according to the caseload of the center that performed KPE: Group A (≥5 KPE/year) and Group B (<5 KPE/year). We analyzed total transplant time (TTT), hepatectomy time, amount of plasma and red blood cell (RBC) transfusions, occurrence of bowel perforations at LT. RESULTS Among 115 patients, Group A (n 44) and Group B (n 71) were comparable for age, sex, PELD score, TTT. The groups differed for: median hepatectomy time (57 min, IQR = 50-67; vs 65, IQR 55-89, p = 0.045); RBC transfusions (95 ml, IQR 0-250; vs 200 ml, IQR 70-500, p = 0.017); bowel perforations (0/44 vs 15/71, p = 0.001). One-year graft loss in Group A vs Group B was 1/44 vs 7/71 (p = 0.239), whereas deaths were 0/44 vs 5/71 respectively (p = 0.183); 5/15 patients who had a perforation eventually lost the graft. CONCLUSIONS This study found an association between KPE performed in low caseload center and the incidence of complications at LT. These patients tend to have a worse outcome. The centralization of KPE to referral center represents an advantage at the time of LT. MINI ABSTRACT We studied the impact of Kasai portoenterostomy (KPE) caseload on complications at the time of liver transplantation (LT), in 115 patients. We found an association between KPE performed in low caseload center and increased bowel perforations and blood transfusions. We suggest to centralize to experienced center all children requiring KPE.
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Affiliation(s)
- Pietro Betalli
- Department of Paediatric Surgery, "Papa Giovanni XXIII" ASST, Piazza OMS1, Bergamo 24127, Italy.
| | - Maurizio Cheli
- Department of Paediatric Surgery, "Papa Giovanni XXIII" ASST, Piazza OMS1, Bergamo 24127, Italy
| | - Mara Marcella Colusso
- Department of Paediatric Surgery, "Papa Giovanni XXIII" ASST, Piazza OMS1, Bergamo 24127, Italy
| | - Valeria Casotti
- Department of Paediatric Hepatology, Gastroenterology and Transplantation, "Papa Giovanni XXIII" ASST, Bergamo, Italy
| | - Daniele Alberti
- Department of Paediatric Surgery, "Spedali Civili" Children's Hospital, Brescia, Italy
| | - Alberto Ferrari
- From Research Foundation, "Papa Giovanni XXIII" ASST, Bergamo, Italy
| | - Giusy Starita
- Department of Anaesthesia, "Papa Giovanni XXIII" ASST, Bergamo, Italy
| | | | - Domenico Pinelli
- Department of Surgery III, "Papa Giovanni XXIII" ASST, Bergamo, Italy
| | - Michele Colledan
- Department of Surgery III, "Papa Giovanni XXIII" ASST, Bergamo, Italy
| | - Lorenzo D'Antiga
- Department of Paediatric Hepatology, Gastroenterology and Transplantation, "Papa Giovanni XXIII" ASST, Bergamo, Italy
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Alaifan MA, Simbawa SH, Fayoumi TA, Bokhari HF, Al-Ghamdi B. Outcomes of Biliary Atresia in a Single Center in Jeddah, Saudi Arabia. Cureus 2022; 14:e27871. [PMID: 36120286 PMCID: PMC9468508 DOI: 10.7759/cureus.27871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Biliary atresia (BA) is a rare but severe cause of obliterative cholangiopathy in neonates. Its incidence differs worldwide varying from 5/100,000 to 32/100,000 live births. The highest incidence is seen in Asia and the Pacific region. Diagnosing this disease is difficult in its early stages; thus, screening is necessary to avoid serious complications that can be minimized with early intervention during the first few months of life. Currently, although there are no medical treatments for BA, once the diagnosis is confirmed, the Kasai procedure may be a treatment option. The earlier the Kasai surgery is performed, the higher the success rate. Liver transplantation may be needed if the operation fails. This study aimed to determine the incidence of BA and the factors influencing the outcomes of the Kasai procedure at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Methodology This retrospective cohort study was conducted in the Pediatric Department at King Abdulaziz University Hospital, Jeddah from January 2019 to July 2019 and included consecutive patients with BA from 2010 to 2018. Results In total, 14 patients (57.1% female) were included in the study. The median age at the time of presentation was 90 (19-720) days, and the median age at the time of implementing the Kasai procedure was 90 (60-150) days. Eight patients underwent the Kasai procedure, and only one patient had a liver transplant. Conclusions Antenatal screening for BA tended to ensure early diagnosis and better outcomes. Delay in diagnosis and intervention is associated with increased morbidity and mortality.
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Madadi-Sanjani O, Fortmann D, Rolle U, Rodeck B, Sturm E, Pfister ED, Kuebler JF, Baumann U, Schmittenbecher P, Petersen C. Centralization of Biliary Atresia: Has Germany Learned Its Lessons? Eur J Pediatr Surg 2022; 32:233-239. [PMID: 33663007 DOI: 10.1055/s-0041-1723994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The majority of pediatric surgeons and hepatologists recommend the centralization of biliary atresia (BA) treatment within experienced liver units. We aimed to investigate whether voluntary self-restriction and acceptance of the need for this change in practice changed the BA referral policy in Germany during the last decade. MATERIALS AND METHODS In cooperation with pediatric surgeons, gastroenterologists or hepatologists, and pediatric liver transplant units, the 2-year follow-up data of infants with BA born in Germany between 2010 and 2014 were collected using www.bard-online.com or pseudonymized data transfer. Results were compared with our previous analysis of the outcome data of infants with BA born between 2001 and 2005 in Germany. RESULT Overall, 173 infants with BA were identified, of whom 160 underwent Kasai portoenterostomy (KPE; 92.5%) and 13 (7.5%) underwent primary liver transplantation at 21 German centers. At 2-year follow-up, overall survival was 87.7% (vs. 81.9% in 2001-2005 [p = 0.19]), survival with native liver post-KPE was 29.2% (vs. 22.8% in 2001-2005 [p = 0.24]), and jaundice-free survival with native liver post-KPE was 24.0% (vs. 20.1% in 2001-2005 [p = 0.5]). Compared with the 2001-2005 analysis, all criteria showed improvement but the differences are statistically not significant. CONCLUSION Our observation shows that KPE management requires improvement in Germany. Centralization of BA patients to German reference liver units is not yet mandatory. However, European and national efforts with regard to the centralization of rare diseases support our common endeavor in this direction.
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Affiliation(s)
| | - David Fortmann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, Goethe University Frankfurt /M., Germany
| | - Burkhard Rodeck
- Department of Pediatric Gastroenterology, Christliches Kinderhospital Osnabrueck, Osnabrueck, Germany
| | - Ekkehard Sturm
- Department of Paediatric Gastroenterology and Hepatology, University Hospital for Children and Adolescents, University of Tuebingen, Baden-Württemberg, Germany
| | - Eva-Doreen Pfister
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Liver Unit, Birmingham Women's and Children's Hospital, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham
| | - Peter Schmittenbecher
- Department of Pediatric Surgery, Municipal Hospital, Karlsruhe, Baden-Wuerttemberg, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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20
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Shpoliansky M, Tobar A, Mozer-Glassberg Y, Rosenfeld Bar-Lev M, Shamir R, Shafir M, Gurevich M, Waisbourd-Zinman O. Portal plate bile duct diameter in biliary atresia is associated with long-term outcome. Pediatr Surg Int 2022; 38:825-831. [PMID: 35322291 DOI: 10.1007/s00383-022-05113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Kasai portoenterostomy (KPE) is the only treatment currently available for biliary atresia (BA). Age at KPE and surgical experience are prognostic factors for a successful KPE. Here, we aimed to assess whether the size of bile ductules at the porta hepatis during KPE correlates with KPE success and transplant-free survival (TFS). METHODS A retrospective analysis of patients diagnosed with BA during 2000-2019. Porta hepatis biopsies were reviewed for diameters of five representative ducts, and a mean ductal diameter (MDD) was calculated. Laboratory values including pre- and postoperative bilirubin levels were analyzed. RESULTS The cohort included 77 patients; for 33, ductal plate biopsy was available. KPE was successful in six of eight patients with MDD ≥ 50 µm, and in five of 25 with MDD < 50 µm, p = 0.008, OR = 12.0 (95% CI 1.83-78.3). Ten-year survival with native liver was higher in patients with MDD ≥ 50 µm than in patients with MDD < 50 µm, p < 0.001, HR 0.038 (95% CI 0.007-0.207). Direct bilirubin < 1 mg/dl 3 months post-KPE was associated with improved 2-year post-KPE TFS (27.7% vs. 13.9%, p < 0.0001). CONCLUSIONS MDD ≥ 50 µm correlates with KPE success and a higher rate of TFS. Direct bilirubin < 1 mg/dl 3 months post-operation may serve as a marker of successful biliary excretion, and a predictor of 2-year TFS.
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Affiliation(s)
- Michael Shpoliansky
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ana Tobar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pathology, Rabin Medical Center, Petach Tikva, Israel
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Rosenfeld Bar-Lev
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Shafir
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Michael Gurevich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Transplant Surgery, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Orith Waisbourd-Zinman
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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21
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Primary Liver Transplantation vs. Transplant after Kasai Portoenterostomy for Infants with Biliary Atresia. J Clin Med 2022; 11:jcm11113012. [PMID: 35683401 PMCID: PMC9181323 DOI: 10.3390/jcm11113012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Primary liver transplants (pLT) in patients with biliary atresia (BA) are infrequent, since most babies with BA undergo a prior Kasai portoenterostomy (KPE). This study compared transplant outcomes in children with BA with or without a prior KPE. We hypothesized that pLT have less morbidity and better outcomes compared to those done after a failed KPE. Methods: A retrospective review of patients with BA transplanted at our institution was performed. Patients were included if they received a pLT or if they were transplanted less than 2 years from KPE. Outcomes were compared between those groups. Comparisons were also made based on era (early: 1997−2008 vs. modern: 2009−2020). p < 0.05 was considered significant. Results: Patients who received a pLT were older at diagnosis (141.5 ± 46.0 vs. KPE 67.1 ± 25.5 days, p < 0.001). The time between diagnosis and listing for transplant was shorter in the pLT group (44.5 ± 44.7 vs. KPE 140.8 ± 102.8 days, p < 0.001). In the modern era, the calculated PELD score for the pLT was significantly higher (23 ± 8 vs. KPE 16 ± 8, p = 0.022). Two waitlist deaths occurred in the KPE group (none in pLT, p = 0.14). Both the duration of transplant surgery and transfusion requirements were similar in both groups. There was a significant improvement in graft survival in transplants after KPE between eras (early era 84.3% vs. modern era 97.8%, p = 0.025). The 1-year patient and graft survival after pLT was 100%. Conclusions: Patient and graft survival after pLT are comparable to transplants after a failed KPE but pLT avoids a prior intervention. There was no significant difference in pre- or peri-transplant morbidity between groups other than wait list mortality. A multicenter collaboration with more patients may help demonstrate the potential benefits of pLT in patients predicted to have early failure of KPE.
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22
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Xu X, Dou R, Zhao S, Zhao J, Gou Q, Wang L, Zhan J. Outcomes of biliary atresia splenic malformation (BASM) syndrome following Kasai operation: a systematic review and meta-analysis. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000346. [DOI: 10.1136/wjps-2021-000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 03/06/2022] [Indexed: 11/04/2022] Open
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23
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Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement. J Clin Med 2022; 11:jcm11082142. [PMID: 35456234 PMCID: PMC9032543 DOI: 10.3390/jcm11082142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/24/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.
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24
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O'Connor E, Jaffray B. Surgeon-Level Variation in Outcome following Esophageal Atresia Repair Is Not Explained by Volume. Eur J Pediatr Surg 2022; 32:160-169. [PMID: 33368086 DOI: 10.1055/s-0040-1721419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION To assess whether there is a difference in operative outcome for esophageal atresia (EA) depending on a surgeon's seniority as defined by years in consultant practice or number of cases performed. In addition a Clavien-Dindo score was used to sequentially analyze the outcome of each surgeon's EA procedure. MATERIALS AND METHODS All repairs performed over 22 years in an English regional center were analyzed. Outcomes were: death, anastomotic leak, need for dilatation, need for more than three dilatations, need for fundoplication, and a Clavien-Dindo adverse outcome of ≥3b. Possible explanatory variables were: number of prior repairs by the surgeon, surgeon's years of consultant experience. We also examined the effect of variables intrinsic to the infant as possible confounding variables and as independent predictors of outcome. RESULTS A total of 190 repairs were performed or supervised by 12 consultants. There was no significant association between consultant experience and any objective outcome. However, sequential analysis suggests there is variation between surgeons in the incidence of Clavien-Dindo events of ≥3b. Performance showed deterioration in one case. Mortality was explicable by cardiac and renal anomalies. CONCLUSION There are surgeon-level variations in outcomes for the procedure of EA repair, but they are not explained by volume. Surgeon performance can deteriorate. Our study would not support the concept that patient outcomes could be improved by concentrating the provision of this surgery to fewer hospitals or surgeons.
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Affiliation(s)
- Elizabeth O'Connor
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
| | - Bruce Jaffray
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
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25
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Hulscher JBF, Kuebler JF, Bruggink JM, Davenport M, Scholz S, Petersen C, Madadi-Sanjani O, Schukfeh N. Controversies in Choledochal Malformation in Children: An International Survey among Pediatric Hepatobiliary Surgeons and Gastroenterologists. J Clin Med 2022; 11:jcm11041148. [PMID: 35207421 PMCID: PMC8879848 DOI: 10.3390/jcm11041148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 12/10/2022] Open
Abstract
BACKGROUND While congenital choledochal malformation (CCM) is relatively well known within the pediatric surgical and pediatric gastroenterological communities, many controversies and questions remain. METHODS In this paper, we will discuss the results of an international Delphi survey among members of the European Reference Network RARE-LIVER and of the faculty of the Biliary Atresia and Related Diseases (BARD) network to identify the most common practices as well as controversies regarding diagnosis, treatment and follow-up of this still enigmatic disease. RESULTS Twenty-two individual respondents completed the survey. While there seems to be agreement on the definitions of CCM, preoperative workup, surgical approach and follow-up still vary considerably. The mainstay of treatment remains the removal of the entire extrahepatic biliary tract, clearance of debris both proximally and distally, followed by reconstruction with (according to 86% of respondents) a Roux-en-Y hepaticojejunostomy. Nonetheless, both laparoscopic and robotic-assisted resections are gaining ground with the suggestion that this might be facilitated by concentration of care and resources in specialized centers. However, long-term outcomes are still lacking. CONCLUSIONS As even post-surgical CCM has to be considered as having premalignant potential, follow-up should be well-organized and continued into adulthood. This seems to be lacking in many centers. International cooperation for both benchmarking and research is paramount to improving care for this rare disease.
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Affiliation(s)
- Jan B. F. Hulscher
- Division of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, 9800RB Groningen, The Netherlands; (J.B.F.H.); (J.M.B.)
- European Reference Network RARE-LIVER, 20246 Hamburg, Germany; (J.F.K.); (C.P.); (O.M.-S.)
| | - Joachim F. Kuebler
- European Reference Network RARE-LIVER, 20246 Hamburg, Germany; (J.F.K.); (C.P.); (O.M.-S.)
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Janneke M. Bruggink
- Division of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, 9800RB Groningen, The Netherlands; (J.B.F.H.); (J.M.B.)
- European Reference Network RARE-LIVER, 20246 Hamburg, Germany; (J.F.K.); (C.P.); (O.M.-S.)
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS, UK;
| | - Stefan Scholz
- Division of Pediatric General and Thoracic Surgery, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224, USA;
| | - Claus Petersen
- European Reference Network RARE-LIVER, 20246 Hamburg, Germany; (J.F.K.); (C.P.); (O.M.-S.)
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Omid Madadi-Sanjani
- European Reference Network RARE-LIVER, 20246 Hamburg, Germany; (J.F.K.); (C.P.); (O.M.-S.)
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Nagoud Schukfeh
- European Reference Network RARE-LIVER, 20246 Hamburg, Germany; (J.F.K.); (C.P.); (O.M.-S.)
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany
- Correspondence:
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26
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Wijnen MH, Hulscher JB. Centralization of pediatric surgical care in the Netherlands: Lessons learned. J Pediatr Surg 2022; 57:178-181. [PMID: 34836641 DOI: 10.1016/j.jpedsurg.2021.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 10/20/2022]
Abstract
Centralization of care is a difficult process, as there are several stakeholders that are involved and should be heard. What can be the best option for a small group of patients may be detrimental to a larger group of patients that cannot be adequately treated close to home. The weighing of these factors is different in every environment. One universal rule however is: if you don't do it yourselves, others will do it for you. In the Netherlands, pediatric oncology, including surgery, is centralized in one center (Utrecht) with the help of several shared care centers scattered throughout the country for things that can be managed close to home.
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Affiliation(s)
- Marc Hwa Wijnen
- Department of Surgery, Princess Maxima Center, Heidelberglaan 25, Utrecht 3584 CS, the Netherland.
| | - Jan Bf Hulscher
- President of the Netherlands Society of Pediatric Surgeons, UMC Groningen, Groningen, the Netherland
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27
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Wu LN, Zhu ZJ, Sun LY. Genetic Factors and Their Role in the Pathogenesis of Biliary Atresia. Front Pediatr 2022; 10:912154. [PMID: 35844731 PMCID: PMC9277099 DOI: 10.3389/fped.2022.912154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/08/2022] [Indexed: 12/12/2022] Open
Abstract
Biliary Atresia, a common basis for neonatal cholestasis and primary indication for Liver Transplantation, accounts for 60% of pediatric Liver Transplantations. While the pathogenesis of Biliary Atresia remains obscure, abnormalities within bile ducts and the liver, inflammation, fibrosis and cilia defects are thought to comprise the pathological basis for this condition. The findings of genetic variants in Biliary Atresia, such as Copy Number Variations and Single Nucleotide Polymorphism, are considered as essential factors in the development of this condition. In this review, we summarize and analyze these Biliary Atresia variants from a perspective of their pathological characteristics. In conclusion, such analyses may offer novel insights into the pathogenesis of Biliary Atresia and provide a foundation for future studies directed toward a better understanding and treatment of Biliary Atresia.
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Affiliation(s)
- Li-Na Wu
- Department of Critical Liver Diseases, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Li-Ying Sun
- Department of Critical Liver Diseases, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
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28
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Al-Hussaini A, Abanemai M, Alhebbi H, Saadah O, Bader R, Al Sarkhy A, Alhatlani M, Halabi H, Aladsani A, AlEdreesi M, Wali S, Alguofi T, Al-Drees K, Arain Z, Al Saleem B, Asery A, Holdar S, Alrashidi S, Alsayed F, Aldhalan S, NasserAllah A, Alghamdi R, Alhaffaf F, AlAwfi A, AlSweed A, Alshamrani A, AlShaikh M, Saeed A, Assiri H, Bashir MS. The Epidemiology and Outcome of Biliary Atresia: Saudi Arabian National Study (2000-2018). Front Pediatr 2022; 10:921948. [PMID: 35923790 PMCID: PMC9339784 DOI: 10.3389/fped.2022.921948] [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: 04/16/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The epidemiology and outcomes of biliary atresia (BA) have been well-documented in national cohorts from two main ethnicities, namely, the Asian Orientals and Caucasians, with incidence ranging from 1 in 5,000 to 1 in 9,000 live births in East Asia and 1 in 15,000 to 19,000 live births in Europe and North America. OBJECTIVE We report the first nationwide BA study outside North America, Europe, and East Asia to describe the epidemiology and outcomes of BA in Saudi Arabia. METHODS A national database of BA cases diagnosed between 2000 and 2018 was analyzed. We assessed clearance of jaundice (bilirubin <20 μmol/L) in all cases that underwent Kasai portoenterostomy (KPE). We then estimated survival using the Kaplan-Meier method with endpoints of liver transplantation (LT), death, or survival with native liver (SNL). RESULTS BA was diagnosed in 204 infants (106 females; 10% pre-term). The incidence of BA was 1 in 44,365, or 2.254 in 100,000 live births (range, 0.5-4 in 100,000). Polysplenia was diagnosed in 22 cases (11%). The median age at referral was 65 days. A total of 146 children (71.5%) underwent KPE at a median age of 70 days. Clearance of jaundice was achieved in 66 of the 146 (45%) infants. The 10-year SNL after KPE was 25.5%, and the overall 10-year estimated survival was 72.5%. The Kaplan-Meier survival curves for patients undergoing KPE at the age of <60, 61-90, and >90 days showed a SNL rate at 51.6, 33, and 12.5%, respectively, at 5 years (P < 0.001). The 2-, 5-, and 10-year post-LT survival rates were 92.5, 90.6, and 90%, respectively. Undergoing an initial KPE did not impact negatively on the overall LT survival rate when compared to BA cases that underwent primary LT (P = 0.88). CONCLUSION The incidence rate of BA in Saudi Arabia is lower than the incidence reported elsewhere. Late referral of BA cases remains a problem in Saudi Arabia; as a result, the SNL rate was lower than reported by other national registries. Hence, national policies devoted to timely referral and earlier age at KPE are needed.
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Affiliation(s)
- Abdulrahman Al-Hussaini
- Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khaled Celiac Disease Research Chair, Department of Pediatrics, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Abanemai
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Homoud Alhebbi
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Omar Saadah
- Division of Pediatric Gastroenterology, Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Razan Bader
- Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia.,King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed Al Sarkhy
- Gastroenterology Division, Department of Pediatrics, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Maher Alhatlani
- Al Imam Abdulrahman Bin Faisal Hospital, Ministry of National Guard Health Affairs, Dammam, Saudi Arabia
| | - Hana Halabi
- Maternity and Children's Hospital, Makkah, Saudi Arabia
| | - Ahmed Aladsani
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed AlEdreesi
- Specialty Pediatrics Division, Women and Children's Health Institute, Pediatric Gastroenterology, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Sami Wali
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Talal Alguofi
- Organs Transplant Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Al-Drees
- Department of Pediatrics, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Zahid Arain
- Multi-Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia.,King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Badr Al Saleem
- Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Asery
- Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sinan Holdar
- Division of Pediatric Gastroenterology, Department of Pediatrics, Royal Commission Hospital, Jubail, Saudi Arabia
| | - Sami Alrashidi
- Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad Alsayed
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sulaiman Aldhalan
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Rawabi Alghamdi
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Faisal Alhaffaf
- Division of Pediatric Gastroenterology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahmed AlAwfi
- Division of Pediatric Gastroenterology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman AlSweed
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Manal AlShaikh
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Anjum Saeed
- Gastroenterology Division, Department of Pediatrics, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Heba Assiri
- Gastroenterology Division, Department of Pediatrics, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Muhammed Salman Bashir
- Department of Biostatistics, Research Services Administration, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
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Zhang Y, Wang Q, Pu S, Wang J, Xiang B, Liu J, Jin S. A Novel Model for Predicting the Clearance of Jaundice in Patients With Biliary Atresia After Kasai Procedure. Front Pediatr 2022; 10:837247. [PMID: 35174110 PMCID: PMC8841871 DOI: 10.3389/fped.2022.837247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/06/2022] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The failed clearance of jaundice (CJ) in patients with biliary atresia (BA) after the Kasai procedure (KP) often leads to a shorter native liver survival (NLS) time and earlier liver transplantation. We aimed to investigate risk factors of failed CJ and establish a novel nomogram model to predict the status of CJ. METHODS We retrospectively reviewed institutional medical records from January 2015 to April 2020 and enrolled BA patients post-KP, randomly divided into training and testing cohorts at a ratio of 7:3, and further subdivided into cleared and uncleared jaundice groups. Univariate and multiple logistic regression analyses were used to select risk factors to establish the nomogram in the training cohort. The performance of the nomogram was evaluated by calculating the areas under the receiver operating curve (AUC) in both cohorts. RESULTS This study included 175 BA patients post-KP. After univariate and multiple logistic regression analyses, Cytomegalovirus IgM +ve associated BA (OR = 3.38; 95% CI 1.01-11.32; P = 0.04), ln γ-glutamyl transpeptidase (GGT) (OR = 0.41; 95% CI 0.22-0.80; P = 0.009), thickness of the fibrous portal plate (OR = 0.45; 95% CI 0.27-0.76; P = 0.003), liver stiffness measurement (LSM) (OR = 1.19; 95% CI 1.06-1.34; P = 0.002), and multiple episodes of cholangitis (OR = 1.65; 95% CI 1.13-2.41; P = 0.01) were identified as independent risk factors of unsuccessful CJ to construct the nomogram. The receiver operating characteristic curve (ROC) analysis suggested good nomogram performance in both the training (AUC = 0.96) and testing cohorts (AUC = 0.91). CONCLUSION Our nomogram model including several risk factors effectively predicts CJ in patients post-KP, which could aid in clinical decision-making.
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Affiliation(s)
- Yimao Zhang
- Department of Pediatric Surgery, West China of Hospital, Sichuan University, Chengdu, China
| | - Qi Wang
- Department of Pediatric Surgery, West China of Hospital, Sichuan University, Chengdu, China
| | - Siyu Pu
- Department of Pediatric Surgery, West China of Hospital, Sichuan University, Chengdu, China
| | - Junxiang Wang
- Department of Neonatal Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Bo Xiang
- Department of Pediatric Surgery, West China of Hospital, Sichuan University, Chengdu, China
| | - Juxian Liu
- Department of Ultrasound, West China of Hospital, Sichuan University, Chengdu, China
| | - Shuguang Jin
- Department of Pediatric Surgery, West China of Hospital, Sichuan University, Chengdu, China
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Sun S, Zheng S, Shen C, Dong R, Dong K, Jiang J, Yang Y, Chen G. Low gamma-glutamyl transpeptidase levels at presentation are associated with severity of liver illness and poor outcome in biliary atresia. Front Pediatr 2022; 10:956732. [PMID: 36210948 PMCID: PMC9537731 DOI: 10.3389/fped.2022.956732] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the clinical features and prognosis of biliary atresia (BA) with normal or minimally elevated gamma-glutamyl transpeptidase (GGT). METHODS The clinical data of patients with BA in our hospital between 2012 and 2017 were retrospectively studied. The patients were divided into a low-GGT group (GGT ≤ 300 IU/L) and a high-GGT group (GGT > 300 IU/L) according to the preoperative GGT level. The perioperative clinical parameters, the postoperative jaundice clearance within 6 months, and the 2-year native liver survival were compared among the groups. RESULTS A total of 1,998 children were included in this study, namely, 496 in the low-GGT group and 1,502 in the high-GGT group. The ages and weights at the surgery in the low-GGT group were significantly lower than those in the high-GGT group (64.71 ± 21.35 vs. 68.64 ± 22.42 days, P = 0.001; 4.67 ± 1.03 vs. 4.89 ± 0.98 kg, P < 0.001). The levels of serum ALP, ALT, and AST in the low-GGT group were significantly higher than those in the high-GGT group before and 2 weeks after the surgery (ALP: 647.52 ± 244.10 vs. 594.14 ± 228.33 U/L, P < 0.001; ALT: 119.62 ± 97.14 vs. 96.01 ± 66.28 U/L, P < 0.001; AST: 218.00 ± 173.82 vs. 160.71 ± 96.32 U/L; P < 0.001). The INR of the low-GGT group was higher than that of the high-GGT group (1.05 ± 0.34 vs. 0.98 ± 0.20, P < 0.001), while FIB was lower than the high-GGT group (2.54 ± 0.67 vs. 2.73 ± 1.44 g/L; P = 0.006). The decreasing amplitude of TB and DB within 2 weeks after surgery in the low-GGT group was smaller than those in the high-GGT group (TB: 51.62 ± 71.22 vs. 61.67 ± 53.99 μmol/L, P = 0.003; DB: 33.22 ± 35.57 vs. 40.20 ± 35.93 μmol/L, P < 0.001). The jaundice clearance rate in the low-GGT group was significantly lower than that in the high-GGT group at 1, 3, and 6 months after surgery (17.70 vs. 26.05%; 35.17 vs. 48.58%; 38.62 vs. 54.64%, P < 0.001). In addition, the 2-year native liver survival rate in the low-GGT group was significantly lower than that of the high-GGT group (52.5 vs. 66.3%, P < 0.001 HR 1.80, 95% CI 1.38-2.33). CONCLUSION Compared to patients with high GGT, patients with normal or minimally elevated pre-operative GGT in BA were found to have poorer pre-operative liver function parameters, and post-operatively had lower jaundice clearance rates and worse 2-year native liver survival. This suggests a lower GGT at presentation in biliary atresia could be a sign of more severe liver injury.
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Affiliation(s)
- Song Sun
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Shan Zheng
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Chun Shen
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Rui Dong
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Kuiran Dong
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Jingying Jiang
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Yifan Yang
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
| | - Gong Chen
- Surgical Department, Children's Hospital of Fudan University, Shanghai, China
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Weng Z, Ye F, Zhou L, Chen F, Ling W, Fang Y, Liu M, Wu Q, Qiu X, Lyu G. A nomogram model based on preoperative grey-scale US features and routine serum biomarkers to predict the outcome of infants with biliary atresia after Kasai portoenterostomy. Front Pediatr 2022; 10:972855. [PMID: 36340714 PMCID: PMC9631934 DOI: 10.3389/fped.2022.972855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To establish a nomogram to predict the outcome of biliary atresia (BA) infants 3-months post- Kasai portoenterostomy (KPE). METHODS BA Infants who underwent KPE from two hospitals were included in the training (n = 161) and validation cohorts (n = 64). A logistic regression equation (Equation A) for predicting the serum total bilirubin (TBIL) level 3-month post-KPE was established in the training cohort. Then, a nomogram was developed based on Equation A in the training cohort and validated in the validation cohort. Moreover, a new equation (Equation B) was generated based on the nomogram and the size of the enlarged hilar lymph nodes (LNs) in the validation cohort. The predictive performance of the nomogram was evaluated by the receiver operating characteristic (ROC) curve and by calculating the area under the ROC curve (AUC), sensitivity, specificity, and positive (PPV) and negative (NPV) prediction values. RESULTS A nomogram based on gallbladder morphology and serum levels of TBIL and total protein (TP) was established with AUC (95%CI) of 0.673 (0.595, 0.745) and 0.647 (0.518, 0.763), sensitivity (95%CI) of 71.4% (62.1%,79.6%) and 81.8% (59.7%,94.8%), specificity (95%CI) of 63.3% (48.3%,76.6%) and 47.6% (32.0%,63.6%), PPV (95%CI) of 81.6% (72.5%,88.9%) and 45.0% (29.3%,61.5%), and NPV (95%CI) 49.2% (36.4%,62.1%) and 83.3% (62.6%,95.3%), respectively, in the training and validation cohorts. Furthermore, in the validation cohort, the AUC (95%CI) of Equation B was 0.798 (95%CI: 0.679, 0.888), which was significantly higher than that of the nomogram (P = 0.042). CONCLUSION A nomogram based on the pre-KPE gallbladder morphology, TBIL, and TP to predict the outcome of BA 3-months post-KPE is established. Moreover, the addition of the size of the enlarged hilar LNs into the nomogram further improves its predictive value.
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Affiliation(s)
- Zongjie Weng
- Department of Medical Ultrasonics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China.,Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Fengying Ye
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Luyao Zhou
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Fa Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China
| | - Wen Ling
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yifan Fang
- Department of Pediatric Surgery, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Min Liu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiumei Wu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiuqing Qiu
- Department of Gynecology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics / Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Guorong Lyu
- Department of Medical Ultrasonics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China.,Department of Clinical Medicine, Quanzhou Medical College, Quanzhou, China
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Jiang J, Wan R, He S, Wu Y, Shen Z, Chen G, Sun S, Yan W, Zheng S. Epidemiological characteristics and risk factors of biliary atresia: a case-control study. BMJ Open 2021; 11:e049354. [PMID: 34903536 PMCID: PMC8671910 DOI: 10.1136/bmjopen-2021-049354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Biliary atresia (BA) is regarded as a serious neonatal hepatobiliary disease, and its aetiology and pathogenesis remain unclear. Epidemiological studies are limited, especially for the data from China. This study aims to explore risk factors of BA and provide new evidence to improve understanding of its aetiology. DESIGN This is a case-control study from 1 January 2015 to 31 December 2016. SETTING Cases were consecutively recruited from an urban tertiary care academic children's hospital in Shanghai, China, while the controls were recruited from a community hospital in Shanghai through a random sampling system. PARTICIPANTS 721 patients suspected for BA who planned to take the diagnostic surgery were enrolled preoperatively. 613 were diagnosed with BA and recruited into the case group. Meanwhile, 688 infants without any observed major congenital anomalies or jaundice were enrolled. Finally, 594 valid questionnaires from the case group and 681 from the control group were obtained. PRIMARY AND SECONDARY OUTCOME MEASURES Standardised questionnaires were used for data collection. Multivariate logistic regression analysis was performed to evaluate associations reported as ORs and precision, by adjusting covariates. RESULTS Anxiety or stress during pregnancy was strongly associated with increased risk of BA (OR 8.36 (95% CI: 4.08 to 17.15); p<0.001), respectively. Lower birth weight, fathers from ethnic minorities of China, older age of fathers, lower income of parents, and exposure to infection, diseases and medication during pregnancy all made differences. CONCLUSIONS Social factors including the educational and economic background and its related anxiety and stress during pregnancy might be noticed in the occurrence of BA. Maternal infections during pregnancy in the prevalence of BA were demonstrated. TRIAL REGISTRATION NUMBER ChiCTR-IPR-15005885.
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Affiliation(s)
- Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Rou Wan
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Shiwei He
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Wu
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Song Sun
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Weili Yan
- Department of Clinical Epidemiology, Clinical Trial Unit (CTU), Children's Hospital of Fudan University, Shanghai, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
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Lendahl U, Lui VCH, Chung PHY, Tam PKH. Biliary Atresia - emerging diagnostic and therapy opportunities. EBioMedicine 2021; 74:103689. [PMID: 34781099 PMCID: PMC8604670 DOI: 10.1016/j.ebiom.2021.103689] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/15/2021] [Accepted: 10/28/2021] [Indexed: 02/06/2023] Open
Abstract
Biliary Atresia is a devastating pediatric cholangiopathy affecting the bile ducts of the liver. In this review, we describe recent progress in the understanding of liver development with a focus on cholangiocyte differentiation and how use of technical platforms, including rodent, zebrafish and organoid models, advances our understanding of Biliary Atresia. This is followed by a description of potential pathomechanisms, such as autoimmune responses, inflammation, disturbed apical-basal cell polarity, primary cilia dysfunction as well as beta-amyloid accumulation. Finally, we describe current and emerging diagnostic opportunities and recent translation breakthroughs for Biliary Atresia in the area of emerging therapy development, including immunomodulation and organoid-based systems for liver and bile duct repair.
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Affiliation(s)
- Urban Lendahl
- Department of Cell and Molecular Biology, Karolinska Institutet, Stockholm, Sweden; Dr. Li Dak-Sum Research Centre, the University of Hong Kong, Hong Kong.
| | - Vincent C H Lui
- Dr. Li Dak-Sum Research Centre, the University of Hong Kong, Hong Kong; Department of Surgery, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Patrick H Y Chung
- Department of Surgery, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong; Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Paul K H Tam
- Dr. Li Dak-Sum Research Centre, the University of Hong Kong, Hong Kong; Department of Surgery, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong; Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China.
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Laparoscopic Kasai portoenterostomy for cystic biliary atresia: midterm follow-up results of 35 patients. Surg Today 2021; 51:1924-1931. [PMID: 33977383 DOI: 10.1007/s00595-021-02297-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/10/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the clinical characteristics of cystic biliary atresia (CBA) and evaluate the midterm follow-up outcomes after laparoscopic treatment. METHODS We analyzed and compared data retrospectively on CBA patients (group A) and nonsyndromic type III biliary atresia (BA) patients (group B), who underwent laparoscopic Kasai portoenterostomy (LKPE) during the same period. RESULTS There were no significant differences in operative time, conversion rate, or the incidence of any postoperative complications between groups A and B (P > 0.05). The mean age at surgery (P < 0.01), rates of clearance of jaundice (CJ), cholangitis (P < 0.05), and 5-year survival with a native liver (SNL) were significantly lower in group A than in group B. Among the 35 patients with CBA, the CJ and 5-year SNL rates were significantly better in those with type I (n = 27) than in those with type IIId (n = 8) (P < 0.05). CONCLUSIONS LKPE is a feasible and safe procedure for CBA. The 5-year SNL after LKPE was better in patients with CBA than in those with nonsyndromic type III BA. The 5-year SNL after LKPE for type I CBA was better than that for type IIId CBA.
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Role of percutaneous liver biopsy in infantile cholestasis: cohort from Arabs. BMC Gastroenterol 2021; 21:118. [PMID: 33711954 PMCID: PMC7953702 DOI: 10.1186/s12876-021-01699-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/18/2021] [Indexed: 11/11/2022] Open
Abstract
Background Investigators from different parts of the world are calling for a re-evaluation of the role of liver biopsy (LB) in the evaluation of infantile cholestasis (IC), especially in the light of emerging non-invasive diagnostic technologies. Therefore, this retrospective single-center study was conducted to determine the impact of LB on the diagnosis and management of IC in a cohort from Arabs. Methods From 2007 until 2019, 533 cases of IC were referred for evaluation. All infants who underwent LB were included in the study. We categorized the yield of LB into: (1) defined specific diagnosis; (2) excluded an important diagnosis. A single pathologist reviewed and made the histology report. Results 122 LB specimens met the inclusion criteria. The main indication for LB was a high suspicion of biliary atresia (BA) [high gamma-glutamyl transferase (GGT) cholestasis and pale stool] in 46 cases (37.8%). Liver biopsy had sensitivity of 86.4%, specificity (66.7%), PPV (70.4%), NPV (84.2%) in diagnosing BA. LB had a direct impact on clinical management in 52 cases (42.6%): (1) The true diagnosis was suggested by LB in 36 cases; (2) LB excluded BA and avoided intraoperative cholangiogram in 16 cases with high suspicion of BA. Among the 76 cases with low suspicion of BA, LB suggested the true diagnosis or helped to initiate specific management in 8 cases only (10.5%). In contrast, molecular testing confirmed the diagnosis in 48 (63%). Conclusion LB continues to be an important tool in the workup of cases with a high suspicion of BA. The low yield of LB in cases with low suspicion of BA calls for a re-evaluation of its role in these cases in whom early incorporation of cholestasis sequencing gene panels can have a better diagnostic yield.
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Gad EH, Kamel Y, Salem TAH, Ali MAH, Sallam AN. Short- and long-term outcomes after Kasai operation for type III biliary atresia: Twenty years of experience in a single tertiary Egyptian center-A retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2021. [PMID: 33552489 DOI: 10.1016/j.amsu.2021.01.052.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Kasai portoenterostomy(KPE) is the treatment of choice for the fatal devastating infantile type III biliary atresia (BA). The study aimed to analyze short-and long-term outcomes after this procedure and their predictors in a tertiary center. METHODS We retrospectively analyzed 410 infants who underwent KPE for type III BA in the period from February 2000 to December 2019. The overall male/female ratio was 186/224. RESULTS The early (>6months) complications involved 187(45.6%) of our infants with a higher incidence of early cholangitis that affected 108(26.3%) of them. The jaundice clearance at the 6th post-operative month that reached 138(33.7%) of them had an independent correlation with mild portal tracts ductal and/or ductular proliferation, using postoperative steroids therapy, and absence of early postoperative cholangitis. The early infant mortality that affected 70(17.1%) of our patients was mostly from sepsis. On the other hand, late (<6months) patients complications and mortalities affected 256(62.4%) and 240(58.5%) of patients respectively; moreover, liver failure and sepsis were the most frequent causes of late mortalities in non-transplanted and transplanted cases respectively. Lastly, the long-term (20-year) native liver survival (NLS) that reached 91(22.2%) of patients had an independent correlation with age at operation ≤ 90 days, higher preoperative mean serum alb, portal tract fibrosis grades F0 and F1, absence of intraoperative bleeding, absence of post-operative cholangitis, the occurrence of jaundice clearance at the 6th postoperative month and absence of post-operative portal hypertension (PHN). CONCLUSIONS Sepsis had a direct effect on early and late patient mortalities after Kasai operation for type III BA; moreover, patient age at operation<90 days, higher fibrosis grades, the occurrence of postoperative cholangitis and PHN, and persistence of post-operative jaundice had negative insult on long-term postoperative outcome. So, it is crucial to modulate these factors for a better outcome.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
| | | | | | - Ahmed Nabil Sallam
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebeen Elkoum, Egypt
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Short- and long-term outcomes after Kasai operation for type III biliary atresia: Twenty years of experience in a single tertiary Egyptian center-A retrospective cohort study. Ann Med Surg (Lond) 2021; 62:302-314. [PMID: 33552489 PMCID: PMC7847812 DOI: 10.1016/j.amsu.2021.01.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 02/08/2023] Open
Abstract
Kasai portoenterostomy(KPE) is the treatment of choice for the fatal devastating infantile type III biliary atresia (BA). The study aimed to analyze short-and long-term outcomes after this procedure and their predictors in a tertiary center. METHODS We retrospectively analyzed 410 infants who underwent KPE for type III BA in the period from February 2000 to December 2019. The overall male/female ratio was 186/224. RESULTS The early (>6months) complications involved 187(45.6%) of our infants with a higher incidence of early cholangitis that affected 108(26.3%) of them. The jaundice clearance at the 6th post-operative month that reached 138(33.7%) of them had an independent correlation with mild portal tracts ductal and/or ductular proliferation, using postoperative steroids therapy, and absence of early postoperative cholangitis. The early infant mortality that affected 70(17.1%) of our patients was mostly from sepsis. On the other hand, late (<6months) patients complications and mortalities affected 256(62.4%) and 240(58.5%) of patients respectively; moreover, liver failure and sepsis were the most frequent causes of late mortalities in non-transplanted and transplanted cases respectively. Lastly, the long-term (20-year) native liver survival (NLS) that reached 91(22.2%) of patients had an independent correlation with age at operation ≤ 90 days, higher preoperative mean serum alb, portal tract fibrosis grades F0 and F1, absence of intraoperative bleeding, absence of post-operative cholangitis, the occurrence of jaundice clearance at the 6th postoperative month and absence of post-operative portal hypertension (PHN). CONCLUSIONS Sepsis had a direct effect on early and late patient mortalities after Kasai operation for type III BA; moreover, patient age at operation<90 days, higher fibrosis grades, the occurrence of postoperative cholangitis and PHN, and persistence of post-operative jaundice had negative insult on long-term postoperative outcome. So, it is crucial to modulate these factors for a better outcome.
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Pang X, Cao J, Chen S, Gao Z, Liu G, Chong Y, Chen Z, Gong J, Li X. Unsupervised Clustering Reveals Distinct Subtypes of Biliary Atresia Based on Immune Cell Types and Gene Expression. Front Immunol 2021; 12:720841. [PMID: 34646264 PMCID: PMC8502897 DOI: 10.3389/fimmu.2021.720841] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/25/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Biliary atresia (BA) is a severe cholangiopathy of early infancy that destroys cholangiocytes, obstructs ductular pathways and if left untreated, culminates to liver cirrhosis. Mechanisms underlying the etiological heterogeneity remain elusive and few studies have attempted phenotyping BA. We applied machine learning to identify distinct subtypes of BA which correlate with the underlying pathogenesis. METHODS The BA microarray dataset GSE46995 was downloaded from the Gene Expression Omnibus (GEO) database. Unsupervised hierarchical cluster analysis was performed to identify BA subtypes. Then, functional enrichment analysis was applied and hub genes identified to explore molecular mechanisms associated with each subtype. An independent dataset GSE15235 was used for validation process. RESULTS Based on unsupervised cluster analysis, BA patients can be classified into three distinct subtypes: Autoimmune, Viral and Embryonic subtypes. Functional analysis of Subtype 1 correlated with Fc Gamma Receptor (FCGR) activation and hub gene FCGR2A, suggesting an autoimmune response targeting bile ducts. Subtype 2 was associated with immune receptor activity, cytokine receptor, signaling by interleukins, viral protein interaction, suggesting BA is associated with viral infection. Subtype 3 was associated with signaling and regulation of expression of Robo receptors and hub gene ITGB2, corresponding to embryonic BA. Moreover, Reactome pathway analysis showed Neutrophil degranulation pathway enrichment in all subtypes, suggesting it may result from an early insult that leads to biliary stasis. CONCLUSIONS The classification of BA into different subtypes improves our current understanding of the underlying pathogenesis of BA and provides new insights for future studies.
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Affiliation(s)
- Xiuqing Pang
- Department of Infectious Diseases, Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jing Cao
- Department of Infectious Diseases, Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shuru Chen
- Department of Infectious Diseases, Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiliang Gao
- Department of Infectious Diseases, Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guangjian Liu
- Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yutian Chong
- Department of Infectious Diseases, Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhuanggui Chen
- Department of Pediatrics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zhuanggui Chen, ; Jiao Gong, ; Xinhua Li,
| | - Jiao Gong
- Department of Laboratory Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zhuanggui Chen, ; Jiao Gong, ; Xinhua Li,
| | - Xinhua Li
- Department of Infectious Diseases, Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zhuanggui Chen, ; Jiao Gong, ; Xinhua Li,
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The Right Child/Right Surgeon initiative: A position statement on pediatric surgical training, sub-specialization, and continuous certification from the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:2566-2574. [PMID: 32950245 PMCID: PMC7423589 DOI: 10.1016/j.jpedsurg.2020.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/12/2020] [Accepted: 08/01/2020] [Indexed: 12/11/2022]
Abstract
The past 50 years have witnessed profound changes in the specialty of pediatric surgery in North America. There has been a marked increase in the number of both pediatric surgical training programs and practicing pediatric general and thoracic surgeons. Despite this trend, the population of children in the United States and the birth rate have recently remained relatively flat. Some pediatric surgeons have become "super specialists", concentrating their practices in oncology or colorectal surgery. This has the potential to result in a dilution of experience for both pediatric surgical trainees and practicing pediatric surgeons, thus limiting their ability to acquire and maintain expertise, respectively. Coincident with this, there has been a relative paradigm shift in recognition that "quality of life" is based more on maintaining a creative balance in lifestyle and is not "all about work". There has been a parallel growth in the number of practicing pediatric general and thoracic surgeons in urban settings, but we have not appreciated as much growth in rural and underserved areas, where access to pediatric surgical care remains limited and fewer pediatric general and thoracic surgeons practice. This is a complex issue, as some underserved areas are economically depressed and geographically sparse, but others are just underserved with adult providers taking care of children in settings that are often under resourced for pediatric surgical care. This problem may extend beyond the boundaries of pediatric general and thoracic surgery to other specialties. As the premier association representing all pediatric surgeons in the United States, the American Pediatric Surgical Association (APSA) has concluded that the quality of pediatric surgical care will likely decline should the status quo be allowed to continue. Therefore, APSA has initiated a Right Child/Right Surgeon initiative to consider these issues and propose some potential solutions. What follows is a brief statement of intent.
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Evans HM, Siew SM. Neonatal liver disease. J Paediatr Child Health 2020; 56:1760-1768. [PMID: 33197975 DOI: 10.1111/jpc.15064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 12/01/2022]
Abstract
Neonatal liver disease encompasses many diagnoses, including structural and genetic aetiologies. Many have significant health implications requiring long-term specialist treatment including liver transplantation. Jaundice is a common presenting feature. The ability of health-care professionals to differentiate neonatal liver disease from benign diagnoses such as physiological jaundice is very important. Persistent (more than 2 weeks) of conjugated jaundice always warrants investigation. Severe unconjugated jaundice (requiring prolonged phototherapy) should also be promptly investigated. Recent advances in genomics have enabled previously elusive, precise diagnoses in some patients with neonatal liver disease. This review paper discusses the commoner causes, with a focus on early detection and need for referral to paediatric liver services.
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Affiliation(s)
- Helen M Evans
- Department of Paediatric Gastroenterology and Hepatology, Starship Child Health, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Susan M Siew
- Department of Gastroenterology and James Fairfax Institute of Paediatric Nutrition, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Ge L, Zhan J, Gao W, Zhao S, Xu X, Dou R. Relevant factors for early liver transplantation after Kasai portoenterostomy. BMC Pediatr 2020; 20:484. [PMID: 33081738 PMCID: PMC7574207 DOI: 10.1186/s12887-020-02355-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/20/2020] [Indexed: 12/15/2022] Open
Abstract
Background To explore the relevant factors for early liver transplantation (LT) after Kasai portoenterostomy (KP). Methods Retrospective analysis was performed for 200 children with biliary atresia, who underwent LT with hepatic failure after KP. According to the interval between KP and LT, they were divided into three groups: G1 (≤6-month), G2 (6-month~ 2-year) and G3 (> 2-year). Gender, age of Kasai portoenterostomy, jaundice-clearance, cholangitis after KP and liver function indexes before LT were compared among the three groups. Results The proportion of patients with age of KP (≤90-day) in G1 was lower than that in G3 (P = 0.003). Jaundice-clearance occurred in 6 (7.6%), 26(28.6%) and 26 (86.7%) patients after KP in G1, G2 and G3 respectively (P < 0.001). There were statistical differences in the incidence of early cholangitis, late cholangitis and repeated cholangitis among the three groups (P = 0.035, < 0.001 and 0.022). The native liver survival (NLS) rate of children at operation age > 90-day was lower than that of children at operation age ≤ 90-day (P = 0.002). The NLS rate of the children with jaundice-clearance after KP was significantly better than that of the children without jaundice-clearance (P < 0.001). The NLS rate of the children with early cholangitis after operation was lower than that in children without early cholangitis (P = 0.026). The NLS rate of patients of G2 and G3 with cholangitis after KP was lower than that in children without cholangitis (P = 0.017). Multiple logistic regression analysis showed uncleared jaundice after KP was a risk factor for the NLS time in patients. Conclusion The age of KP (> 90-day), jaundice-unclear and early cholangitis could reduce the NLS time after KP, which were related to early liver transplantation. Jaundice-unclear was a risk factor for early liver transplantation.
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Affiliation(s)
- Liang Ge
- Graduate School of Tianjin Medical University, Tianjin, 300070, China
| | - Jianghua Zhan
- Department of Pediatric Surgery, Tianjin Children's Hospital, LongYan Road 238, Beichen District, Tianjin, 300134, PR China.
| | - Wei Gao
- Department of Transplantation, Tianjin First Central Hospital, Tianjin, 300192, China
| | - Shengqiao Zhao
- Graduate School of Tianjin Medical University, Tianjin, 300070, China
| | - Xiaodan Xu
- Graduate School of Tianjin Medical University, Tianjin, 300070, China
| | - Ran Dou
- Graduate School of Tianjin Medical University, Tianjin, 300070, China
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Venkat V, Ng VL, Magee JC, Ye W, Hawthorne K, Harpavat S, Molleston JP, Murray KF, Wang KS, Soufi N, Bass LM, Alonso EM, Bezerra JA, Jensen MK, Kamath BM, Loomes KM, Mack CL, Rosenthal P, Shneider BL, Squires RH, Sokol RJ, Karpen SJ. Modeling Outcomes in Children With Biliary Atresia With Native Liver After 2 Years of Age. Hepatol Commun 2020; 4:1824-1834. [PMID: 33305153 PMCID: PMC7706301 DOI: 10.1002/hep4.1602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 12/15/2022] Open
Abstract
Approximately 50% of infants with biliary atresia (BA) undergoing Kasai portoenterostomy show survival with native liver (SNL) at age 2 years. Predictors of disease progression after age 2 years are unknown, despite estimates of 20%-30% undergoing liver transplant (LT) between age 2 and 18 years. We sought to address this knowledge gap by developing prognostic models in participants of the multicenter prospective National Institutes of Health-supported Childhood Liver Disease Research Network. We extracted 14 clinical and biochemical variables at age 2 years to develop two models for future outcomes: 1) LT or death (LTD) and 2) first sentinel event (SE), either new onset ascites, hepatopulmonary syndrome (HPS), or gastrointestinal (GI) bleed. A total of 240 participants, enrolled between 2004 and 2017, were followed until a median age of 5.1 years (range, 2.0-13.3 years). Of these participants, 38 underwent LT (n = 37) or death (n = 1); cumulative incidence, 23.7% (95% confidence interval [CI], 16.2%-32.0%). Twenty-seven experienced either new-onset ascites (n = 13), HPS (n = 1), or GI bleed (n = 14). One participant had ascites and GI bleed concurrently; cumulative incidence, 21.5% (95% CI, 14.2%-29.8%) by age 10 years. The Cox proportional hazard model predicted risk of LTD, using total bilirubin, albumin, platelet count, and history of either ascites or cholangitis (BA LTD model), with a C-index of 0.88 (range, 0.86-0.89). A cause-specific hazard competing risk model predicted SE using platelet count and gamma glutamyltransferase levels (BA SE model) with a C-index of 0.81 (range, 0.80-0.84). Internal model validity was assessed using Harrell's C-index with cross-validation. Conclusion: Stratification using these models identified risk of poor outcomes in patients with BA SNL after age 2 years. The models may identify those who would benefit from enhanced clinical surveillance and prioritization in clinical trials.
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Affiliation(s)
- Veena Venkat
- UPMC Children's Hospital of Pittsburgh Pittsburgh PA
| | - Vicky L Ng
- Hospital for Sick Children University of Toronto Toronto Canada
| | - John C Magee
- University of Michigan Hospitals and Health Centers Ann Arbor MI
| | - Wen Ye
- University of Michigan Hospitals and Health Centers Ann Arbor MI
| | | | - Sanjiv Harpavat
- Texas Children's Hospital Liver Center, Baylor College of Medicine Houston TX
| | | | | | | | | | - Lee M Bass
- Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | | | | | - M Kyle Jensen
- University of Utah School of Medicine Primary Children's Hospital Salt Lake City UT
| | - Binita M Kamath
- Hospital for Sick Children University of Toronto Toronto Canada
| | | | - Cara L Mack
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
| | | | - Benjamin L Shneider
- Texas Children's Hospital Liver Center, Baylor College of Medicine Houston TX
| | | | - Ronald J Sokol
- University of Colorado School of Medicine Children's Hospital Colorado Aurora CO
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Cholangitis in Patients With Biliary Atresia Receiving Hepatoportoenterostomy: A National Database Study. J Pediatr Gastroenterol Nutr 2020; 71:452-458. [PMID: 32639448 DOI: 10.1097/mpg.0000000000002836] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Biliary atresia (BA) is a progressive form of liver disease in the neonatal period usually requiring hepatoportoenterostomy (HPE). Cholangitis is a common sequelae of HPE but data about which patients are at risk for this complication are limited. OBJECTIVE The objective of the study was to determine risk factors associated with cholangitis in a large retrospective cohort after HPE. METHODS The Pediatric Health Information System (PHIS) was queried for BA (ICD-9 975.61) and HPE (ICD-9-CM 51.37) admissions from 2004 to 2013. We performed univariate analysis and linear regression with dependent variables of ≥ 2 or ≥ 5 episodes of cholangitis, and independent variables of age at time of HPE, race, ethnicity, gender, insurance, ursodeoxycholic acid (UDCA) use, steroid use, presence of esophageal varices (EV), and portal hypertension (PH). RESULTS We identified 1112 subjects with a median age at HPE of 63 days and median number of cholangitis episodes of 2 within 2 years. On multiple regression analysis, black race (odds ratio (OR) 1.51, P = 0.044) and presence of PH (OR 2.24, P < 0.001) were associated with increased risk of ≥ 2 episodes of cholangitis, whereas HPE at >90 days was associated with less risk (OR 0.46, P = 0.001). Among those with ≥5 episodes, Asian race (OR 2.66, P = 0.038), public insurance (OR 1.72, P = 0.043), EV (OR 1.81, P = 0.017), and PH (OR 2.88, P < 0.001) were associated with higher risk. CONCLUSIONS Complications, such as cholangitis remain a common problem for patients, after HPE, with median of 2 episodes within 2 years. Higher rates of cholangitis are associated with portal hypertension whereas lower rate is associated with age at HPE of >90 days. Asians, patients with public insurance, and those with portal hypertension are more likely to have recurrent cholangitis.
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Long-Term Effects of Kasai Portoenterostomy for Biliary Atresia Treatment in Russia. Diagnostics (Basel) 2020; 10:diagnostics10090686. [PMID: 32932921 PMCID: PMC7555057 DOI: 10.3390/diagnostics10090686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022] Open
Abstract
This prospective study enrolled 144 patients after surgical treatment of biliary atresia in early infancy. We analyzed the immediate effectiveness of the surgery and the age-related structure of complications in the up to 16-year follow-up. The immediate 2-year survival rate after the surgery constituted 49.5%. At the time of this writing, 17 of the patients had celebrated their 10th birthdays with good quality of life and no indications for transplantation of the liver. The obtained results underscore the critical importance of surgical correction of biliary atresia by Kasai surgery in the first 60 days of life and subsequent dynamic follow-up of patients for the purpose of the early detection and timely correction of possible complications.
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Abstract
Biliary atresia is characterised as an obliterative cholangiopathy of both extra-and intra-hepatic bile ducts. There is marked aetiological heterogeneity with a number of different variants, some syndromic and others perhaps virally-mediated. Current research aims to try and define possible mechanisms and pathogenesis though an actual breakthrough remains elusive. There has been little in the way of surgical advances beyond subtle variations in the Kasai portoenterostomy and laparoscopic equivalents have no declared advantage and have yet to prove equivalence in measures of outcome. The next target has been to maximise potential with better adjuvant therapy, though the evidence base for most currently available therapies such as steroids and ursodeoxycholic acid remains limited. Still high-dose steroid use is widespread, certainly in Europe and the Far East. Clearance of jaundice can be achieved in 50-60% of those subjected to portoenterostomy at <70 days and should be an achievable benchmark. Transplantation is a widely available "rescue" therapy though whether it should be an alternative as a primary procedure is arguable but becoming increasingly heard. The aim of clinical practice remains to get these infants for surgery as early as is possible though this can be difficult to accomplish in practice, and "low-cost" screening projects using stool colour charts have been limited outside of Taiwan and Japan. Centralisation of resources (medical and surgical) is associated with a diminution of time to portoenterostomy but application has been limited by entrenched health delivery models or geographical constraints.
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Affiliation(s)
- Federico Scottoni
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS, United Kingdom
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS, United Kingdom.
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Smith M, Zuckerman M, Kandanearatchi A, Thompson R, Davenport M. Using next-generation sequencing of microRNAs to identify host and/or pathogen nucleic acid signatures in samples from children with biliary atresia - a pilot study. Access Microbiol 2020; 2:acmi000127. [PMID: 32974591 PMCID: PMC7497833 DOI: 10.1099/acmi.0.000127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/24/2020] [Indexed: 12/11/2022] Open
Abstract
Biliary atresia (BA) is a progressive disease affecting infants resulting in inflammatory obliteration and fibrosis of the extra- and intra-hepatic biliary tree. BA may be grouped into type 1 isolated; type 2 syndromic, where other congenital malformations may be present; type 3 cystic BA, where there is cyst formation within an otherwise obliterated biliary tree; and cytomegalovirus-associated BA. The cause of BA is unclear, with immune dysregulation, inflammation and infection, particularly with cytomegalovirus (CMV), all implicated. In this study a total of 50/67 samples were tested for CMV DNA using quantitative real-time PCR. Ten liver tissue and 8 bile samples from 10 patients representing the range of BA types were also analysed by next-generation sequencing. CMV DNA was found in 8/50 (16 %) patients and a total of 265 differentially expressed microRNAs were identified. No statistically significant differences between the various types of BA were found. However, differences were identified in the expression patterns of 110 microRNAs in bile and liver tissue samples (P<0.05). A small number of bacterial and viral sequences were found, although their relevance to BA remains to be determined. No direct evidence of viral causes of BA were found, although clear evidence of microRNAs associated with hepatocyte and cholangiocyte differentiation together with fibrosis and inflammation were identified. These include miR-30 and the miR-23 cluster (liver and bile duct development) and miR-29, miR-483, miR-181, miR-199 and miR-200 (inflammation and fibrosis).
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Affiliation(s)
- Melvyn Smith
- Viapath Analytics, South London Specialist Virology Centre, Denmark Hill, London
| | - Mark Zuckerman
- Viapath Analytics, South London Specialist Virology Centre, Denmark Hill, London
| | | | - Richard Thompson
- Institute of Liver Studies and Paediatric Liver Services, Denmark Hill, London
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS
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Gou Q, Chen Y, Yu C, Jia J, Feng J, Gao W, Zhu Z, Tang W, Tou J, Bian H, Wang B, Li Y, Li L, Ren H, Wu Y, Zhan J. Biliary atresia in twins'population: a retrospective multicenter study in mainland China. Pediatr Surg Int 2020; 36:711-718. [PMID: 32367198 DOI: 10.1007/s00383-020-04662-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 11/29/2022]
Abstract
AIM We evaluated the demographic of biliary atresia (BA) children from twins family and aimed to investigated what it can add to the twins' literature and our understanding of the disease. METHODS This study contains 11 medical centers in mainland China and the medical record of twins with BA was retrospectively analyzed from January 2012 to December 2018. Follow-up was carried out by out-patient review and questionnaire. RESULTS The study included 19 twin pairs in whom there was discordance for BA. Sixteen (84.2%) affected twin underwent Kasai Procedure (KP); median age at KP was 78 (49-168) days. There were ten affected twins that became jaundice-free at 3 months post-KP, and eight occurred with different degrees of cholangitis post-KP. Six affected twins received Liver Transplantation (LT) successfully. The 2 year native liver survival rate and the 2 year overall survival rate of affected twins were 61.1 and 94.4%, respectively. There were three affected monozygotic (MZ) twins and one healthy co-twin with BA-associated congenital malformations, all of which were cardiac malformations. The number of virus infection of affected MZ twins was significantly more (p = 0.04) than affected dizygotic (DZ) twin. CONCLUSIONS Discordance for BA in 19 pairs of twins supported that BA may be related to genetic phenotype or penetrance. The difference in genetic background between MZ and DZ affects the susceptibility of the host to virus infection. High acceptance of KP (84.2%) in our study implied a high motivation for treatment for twins with BA. Delays of KP (78 days) in affected twin may be related to the postnatal gradual onset and the late diagnosis.
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Affiliation(s)
- Qingyun Gou
- Graduate College, Tianjin Medical University, Tianjin, 300070, China.,Department of General Surgery, Tianjin Children's Hospital, LongYan Road 238, Beichen District, Tianjin, 300134, China
| | - Yang Chen
- Department of Center for Reproductive Medicine, Center for Prenatal Diagnosis, First Hospital of Jilin University, Changchun, 130021, China
| | - Chen Yu
- Department of Neonatal Surgery, Anhui Province Children's Hospital, Hefei, 230000, China
| | - Jinfu Jia
- Graduate College, Tianjin Medical University, Tianjin, 300070, China.,Department of General Surgery, Tianjin Children's Hospital, LongYan Road 238, Beichen District, Tianjin, 300134, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wei Gao
- Department of General Surgery, Tianjin First Central Hospital, Tianjin, 300192, China
| | - Zhijun Zhu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Jinfa Tou
- Department of Neonatal Surgery, Children's Hospital, School of Medicine, Zhejiang University, Zhejiang, 310003, China
| | - Hongqiang Bian
- Department General of Surgery, Wuhan Children's Hospital, Wuhan, 430030, China
| | - Bin Wang
- Department of Surgery, Shenzhen Children's Hospital, Shenzhen, 518026, China
| | - Yingchao Li
- Department of Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Le Li
- Department of Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, 511440, China
| | - Hongxia Ren
- Department of Neonatal Surgery, Children's Hospital of Shanxi, Taiyuan, 030013, China
| | - Yurui Wu
- Department of Thoracic and Oncological Surgery, Qilu Children's Hospital of Shandong University, Jinan, 250022, China
| | - Jianghua Zhan
- Department of General Surgery, Tianjin Children's Hospital, LongYan Road 238, Beichen District, Tianjin, 300134, China.
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Yassin NA, El-Tagy G, Abdelhakeem ON, Asem N, El-Karaksy H. Predictors of Short-Term Outcome of Kasai Portoenterostomy for Biliary Atresia in Infants: a Single-Center Study. Pediatr Gastroenterol Hepatol Nutr 2020; 23:266-275. [PMID: 32483548 PMCID: PMC7231743 DOI: 10.5223/pghn.2020.23.3.266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/12/2019] [Accepted: 01/29/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The outcome predictors of Kasai portoenterostomy (KPE) for biliary atresia (BA) are controversial. This study aimed to identify possible short-term outcome predictors of KPE for BA in infants. METHODS This retrospective study included infants with BA who underwent KPE between January 2015 and December 2017 and were followed up for at least 6 months after surgery at the Pediatric Hepatology Unit, Cairo University Pediatric Hospital, Egypt. The short-term outcome was jaundice clearance within 6 months following surgery. All data were compared between the jaundice free group and those with persistent jaundice to identify the predictors of jaundice clearance. RESULTS The study included 75 infants. The mean age at the time of surgery was 82.43±22.77 days (range, 37-150 days), and 28 (37.3%) infants cleared their jaundice within 6 months postoperative. Age at surgery did not significantly affect the outcome (p=0.518). Infants with persistent jaundice had significantly higher pre-operative levels of aspartate aminotransferase (AST) than those who were jaundice free (p=0.041). Receiver operating characteristic curve analysis showed that preoperative AST ≤180 IU/L was predictive of a successful KPE, with sensitivity 74.5% and specificity 60.7%. Infants with bile plugs in liver biopsy had a 6-fold higher risk of persistent jaundice than those without bile plugs (95% confidence interval: 1.59-20.75, p=0.008). CONCLUSION Jaundice clearance after KPE for BA can be predicted using preoperative AST and presence of bile plugs in liver biopsy.
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Affiliation(s)
| | - Gamal El-Tagy
- Department of Pediatric Surgery, Cairo University, Cairo, Egypt
| | | | - Noha Asem
- Department of Community Medicine, Cairo University, Cairo, Egypt
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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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Normal Gamma Glutamyl Transferase Levels at Presentation Predict Poor Outcome in Biliary Atresia. J Pediatr Gastroenterol Nutr 2020; 70:350-355. [PMID: 31738295 DOI: 10.1097/mpg.0000000000002563] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Gamma-glutamyl transferase levels (GGT) are typically elevated in biliary atresia (BA), but normal GGT levels have been observed. This cohort of "normal GGT" BA has neither been described nor has the prognostic value of GGT level on outcomes in BA. We aimed to describe outcomes of a single-centre Australian cohort of infants with BA and assess the impact of GGT level at presentation on outcomes in BA. METHODS Infants diagnosed with BA between 1991 and 2017 were retrospectively analysed. Outcomes were defined as survival with native liver, liver transplantation (LT), and death. Patients were categorized into normal (<200I U/L) or high GGT groups based on a mean of 3 consecutive GGT values done before Kasai portoenterostomy (KPE). Baseline parameters, age at surgery, clearance of jaundice (COJ), and outcomes were compared between the 2 groups. RESULTS One hundred thirteen infants underwent KPE at median 61 (30-149) days. At a median follow-up of 14.2 (0.9-26.3) years, 35% (39/113) patients were surviving with native liver, 55% (62/113) underwent LT and 11% (12/113) died pretransplant. 12.3% (14/113) patients had normal GGT. Age at KPE and time to COJ were similar between normal and high GGT groups. Normal GGT group had shorter time from KPE to LT (11 vs 18 months, P = 0.02), underwent LT at a younger age (14 vs 20 months, P = 0.04), and had poorer transplant-free survival (P = 0.04) than high GGT group. CONCLUSIONS 12.3% of infants with BA had normal GGT levels at diagnosis. Low GGT levels at presentation in BA was associated with a poorer outcome.
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