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Davenport M, Superina R. Primary Liver Transplant in Biliary Atresia: The Case for and Against. J Pediatr Surg 2024; 59:1418-1426. [PMID: 38565475 DOI: 10.1016/j.jpedsurg.2024.03.005] [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: 10/02/2023] [Revised: 02/27/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
The role of liver transplantation as a primary procedure in biliary atresia has been argued over for at least 40 years, indeed since the coming of age of safe liver transplantation during the 1980s. Yet, it is not a common option in most series (usually ≤5%) and typically reserved for those with late presentations (arguably >100 days) with established cirrhosis. This review presents the pros and cons of primary liver transplant. The pros are based upon the observation that at best a Kasai portoenterostomy (KPE) is simply palliative in most, and at worse has no effect whatsoever on restoration of bile flow and is therefore pointless. Set against this are the cons: there is a dearth of prognostic tests (clinical, biochemical, or histological) at the time of presentation which may predict inevitable failure; the possibility of long-term native liver survival to adulthood in a proportion (albeit a minority); and the implied increased need for donor organs suitable for infants - a stressor for an already overstressed system. Improving results from KPE in terms of increasing the proportions clearing their jaundice and minimizing the effects of chronic liver fibrosis and cirrhosis would surely limit the siren calls for primary transplants but the key must be better discrimination at presentation with the use of biomarkers (circulatory or histological, individually or together) to enable better decision making.
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Affiliation(s)
- Mark Davenport
- Department of Pediatric Surgery, Kings College Hospital, London, SE5 9RS, UK.
| | - Riccardo Superina
- Department of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA.
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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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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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The Need for Early Kasai Portoenterostomy: A Western Pediatric Surgery Research Consortium Study. Pediatr Surg Int 2022; 38:193-199. [PMID: 34854975 PMCID: PMC8742784 DOI: 10.1007/s00383-021-05047-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.
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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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Chan KWE, Lee KH, Wong HYV, Tsui SYB, Mou JWC, Tam YH. Impact of Age of Patient and Experience of Surgeon on the Outcome after Kasai Portoenterostomy: Can We Delay the Surgery? Eur J Pediatr Surg 2021; 31:335-340. [PMID: 32629495 DOI: 10.1055/s-0040-1713934] [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: 10/23/2022]
Abstract
INTRODUCTION Age of patient and experience of biliary atresia (BA) center are well-known factors associated with early jaundice clearance (EJC) after Kasai portoenterostomy (KPE) in infants with BA. This study focused on the impact of age and surgeon factor on the short-term outcome after KPE within a single center. MATERIALS AND METHODS Fifty-four consecutive infants (18 boys and 36 girls) who underwent KPE from January 2010 to January 2020 were reviewed. KPE was performed in the earliest available operative session once the initial work-up was completed. In group A (n = 41), KPE was performed by surgeon A. In group B (n = 13), KPE was performed by specialists under the supervision of surgeon B (who is the mentor of surgeon A) when surgeon A was not available for operation. The demographics of patients, the EJC (total bilirubin <20 μmol/L within 6 months of KPE), and 2-year native liver survival (NLS) between the two groups were studied. RESULTS The median age at operation was 52 days (range 26-135 days). The overall EJC rate and 2-year NLS were 85.2 and 89.4%, respectively. Group A (p = 0.015) and male gender (p = 0.029) were statistically associated with EJC but not the age at operation (p = 0.101). Group A was also statistically associated with superior 2-year NLS (p = 0.047). CONCLUSION Balancing between the impact of age at operation and the experience of surgeon on the outcome after KPE, our result suggested that KPE may be deferred until a more experienced surgeon to operate.
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Affiliation(s)
- Kin Wai Edwin Chan
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Kim Hung Lee
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Hei Yi Vicky Wong
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | - Siu Yan Bess Tsui
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
| | | | - Yuk Him Tam
- Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong
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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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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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10
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Abstract
Several patient and treatment related factors significantly modify outcomes of biliary atresia. The extremely variable prognosis mandates intensive postoperative monitoring following portoenterostomy. Accurate prediction of outcome and progression of liver injury would enable individualized treatment and follow-up protocols, patient counseling and meaningful stratification of patients into clinical trials. While results on most biomarkers of cholestasis, hepatocyte function, fibrosis and inflammation studied so far are inconsistent or have not been validated in independent patient cohorts, postoperative serum bilirubin level 3 months after portoenterostomy remains the most accurate clinically feasible predictor of native liver survival. Although liver stiffness and a novel marker of cholangiocyte integrity, serum matrix metalloproteinase-7, correlate with liver fibrosis and may discriminate biliary atresia from other causes of neonatal cholestasis, further information on their ability to predict portoenterostomy outcomes is needed. Recent gene expression profiling has shown promise in overcoming the sampling error associated with histological quantification of liver fibrosis, and provides an important possibility to stratify patients for clinical trials according to the prognosis of native liver survival already preoperatively. As activity and extent of ductular reaction is linked with progression of liver fibrosis in cholangiopathies, further research is also warranted to evaluate predictive value of ductular reaction, matrix metalloproteinase-7 and the underlying gene expression signatures in relation to circulating bile acids in biliary atresia. Discovery of accurate predictive tools will ultimately increase our understanding of the unpredictable response to surgery and pathophysiology of progressive liver injury in biliary atresia.
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Direct Health Care Costs, Health Services Utilization, and Outcomes of Biliary Atresia: A Population-based Cohort Study. J Pediatr Gastroenterol Nutr 2020; 70:436-443. [PMID: 31834111 DOI: 10.1097/mpg.0000000000002582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Biliary atresia (BA) is the most common reason for liver transplant in childhood, and outcomes worsen with older age at hepatoportoenterostomy (HPE). We determined direct health care costs in children with BA, compared to controls in a population-based cohort of children in Ontario, Canada. METHODS We used health administrative data to identify all children diagnosed with BA between 2002 and 2016 (n = 121) and matched controls (n = 602). We determined annual direct healthcare costs, and rates of health services utilization, liver transplantation, death, portal hypertension, cirrhosis, esophageal varices, and major upper gastrointestinal bleeding requiring hospitalization. Multivariable regression models determined the association between age at HPE, risk of liver transplant, and direct costs. RESULTS Incidence of BA was 6.07 (4.99-7.15) per 100,000 live births. The annual median (interquartile range) direct health care costs were higher in BA cases ($4210; interquartile range $1091-$16,765) compared to controls ($283; $112-$634). Compared to age at HPE <45 days, there was no significant association between direct costs and HPE ≥90 days (rate ratio 1.24, 95% confidence interval [CI] 0.78-1.97) or 45 to 90 days (rate ratio 1.05, 95% CI 0.73-1.50). Age at HPE ≥90 days was significantly associated with risk of undergoing liver transplant compared to age <45 days (hazard ratio 5.27, 95% CI 2.45-11.34). Direct costs were higher in patients with BA who underwent liver transplantation compared to those who did not ($39,476±$84,367 vs $22,579 ± $67,913). CONCLUSIONS Direct ealth care costs were high in patients with BA, especially in those who underwent liver transplantation. Age at HPE was associated with risk of liver transplantation, but not direct health care costs, utilization, or other risk outcomes.
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12
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Abstract
OBJECTIVES This study analyses the prognosis of biliary atresia (BA) in France since 1986, when both Kasai operation (KOp) and liver transplantation (LT) became widely available. METHODS The charts of all patients diagnosed with BA born between 1986 and 2015 and living in France were reviewed. RESULTS A total of 1428 patients were included; 1340 (94%) underwent KOp. Total clearance of jaundice (total bilirubin ≤20 μmol/L) was documented in 516 patients (39%). Age at KOp (median 59 days, range 6-199) was stable over time. Survival with native liver after KOp was 41%, 35%, 26%, and 22% at 5, 10, 20, and 30 years, stable in the 4 cohorts. 25-year survival with native liver was 38%, 27%, 22%, and 19% in patients operated in the first, second, third month of life or later, respectively (P = 0.0001). Center caseloads had a significant impact on results in the 1986 to 1996 cohort only. 16%, 7%, 7%, and 8% of patients died without LT in the 4 cohorts (P = 0.0001). A total of 753 patients (55%) underwent LT. Patient survival after LT was 79% at 28 years. Five-year patient survival after LT was 76%, 91%, 88%, and 92% in cohorts 1 to 4, respectively (P < 0.0001). Actual BA patient survival (from diagnosis) was 81%. Five-year BA patient survival was 72%, 88%, 87%, and 87% in cohorts 1986 to 1996, 1997 to 2002, 2003 to 2009, and 2010 to 2015, respectively (P < 0.0001). CONCLUSIONS In France, 87% of patients with BA survive nowadays and 22% reach the age of 30 years without transplantation. Improvement of BA prognosis is mainly due to reduced mortality before LT and better outcomes after LT.
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Ihn K, Na Y, Ho IG, Lee D, Koh H, Han SJ. A periodic comparison of the survival and prognostic factors of biliary atresia after Kasai portoenterostomy: a single-center study in Korea. Pediatr Surg Int 2019; 35:285-292. [PMID: 30607544 DOI: 10.1007/s00383-018-04434-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE We explored the chronologic changes in prognostic factors and clinical outcomes of Kasai portoenterostomy (KPE) for biliary atresia (BA). METHODS Patients undergoing KPE between 1997 and 2016 were analyzed retrospectively. Ninety-two consecutive patients who underwent KPE from 1997 to 2006 (Era 1) were compared with 150 patients who underwent KPE from 2007 to 2016 (Era 2) for clinical outcomes and prognostic factors. RESULTS The jaundice clearance rate increased by 8.8% (66.7% vs. 75.5% for Eras 1 and 2, respectively, p = 0.180), and the 5-year native liver survival (NLS) rate improved slightly (62.5% vs. 64.0% for Eras 1 and 2, respectively, p = 0.617) in Era 2. The hazard ratio for age at KPE (≥ 90 days) with regard to 5-year NLS and the odds ratio for age at KPE (< 90 days) with regard to jaundice clearance were both lower in Era 2 than in Era 1 (1.95 vs. 2.25 and 2.67 vs. 5.21, respectively). CONCLUSION The clinical outcomes improved over a period in a single surgeon's practice. We demonstrated that the impact of age at the time of KPE on operative outcomes became less significant over time with the increase in the single surgeon's experience and improvement in medical treatment for BA.
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Affiliation(s)
- Kyong Ihn
- Department of Pediatric Surgery, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Younghyun Na
- Department of Pediatric Surgery, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - In Geol Ho
- Department of Pediatric Surgery, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Dongeun Lee
- Department of Pediatric Surgery, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea
| | - Hong Koh
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Joo Han
- Department of Pediatric Surgery, Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722, Seoul, Korea.
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Wang Y, Zhang Y, Wang H, Wang T, Xia S, Chen W, Li B. Learning Curve Analysis of Open Kasai Portoenterostomy for Biliary Atresia. J Surg Res 2019; 239:38-43. [PMID: 30798170 DOI: 10.1016/j.jss.2019.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/10/2018] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Open Kasai portoenterostomy (KPE) remains the mainstay of treatment for biliary atresia (BA) even in the era of minimally invasive surgery and is generally considered to be technically challenging. This study describes the learning curve (LC) of open KPE and its effect on outcomes. MATERIALS AND METHODS In our center, the caseload of BA was relatively low with average annual caseload below five in the past, and open KPE was started in the early 2000s. This study retrospectively enrolled the first 35 consecutive children undergoing open KPE for BA by the same surgeon in our center between June 2003 and April 2014. The LC was evaluated using the cumulative sum (CUSUM) method for operative time (OT). RESULTS The CUSUM LC of OT, which peaked at the 23rd case, was best modeled as a second-order polynomial with equation CUSUM (min) = -0.8851 × case number2 + 33.54 × case number -45.978 (R2 = 0.7287). The LC consisted of two distinct phases: phase 1 (the initial 23 cases), representing the initial learning phase and phase 2 (the remaining 12 cases), representing acquisition of technical competency. Preoperative parameters were comparable between the two phases (each P > 0.05). Of note, OT and estimated blood loss significantly decreased in phase 2 compared with phase 1 (P < 0.001; P < 0.001, respectively). Furthermore, the rates of early jaundice clearance and 2-y native liver survival significantly increased in phase 2 (P = 0.032; P = 0.034, respectively). CONCLUSIONS The two phases identified by CUSUM analysis of OT represents characteristic stages of LC for open KPE of the surgeon in our center. It is possible for surgeons to achieve competency of this demanding technique in centers with relatively low caseload of BA and late start of KPE.
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Affiliation(s)
- Yujiao Wang
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China.
| | - Yuanyuan Zhang
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Hui Wang
- Department of Public Health, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Ting Wang
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Shunlin Xia
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Weibing Chen
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Bing Li
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China.
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Prognosis of Biliary Atresia After 2-year Survival With Native Liver: A Nationwide Cohort Analysis. J Pediatr Gastroenterol Nutr 2018; 67:689-694. [PMID: 30095577 DOI: 10.1097/mpg.0000000000002130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The aim of the study is to determine the prognosis of patients with biliary atresia after 2 years of native liver survival (NLS) and to identify prognostic factors for continued NLS after 2 years of age. METHODS We retrospectively analyzed perioperative, laboratory, and outcome parameters of all biliary atresia patients in The Netherlands between January 1987 and June 2015 with NLS of at least 2 years. We compared parameters between patients who continued to have their native liver (NLS+) to those who did not, either by transplant or death (NLS-). RESULTS We included 100 patients. Upon a median follow-up of 16.4 years, NLS ended in 37% by liver transplantation (LTx) and in 6% by (pre-transplant) mortality. NLS rates at 5, 10, 15, 18 years of age were 89%, 72%, 60%, 54%, respectively. Corresponding overall survival rates were 98%, 90%, 87%, 87%, respectively. Six months post-Kasai, NLS+ patients had higher clearance of jaundice (COJ) rate, significantly lower total and direct serum bilirubin, aspartate-aminotransferase and alkaline phosphatase levels, compared with NLS- patients (each P < 0.05). Cox regression could only assess a significant effect of COJ on continued NLS. Main indications for LTx after the age of 2 were irreversible jaundice and portal hypertension. CONCLUSIONS Eighty-seven percent of patients with 2-year NLS reach adult age and more than 50% with their native liver. A pre-transplant mortality of 6%, however, exists among patients who reach the age of 2 years with their native livers. Early life parameters, other than COJ, did not have a significant effect on continued NLS after 2 years of age.
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Pakarinen MP, Johansen LS, Svensson JF, Bjørnland K, Gatzinsky V, Stenström P, Koivusalo A, Kvist N, Almström M, Emblem R, Björnsson S, Backman T, Almaas R, Jalanko H, Fischler B, Thorup J. Outcomes of biliary atresia in the Nordic countries - a multicenter study of 158 patients during 2005-2016. J Pediatr Surg 2018; 53:1509-1515. [PMID: 28947328 DOI: 10.1016/j.jpedsurg.2017.08.048] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND/PURPOSE Biliary atresia is the most common reason for newborn cholestasis and pediatric liver transplantation. Even after normalization of serum bilirubin after portoenterostomy, most patients require liver transplantation by adulthood due to expanding fibrosis. We addressed contemporary outcomes of biliary atresia in the Nordic countries. METHODS Data on center and patients characteristics, diagnostic practices, surgical treatment, adjuvant medical therapy after portoenterostomy, follow-up and outcomes were collected from all the Nordic centers involved with biliary atresia care during 2005-2016. RESULTS Of the 154 patients, 148 underwent portoenterostomy mostly by assigned surgical teams at median age of 64 (interquartile range 37-79) days, and 95 patients (64%) normalized their serum bilirubin concentration while living with native liver. Postoperative adjuvant medical therapy, including steroids, ursodeoxycholic acid and antibiotics was given to 137 (93%) patients. Clearance of jaundice associated with young age at surgery and favorable anatomic type of biliary atresia, whereas annual center caseload >3 patients and diagnostic protocol without routine liver biopsy predicted early performance of portoenterostomy. The cumulative 5-year native liver and overall survival estimate was 53% (95% CI 45-62) and 88% (95% CI 83-94), respectively. Portoenterostomy age <65days and annual center caseload >3 patients were predictive for long-term native liver survival, while normalization of serum bilirubin after portoenterostomy was the major predictor of both native liver and overall 5-year survival. CONCLUSIONS The outcomes of biliary atresia in the Nordic countries compared well with previous European studies. Further improvement should be pursued by active measures to reduce patient age at portoenterostomy. RETROSPECTIVE PROGNOSIS STUDY Level II.
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Affiliation(s)
- Mikko P Pakarinen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland.
| | | | - Jan F Svensson
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Sweden
| | | | | | | | - Antti Koivusalo
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
| | - Nina Kvist
- Department of Pediatric Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Markus Almström
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Sweden
| | | | | | | | - Runar Almaas
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - Hannu Jalanko
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
| | - Björn Fischler
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Sweden
| | - Jørgen Thorup
- Department of Pediatric Surgery, Rigshospitalet, Copenhagen, Denmark
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Kohaut J, Guérin F, Fouquet V, Gonzales E, de Lambert G, Martelli H, Jacquemin E, Branchereau S. First liver transplantation for biliary atresia in children: The hidden effects of non-centralization. Pediatr Transplant 2018; 22:e13232. [PMID: 29869366 DOI: 10.1111/petr.13232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 11/30/2022]
Abstract
The aim of our study was to determine the impact of initial orientation for medical and surgical care of children with BA on procedures and outcomes of the first LT. We retrospectively analyzed charts of children with BA who underwent first LT between 2006 and 2015. Patients were divided into two groups for comparison: a single-center management group (from diagnosis to transplantation) and a secondarily referred group (children referred after failure of KP). We focused analysis on disease severity at transplantation, blood transfusion, and overall survival. One hundred and eighty-five children were included. The median delay between pretransplant check-up and transplantation was shorter in patients secondarily referred. A severe undernutrition was observed in 23.7% of children secondarily referred compared to 11.1% in children with a single-center management (P = .024). At transplantation, INR and factor V level were higher in single-center group patients (respectively, 67% vs 55%, P < .001 and 61% vs 49%, P = .002). The total of red blood cell and fresh frozen plasma administrated during procedure was two times higher in patients secondarily referred. Finally, patients with a single-center management had a higher overall 12 months of survival rate (92.1% vs 83.1%, P = .033). In a country without low-density population issues, the authors advocate an early referring to transplant center to further improving LT outcomes in children with BA.
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Affiliation(s)
- Jules Kohaut
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
- University Paris-Sud, Le Kremlin-Bicêtre, France
| | - Florent Guérin
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Virginie Fouquet
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Emmanuel Gonzales
- University Paris-Sud, Le Kremlin-Bicêtre, France
- Department of Pediatric Hepatology, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Guénolée de Lambert
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Hélène Martelli
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
- University Paris-Sud, Le Kremlin-Bicêtre, France
| | - Emmanuel Jacquemin
- University Paris-Sud, Le Kremlin-Bicêtre, France
- Department of Pediatric Hepatology, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Sophie Branchereau
- Department of Pediatric Surgery, Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, AP-HP, Le Kremlin-Bicêtre, France
- University Paris-Sud, Le Kremlin-Bicêtre, France
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Province-wide Biliary Atresia Home Screening Program in British Columbia: Evaluation of First 2 Years. J Pediatr Gastroenterol Nutr 2018; 66:845-849. [PMID: 29570556 DOI: 10.1097/mpg.0000000000001950] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Biliary atresia (BA), a rare newborn liver disease, is the leading cause of liver-related death in children. Early disease recognition and timely surgical Kasai hepatoportoenterostomy (KP) offers long-term survival without liver transplant. Universal BA screening in Taiwan using infant stool color cards (ISCCs) has proven effectiveness. We report our experience with infant stool color card (ISCC) BA screening in a province-wide program in British Columbia (BC). The objective of this study is to assess program performance and cost from launch April 1, 2014 to March 31, 2016. METHODS ISCCs distributed to families upon maternity ward discharge. Parents were instructed to monitor their infant's stool color for 1 month and contacted the screening center with concerns. The number of live births, ISCC distribution, BA cases, and costs were recorded. Cases with Program screen success had both acholic stool recognition (ISCC screen success) and timely referral for BA. RESULTS All 126 maternity units received ISCCs. Of 87,583 live births there were 6 BA cases. Of the 5 cases with ISCC Screen Success 3 had Program Screen Success. The median KP age in the program screen success and failure groups was 49 (42-52) and 116 (49-184) days, respectively. Program sensitivity was 50%, specificity 99%, positive predictive value 4%, and negative predictive value 99%. A random sample of 1054 charts at BC Children's Hospital found an ISCC distribution rate of 94%. After a phase-in period, the annual program cost was $30,033.82, and the ISCC cost per birth was $0.68. CONCLUSIONS The screening program has high specificity and distribution with low cost. Successful program case identification had earlier age at KP. Program modifications aim to improve sensitivity. Longer-term studies will determine program impact on health outcomes.
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Chen SY, Lin CC, Tsan YT, Chan WC, Wang JD, Chou YJ, Lin CH. Number of cholangitis episodes as a prognostic marker to predict timing of liver transplantation in biliary atresia patients after Kasai portoenterostomy. BMC Pediatr 2018; 18:119. [PMID: 29606115 PMCID: PMC5880092 DOI: 10.1186/s12887-018-1074-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 02/20/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cholangitis may affect liver failure of biliary atresia (BA) patients after Kasai portoenterostomy (KP). We examined whether the number of cholangitis episodes could be a prognostic marker for liver transplant (LT) in children with BA after Kasai portoenterostomy (KP). METHODS Data for BA patients born after 1998 and undergoing KP were obtained from National Health Insurance Research Database (NHIRD), Taiwan. Patients were followed up until the end of 2011. Incidence and the number of cholangitis episodes were recorded and compared between patients based on LT status. RESULTS Ninety-six (26.8%) of the 366 BA patients underwent LT. More patients who underwent KP at < 60 days of age survived with their native liver (P = 0.007). The mean age at first cholangitis was 0.9 years and 0.8 years in the LT and non-LT groups, respectively (P = 0.868). The cumulative incidence of cholangitis within 2 years after KP did not differ between the groups (hazard ratio 1.2; 95% CI 0.9-1.6). However, the total number of cholangitis episodes was higher in the LT group within 2 years after KP (P < 0.001). CONCLUSIONS Cholangitis occurrence was not related to LT in the first 2 years after KP in BA patients, but the number of cholangitis episodes could be a prognostic marker for future LT.
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Affiliation(s)
- Szu-Ying Chen
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, 40705, Taichung, Taiwan, Republic of China.,Wuri Lin Shin Hospital, Taichung, Taiwan
| | - Chieh-Chung Lin
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, 40705, Taichung, Taiwan, Republic of China
| | - Yu-Tse Tsan
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Wei-Cheng Chan
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jiaan-Der Wang
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, 40705, Taichung, Taiwan, Republic of China. .,School of Medicine, China Medical University, Taichung, Taiwan.
| | - Yi-Jung Chou
- Institute of Public Health, China Medical University, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
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Bjørnland K, Hinna M, Aksnes G, Stensrud KJ, Ertresvåg K, Bjørnstad-Østensen A, Sanengen T, Line PD, Aagenæs I, Aabakken L, Emblem R, Almaas R. Outcome for biliary atresia patients treated at a low-volume centre. Scand J Gastroenterol 2018; 53:471-474. [PMID: 29546790 DOI: 10.1080/00365521.2018.1439097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The importance of case load for treatment of extrahepatic biliary atresia (BA) is debated. The aim of this study was to register results of BA treatment in a small volume centre. METHODS Retrospective chart review study of patients with BA treated from 2000 to 2017. The institutional review board approved the study. RESULTS Forty-five babies were identified of which 42 (93%) are alive. Forty-one patients had a Kasai portoenterostomy (PE), two had a hepaticojejunostomy and two had a primary liver transplantation. The age at PE/hepaticojejunostomy was median 63 (4-145 days). Seven surgeons performed the operations, and the median duration of the diagnostic work-up was 8 (3-24) days. Clearance of jaundice was achieved in 23/43 (53%) babies, and 3- and 5-year native liver survival was 47% and 40%, respectively. Clearance of jaundice post-PE/hepaticojejunostomy was a strong predictor of native liver survival (adjusted OR: 0.027; 95%; p = .009). Plasma level of conjugated bilirubin at time of referral was also a significant predictor of native liver survival (adjusted OR: 1.053; p = .017). CONCLUSION A small volume centre may achieve satisfactory results for BA patients. The study has, however, identified factors that may further improve results; earlier referral, optimizing diagnostic work-up and establishing one dedicated surgical team.
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Affiliation(s)
- Kristin Bjørnland
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,b University of Oslo , Oslo , Norway
| | | | - Gunnar Aksnes
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Kjetil Juul Stensrud
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Kjetil Ertresvåg
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Anniken Bjørnstad-Østensen
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,c Department of Paediatrics , Oslo University Hospital , Oslo , Norway
| | - Truls Sanengen
- c Department of Paediatrics , Oslo University Hospital , Oslo , Norway
| | - Pål-Dag Line
- b University of Oslo , Oslo , Norway.,d Department of Transplantation Medicine , Oslo University Hospital , Oslo , Norway
| | - Ingegerd Aagenæs
- e Department of Radiology , Oslo University Hospital , Oslo , Norway
| | - Lars Aabakken
- b University of Oslo , Oslo , Norway.,f Department of Medicine , Oslo University Hospital , Oslo , Norway
| | - Ragnhild Emblem
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,b University of Oslo , Oslo , Norway
| | - Runar Almaas
- c Department of Paediatrics , Oslo University Hospital , Oslo , Norway.,g Department of Pediatric Research , Oslo University Hospital , Oslo , Norway
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21
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Treatment Policy and Liver Histopathology Predict Biliary Atresia Outcomes: Results after National Centralization and Protocol Biopsies. J Am Coll Surg 2017; 226:46-57.e1. [PMID: 28958913 DOI: 10.1016/j.jamcollsurg.2017.09.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/28/2017] [Accepted: 09/07/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Different treatment policies can influence biliary atresia outcomes, but the pathophysiology of expanding fibrosis occurring even after successful portoenterostomy remains unclear. STUDY DESIGN Clearance of jaundice (COJ) (bilirubin <20 μmol/L), native liver survival, and overall survival rates of biliary atresia patients were analyzed before and after national centralization of management, as well as in relation to native liver histopathology of protocol biopsies. RESULTS Of the 59 patients, 35 were managed after centralization and received standardized postoperative adjuvant therapy, including corticosteroids. After centralization, age at portoenterostomy decreased from 73 days to 54 days (p = 0.014) and COJ rate increased from 42% to 80% (p = 0.005), 5-year native liver survival increased from 38% to 70% (p = 0.014), and 5-year overall survival increased from 68% to 94% (p = 0.007). High-grade portal inflammation at portoenterostomy predicted COJ (odds ratio 3.66; p = 0.011) and slower fibrosis progression (β = -0.74; p = 0.005). Native liver survival was extended in patients with high-grade portal inflammation (p = 0.002) and in patients whose bilirubin normalized within 3 months (p < 0.001). Portal inflammation and cholestasis reduced only after COJ (p < 0.001), and persisting ductal reaction, reflected by cytokeratin 7-positive proliferating bile ductules and periportal hepatocytes, correlated with follow-up fibrosis (r = 0.454 to 0.763; p < 0.001 to 0.003). Cytokeratin 7 immunopositivity of periportal hepatocytes increased after COJ (p = 0.015) and was the only predictor of follow-up liver fibrosis (β = 0.36; p = 0.002) in multiple regression. CONCLUSIONS Biliary atresia outcomes improved significantly after centralization and standardized management. Resolution of cholestasis and reduction of high-grade portal inflammation postoperatively predict slower fibrosis progression and improved native liver survival, and persisting ductal reaction parallels progressive native liver fibrosis despite COJ.
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Bagwell CE, Chiu P, Fecteau A, Gow KW, Mueller CM, Price D, Zigman AF. 2016 CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: resiliency, well-being, and burnout. J Pediatr Surg 2017; 52:864-871. [PMID: 28216079 DOI: 10.1016/j.jpedsurg.2017.01.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 01/23/2017] [Indexed: 12/20/2022]
Abstract
The following is the conference proceeding of the Second Ein Debate from the 48th Annual Meeting of the Canadian Association of Paediatric Surgeons held in Vancouver, BC, from September 22 to 24, 2016. The three main topics for debate, as prepared by the members of the CAPS Ethics Committee, are: 1. Regionalization of care: pros and cons, 2. Innovation in clinical care: ethical considerations, and 3. Surgeon well-being: caring for the caregiver. The authors of this paper, as participants in the debate, were assigned their positions at random. Therefore, the opinions they express within this summary might not reflect their own viewpoints. In the first discussion, arguments for and against the regionalization of pediatric surgical care are discussed, primarily in the context of a case of BA. In the pro argument, the evidence and lessons learned from different European countries are explored as well as different models to provide the best BA care outside of large teaching centers. In the counterargument, the author explains how regionalization of care could be detrimental for the patient, the family, the regional center, and for the health care system in general. In the debate on surgical innovation the authors define surgical innovation. They review the pertinent ethical principles, explore a model for its implementation, and the role of the institution at which the innovation is proposed. In the third section, surgeon well-being is examined, and recent literature on surgeon resiliency and burnout both at the attending and resident level is reviewed.
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Affiliation(s)
- Charles E Bagwell
- Division of Pediatric Surgery, Virginia Commonwealth University/Medical College Of Virginia, Richmond, VA, USA
| | - Priscilla Chiu
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Annie Fecteau
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Kenneth W Gow
- Division of General and Thoracic Surgery, Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
| | - Claudia M Mueller
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David Price
- Department of Surgery, Janeway Children's Hospital, St. John's, NL, Canada
| | - Andrew F Zigman
- Department of Surgery, Northwest Permanente and Oregon Health & Science University, Portland, OR, USA
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Webb NL, Jiwane A, Ooi CY, Nightinghale S, Adams SE, Krishnan U. Clinical significance of liver histology on outcomes in biliary atresia. J Paediatr Child Health 2017; 53:252-256. [PMID: 27717116 DOI: 10.1111/jpc.13371] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/18/2016] [Accepted: 08/15/2016] [Indexed: 01/16/2023]
Abstract
AIM Biliary atresia (BA) literature has focussed on the relationship between age at Kasai procedure (KP) and post-KP outcomes. This study primarily examines post-KP outcomes including, 6-month normalisation of bilirubin, 5-year native liver survival (NLS), development of portal hypertension (PHT) and incidence of ascending cholangitis at a single tertiary paediatric centre in Australia. The study also evaluated prognostic factors which may influence these aforementioned outcomes. METHODS Retrospective chart review of all BA cases between 1999 and 2014. Age at KP, liver biopsy results, use of ursodeoxycholic acid or prophylactic antibiotics and occurrence of PHT and ascending cholangitis post-KP were recorded and related to the primary post-KP outcome measures. RESULTS BA was diagnosed in 29 patients. Twenty-four of 29 patients underwent KP. Median age at KP was 68 days (29-104). Fourteen of 24 (58.3%) had bridging fibrosis and 5 of 24 (20.8%) had cirrhosis at time of KP. Median follow-up was 8.4 years (2.08-15.58 years). Bilirubin normalisation within 6 months occurred in 7 of 24 (29.2%) patients and 5-year NLS was 45.8% (11/24). Fourteen of 24 (58.3%) had PHT and 18 of 24 (75%) patients had ascending cholangitis post-KP. Absence of bridging fibrosis in liver histology at KP was the only factor to be significantly associated with improved 5-year NLS. None of the other variables examined had a significant association with either 5-year NLS or bilirubin normalisation by 6 months. CONCLUSION Five-year NLS in this series was 45.8%. Absence of bridging fibrosis at time of KP was the only factor significantly associated with improved 5-year NLS.
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Affiliation(s)
- Nicholas L Webb
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Ashish Jiwane
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Pediatric Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Chee Y Ooi
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Scott Nightinghale
- Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,Discipline of Paediatrics and Child Health, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Susan E Adams
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Pediatric Surgery, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Usha Krishnan
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia
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Cheng CW, Liu FC, Lin JR, Tsai YF, Chen HP, Yu HP. The Impact of Hospital/Surgeon Volume on Acute Renal Failure and Mortality in Liver Transplantation: A Nationwide Cohort Study. PLoS One 2016; 11:e0162992. [PMID: 27706183 PMCID: PMC5051740 DOI: 10.1371/journal.pone.0162992] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/31/2016] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to assess whether the case volume of surgeons and hospitals affects the rates of postoperative complications and survival after liver transplantation. This population-based retrospective cohort study included 2938 recipients of liver transplantation performed between 1998 and 2012, enrolled from the Taiwan National Health Insurance Research Database. They were divided into two groups, according to the cumulative case volume of their operating surgeons and the case volume of their hospitals. The duration of intensive care unit stay and post-transplantation hospitalization, postoperative complications, and mortality were analyzed. The results showed that, in the low and high case volume surgeons groups, respectively, acute renal failure occurred at the rate of 14.11% and 5.86% (p<0.0001), and the overall mortality rates were 19.61% and 12.44% (p<0.0001). In the low and high case volume hospital groups, respectively, acute renal failure occurred in 11% and 7.11% of the recipients (p = 0.0004), and the overall mortality was 18.44% and 12.86% (p<0.0001). These findings suggest that liver transplantation recipients operated on higher case volume surgeons or in higher case volume hospitals have a lower rate of acute renal failure and mortality.
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Affiliation(s)
- Chih-Wen Cheng
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Fu-Chao Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Hsiu-Pin Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
- * E-mail:
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Verkade HJ, Bezerra JA, Davenport M, Schreiber RA, Mieli-Vergani G, Hulscher JB, Sokol RJ, Kelly DA, Ure B, Whitington PF, Samyn M, Petersen C. Biliary atresia and other cholestatic childhood diseases: Advances and future challenges. J Hepatol 2016; 65:631-42. [PMID: 27164551 DOI: 10.1016/j.jhep.2016.04.032] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 02/08/2023]
Abstract
Biliary Atresia and other cholestatic childhood diseases are rare conditions affecting the function and/or anatomy along the canalicular-bile duct continuum, characterised by onset of persistent cholestatic jaundice during the neonatal period. Biliary atresia (BA) is the most common among these, but still has an incidence of only 1 in 10-19,000 in Europe and North America. Other diseases such as the genetic conditions, Alagille syndrome (ALGS) and Progressive Familial Intrahepatic Cholestasis (PFIC), are less common. Choledochal malformations are amenable to surgical correction and require a high index of suspicion. The low incidence of such diseases hinder patient-based studies that include large cohorts, while the limited numbers of animal models of disease that recapitulate the spectrum of disease phenotypes hinders both basic research and the development of new treatments. Despite their individual rarity, collectively BA and other cholestatic childhood diseases are the commonest indications for liver transplantation during childhood. Here, we review the recent advances in basic research and clinical progress in these diseases, as well as the research needs. For the various diseases, we formulate current key questions and controversies and identify top priorities to guide future research.
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Affiliation(s)
- Henkjan J Verkade
- Department of Paediatrics, University of Groningen, Beatrix Children's Hospital/University Medical Center, Groningen, The Netherlands.
| | - Jorge A Bezerra
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Richard A Schreiber
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Georgina Mieli-Vergani
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Jan B Hulscher
- Department of Paediatric Surgery, University of Groningen, Beatrix Children's Hospital-University Medical Center, Groningen, The Netherlands
| | - Ronald J Sokol
- Section of Paediatric Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Deirdre A Kelly
- Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, UK
| | - Benno Ure
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Peter F Whitington
- Department of Paediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marianne Samyn
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Claus Petersen
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
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Qiao G, Li L, Cheng W, Zhang Z, Ge J, Wang C. Conditional probability of survival in patients with biliary atresia after Kasai portoenterostomy: a Chinese population-based study. J Pediatr Surg 2015; 50:1310-5. [PMID: 25917622 DOI: 10.1016/j.jpedsurg.2015.03.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 03/17/2015] [Accepted: 03/29/2015] [Indexed: 01/23/2023]
Abstract
Survival estimates are commonly reported for the outcomes of patients. Conditional probability, which offers more relevant information regarding the prognosis for patients once they have survived for some time, are lacking for patients with biliary atresia. The aim of this study is to calculate the conditional probability of survival in patients with biliary atresia after Kasai portoenterostomy. Clinical data from 244 consecutive patients who underwent Kasai portoenterostomy were reviewed and the actuarial survival estimated. Conditional survival probabilities and 95% CIs were calculated. Of the 244 patients, the overall median NLS was 41.2 months (95% CI:30.8-51.6 months), and the 1-year, 3-year, and 5-year NLS rates were 85.4%, 61.1%, and 43.3%, respectively. The probabilities of surviving at the time point of 5 years given survival to 1, 2, 3, and 4 years were 50%, 56%, 73%, and 93%, respectively. For conditional survival for 1 additional year, patients with age >90 days and cholangitis had significantly predictive values(both P<0.05). Cox proportional hazards model showed that age > 90 days(HR: 2.519, P=0.001), and postoperative cholangitis(HR:2.568, P<0.001) were associated with an adverse NLS in the multivariable adjusted analysis. our findings showed that conditional survival of patients with BA is not linear over time after Kasai operation. Information derived from conditional survival can be used to better manage patients with BA, including the potential subsequent treatment decisions, the chance of listing for transplantation, or even the end-of-life planning.
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Affiliation(s)
- Guoliang Qiao
- Graduate School of Peking Union Medical College, Beijing, People's Republic of China; Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Long Li
- Graduate School of Peking Union Medical College, Beijing, People's Republic of China; Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China.
| | - Wei Cheng
- Department of Surgery, United Family Hospital, Beijing, People's Republic of China; Department of Paediatrics and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Zhen Zhang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Juntao Ge
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Chen Wang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, Beijing, People's Republic of China
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review advances in both the pathogenesis and clinical management of biliary atresia. RECENT FINDINGS Immunologic studies have further characterized roles of helper T-cells, B-cells, and natural killer cells in the immune dysregulation following viral replication within and damage of biliary epithelium. Prominin-1-expressing portal fibroblasts may play an integral role in the biliary fibrosis associated with biliary atresia. A number of genetic polymorphisms have been characterized as leading to susceptibility for biliary atresia. Postoperative corticosteroid therapy is not associated with greater transplant-free survival. Newborn screening may improve outcomes of infants with biliary atresia and may also provide a long-term cost benefit. SUMMARY Although recent advances have enhanced our understanding of pathogenesis and clinical management, biliary atresia remains a significant challenge requiring further investigation.
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Bezerra JA, Spino C, Magee JC, Shneider BL, Rosenthal P, Wang KS, Erlichman J, Haber B, Hertel PM, Karpen SJ, Kerkar N, Loomes KM, Molleston JP, Murray KF, Romero R, Schwarz KB, Shepherd R, Suchy FJ, Turmelle YP, Whitington PF, Moore J, Sherker AH, Robuck PR, Sokol RJ. Use of corticosteroids after hepatoportoenterostomy for bile drainage in infants with biliary atresia: the START randomized clinical trial. JAMA 2014; 311:1750-9. [PMID: 24794368 PMCID: PMC4303045 DOI: 10.1001/jama.2014.2623] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Biliary atresia is the most common cause of end-stage liver disease in children. Controversy exists as to whether use of steroids after hepatoportoenterostomy improves clinical outcome. OBJECTIVE To determine whether the addition of high-dose corticosteroids after hepatoportoenterostomy is superior to surgery alone in improving biliary drainage and survival with the native liver. DESIGN, SETTING, AND PATIENTS The multicenter, double-blind Steroids in Biliary Atresia Randomized Trial (START) was conducted in 140 infants (mean age, 2.3 months) between September 2005 and February 2011 in the United States; follow-up ended in January 2013. INTERVENTIONS Participants were randomized to receive intravenous methylprednisolone (4 mg/kg/d for 2 weeks) and oral prednisolone (2 mg/kg/d for 2 weeks) followed by a tapering protocol for 9 weeks (n = 70) or placebo (n = 70) initiated within 72 hours of hepatoportoenterostomy. MAIN OUTCOMES AND MEASURES The primary end point (powered to detect a 25% absolute treatment difference) was the percentage of participants with a serum total bilirubin level of less than 1.5 mg/dL with his/her native liver at 6 months posthepatoportoenterostomy. Secondary outcomes included survival with native liver at 24 months of age and serious adverse events. RESULTS The proportion of participants with improved bile drainage was not statistically significantly improved by steroids at 6 months posthepatoportoenterostomy (58.6% [41/70] of steroids group vs 48.6% [34/70] of placebo group; adjusted relative risk, 1.14 [95% CI, 0.83 to 1.57]; P = .43). The adjusted absolute risk difference was 8.7% (95% CI, -10.4% to 27.7%). Transplant-free survival was 58.7% in the steroids group vs 59.4% in the placebo group (adjusted hazard ratio, 1.0 [95% CI, 0.6 to 1.8]; P = .99) at 24 months of age. The percentage of participants with serious adverse events was 81.4% [57/70] of the steroids group and 80.0% [56/70] of the placebo group (P > .99); however, participants receiving steroids had an earlier time of onset of their first serious adverse event by 30 days posthepatoportoenterostomy (37.2% [95% CI, 26.9% to 50.0%] of steroids group vs 19.0% [95% CI, 11.5% to 30.4%] of placebo group; P = .008). CONCLUSIONS AND RELEVANCE Among infants with biliary atresia who have undergone hepatoportoenterostomy, high-dose steroid therapy following surgery did not result in statistically significant treatment differences in bile drainage at 6 months, although a small clinical benefit could not be excluded. Steroid treatment was associated with earlier onset of serious adverse events in children with biliary atresia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00294684.
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Affiliation(s)
- Jorge A Bezerra
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | | - Kasper S Wang
- Children's Hospital Los Angeles and University of Southern California, Los Angeles
| | - Jessi Erlichman
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Barbara Haber
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania17Dr Haber is now with Merck Research Laboratories, Upper Gwynedd, Pennsylvania
| | - Paula M Hertel
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Saul J Karpen
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nanda Kerkar
- Mount Sinai School of Medicine, New York, New York18Dr Kerkar is now with Children's Hospital Los Angeles and University of Southern California, Los Angeles
| | | | - Jean P Molleston
- Indiana University School of Medicine and Riley Hospital for Children, Indianapolis
| | | | - Rene Romero
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Ross Shepherd
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Frederick J Suchy
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | | | | | | | - Averell H Sherker
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Patricia R Robuck
- National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
| | - Ronald J Sokol
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
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Tu CG, Khurana S, Couper R, Ford AWD. Kasai hepatoportoenterostomy in South Australia: a case for 'centralized decentralization'. ANZ J Surg 2014; 85:865-8. [PMID: 24529070 DOI: 10.1111/ans.12522] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent follow-up studies have demonstrated significant improvement in overall survival as well as survival with native liver following geographic centralization of services to three centres in the UK. However, this model has not been replicated in countries with relatively low population density such as Australia and Canada. METHODS Retrospective evaluation of all patients born with biliary atresia (BA) in South Australia from 1989 to 2010 was performed. Thirty-one patients with BA were discovered. Two patients were excluded because the initial Kasai procedure (KP) was performed interstate. Outcome parameters measured were (i) clearance of jaundice (bilirubin of less than 20 μmol/L, by 6 months); (ii) survival with native liver; and (iii) overall survival. Kaplan-Meier survival curves were plotted for both survival with native liver and overall survival. RESULTS The incidence of BA in South Australia between 1989 and 2010 was 7.48 per 100,000 live births. Following KP, clearance of jaundice was achieved in 42.9% of patients. Five-year actuarial survival with native liver was 55.2%, and overall 5-year actuarial survival was 89.3%. CONCLUSIONS The results of KP performed at Women's and Children's Hospital from 1989 to 2010 can be considered comparable with international benchmarks. Based on these results, we propose the creation of a 'centralized' pool of surgeons in Australia to help continue providing 'decentralized' care of BA.
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Affiliation(s)
- Chen Gang Tu
- Orthopaedic Department, Modbury Hospital, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Richard Couper
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Andrew W D Ford
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, South Australia, Australia
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Abstract
PURPOSE The purpose of this study was to analyze the survival of patients with biliary atresia (BA) after Kasai operation and liver transplantation (LT) and to analyze the factors affecting survival. METHODS Seventy-two patients diagnosed with BA were operated on between April 1995 and December 2009 and retrospectively analyzed. RESULTS Out of the 72 patients, 59 received Kasai operation and 13 received LT without prior Kasai operation. Twenty-seven patients received LT after Kasai operation. Survival with native liver was 39 % at 10 years. With the application of LT, overall 10-year survival for patients with BA was 94.9 %. Among patients alive with native livers after Kasai operation, 14 patients (58.3 %) have at least one complication associated with biliary cirrhosis and portal hypertension. Age at which Kasai operation was performed (60 days) and postoperative normalization of bilirubin were independent risk factors for survival with the native liver, according to multivariate analysis (HR 2.90, p = 0.033 and HR 9.89, p = 0.002). CONCLUSIONS Survival of BA patients has greatly increased in the era of LT. However, many patients surviving with native livers after Kasai operation continue to have signs of biliary cirrhosis and abnormal liver function.
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Abstract
OBJECTIVES International trends in incidence and outcomes of biliary atresia (BA) are controversial and a wide range of estimates have been reported worldwide. We reviewed the population-based literature to assess international variation of BA incidence and outcomes, and to assess the evidence for seasonal variation in incidence, centralization of Kasai hepatoportoenterostomy, and newborn screening. METHODS We conducted a systematic review (registration number CRD42011001441) of observational or interventional research within MEDLINE, EMBASE, and the Cochrane Database, which reported incidence, prevalence, or outcomes of infants with BA. Population-based studies, defined by inclusion of an entire population or representative sample, were included. Outcomes included overall survival, native liver survival (NLS), and time to Kasai hepatoportoenterostomy. Single- or multicenter studies were excluded unless those centers captured all potential patients within a jurisdiction. Two independent data extractors reviewed the abstracts and articles. RESULTS A total of 40 studies were included following review of 3128 references. A wide range of incidence was reported internationally. Ten-year overall survival ranged from 66.7% to 89%. NLS ranged from 20.3% to 75.8% at 1 to 3 years and 24% to 52.8% at 10 years. Earlier age at Kasai was a predictor of improved NLS. Seasonality was reported in 11 studies, and 3 reported an increased incidence during the months of August to March. The evidence for centralization of Kasai to high-volume centers is promising but does not account for all case-mix, provider, or health system factors involved in volume-outcome relations. Stool color card screening resulted in earlier Kasai and improved NLS in Taiwan. CONCLUSIONS Large, international studies could help fill the gaps in knowledge identified by this review.
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Chan KWE, Lee KH, Tsui SYB, Wong YS, Pang KYK, Mou JWC, Tam YH. Laparoscopic versus open Kasai portoenterostomy in infant with biliary atresia: a retrospective review on the 5-year native liver survival. Pediatr Surg Int 2012; 28:1109-13. [PMID: 22987040 DOI: 10.1007/s00383-012-3172-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE Laparoscopic Kasai portoenterostomy was reported to be a safe and feasible procedure in infant with biliary atresia. We aimed to investigate the long-term results after laparoscopic portoenterostomy as such data in the literature are lacking. METHODS Sixteen infants underwent laparoscopic Kasai portoenterostomy from 2002 to 2006. The age and the sex of the patient, the bilirubin level before the operation, the early clearance of jaundice (total bilirubin <20 μmol/L within 6 months of portoenterostomy), the native liver survival at 2 and 5 years after the operation were reviewed. The results were retrospectively compared with 16 consecutive infants who underwent open Kasai portoenterostomy before 2002. RESULTS All infants had type III biliary atresia. The early clearance of jaundice rate at 6 months was 50 % (8/16) after laparoscopic operation and was 75 % (12/16) after open operation (p = 0.144). Two years after the operation, the native liver survival was 50 % (8/16) in the laparoscopic group and was 81 % (13/16) in the open group (p = 0.076). Five years after the operation, the native liver survival rate was 50 % (8/16) in the laparoscopic group and was 81 % (13/16) in the open group (p = 0.076). The jaundice-free native liver survival rate at 5 years was 50 % (8/16) in laparoscopic group and was 75 % (12/16) in the open group. In the laparoscopic group, all patients with early clearance of jaundice survived and remained jaundice freed 5 years after the operation. CONCLUSION The 5-year native liver survival rate after laparoscopic portoenterostomy was 50 %. Apparently superior result was observed in the open group (81 %) although the figures did not reach statistical difference because of the small sample size. A larger scale study is required to draw a more meaningful conclusion.
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Affiliation(s)
- Kin Wai E Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, The Chinese University of Hong Kong, The Prince of Wales Hospital, Hong Kong SAR, China.
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Oetzmann von Sochaczewski C, Petersen C, Ure BM, Osthaus A, Schubert KP, Becker T, Lehner F, Kuebler JF. Laparoscopic versus conventional Kasai portoenterostomy does not facilitate subsequent liver transplantation in infants with biliary atresia. J Laparoendosc Adv Surg Tech A 2012; 22:408-11. [PMID: 22577810 DOI: 10.1089/lap.2012.0077] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The benefit of laparoscopic Kasai portoenterostomy remains controversial. With the progression of the disease, significant numbers of patients require liver transplantation. It has been reported that reduced internal scarring and fewer adhesions could facilitate the subsequent liver transplantation and thus represent a potential advantage of the laparoscopic technique. SUBJECTS AND METHODS All patients undergoing liver transplantation in our hospital between 2006 to 2008 after a laparoscopic or conventional Kasai procedure were included in this retrospective analysis. Primary outcome measure was duration of liver explantation. Secondary outcome measures were total duration of transplantation, amount of blood transfusion, and need for reoperation within the first year. RESULTS In total, 19 patients were included: 11 patients after open Kasai and 8 patients after laparoscopic Kasai. There was no significant difference in patient characteristics. The mean duration of liver explantation was comparable in laparoscopic (125±8 minutes) and conventional (116±6 minutes) (P>.05) patients. Moreover, we did not identify any significant difference in the need for blood transfusions, total liver transplantation duration, and need for reoperation. CONCLUSIONS We did not detect any measurable benefit of laparoscopic compared with conventional portoenterostomy for subsequent liver transplantation. Thus, prevention of adhesion formation and facilitating subsequent liver transplantation are not rationales for laparoscopic Kasai portoenterostomy.
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de Vries W, de Langen ZJ, Groen H, Scheenstra R, Peeters PMJG, Hulscher JBF, Verkade HJ. Biliary atresia in the Netherlands: outcome of patients diagnosed between 1987 and 2008. J Pediatr 2012; 160:638-644.e2. [PMID: 22082947 DOI: 10.1016/j.jpeds.2011.09.061] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 08/26/2011] [Accepted: 09/28/2011] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine the outcome of biliary atresia (BA) and to identify prognostic factors using a national database. STUDY DESIGN All children born between January 1987 and December 2008 who underwent the Kasai surgical procedure for BA were retrieved from the Netherlands Study Group on Biliary Atresia Registry database. Outcomes were measured in terms of clearance of jaundice (bilirubin <1.17 g/dL, or 20 μmol/L, within 6 months after surgery) and 4-year transplant-free survival. Two cohorts, one from 1987-1997 and the other from 1998-2008, were compared. Survival rates were determined using Kaplan-Meier analysis, and prognostic factors were tested with univariate and multivariate analyses. RESULTS Between January 1987 and December 2008, 214 patients underwent Kasai surgery for BA. In this series, the 4-year transplant-free survival was 46%±4%, and 4-year overall survival was 73%±3%. Clearance of jaundice, surgery within 60 days, and postoperative antibiotic prophylaxis use were independently associated with increased transplant-free survival. The yearly caseload per center (range, 0.5-2.1) was not correlated with transplant-free survival (r=0.024; P=.73). CONCLUSION During the past 2 decades, outcome parameters have remained constant and are comparable with those reported from other Western countries, despite a relatively low annual caseload per center. Timely surgical correction and postoperative antibiotic therapy were associated with a higher transplant-free survival rate.
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Affiliation(s)
- Willemien de Vries
- Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Kumagi T, Drenth JPH, Guttman O, Ng V, Lilly L, Therapondos G, Hiasa Y, Michitaka K, Onji M, Watanabe Y, Sen S, Griffiths W, Roberts E, Heathcote J, Hirschfield GM. Biliary atresia and survival into adulthood without transplantation: a collaborative multicentre clinic review. Liver Int 2012; 32:510-8. [PMID: 22098694 DOI: 10.1111/j.1478-3231.2011.02668.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 09/17/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary atresia is a progressive biliary injury which occurs only in infants. AIMS To review the experience of patients surviving into adulthood without the need for liver transplantation in childhood. METHODS A multicentre review of patients with biliary atresia treated surgically who survived into adulthood without the need for transplantation. RESULTS Twenty-two patients were identified across four centres. Median age at the last follow-up was 25 years (range: 18-46), and 21 patients had clinical features of portal hypertension. At last follow-up values of liver enzymes varied from normal to 15 × the upper limit of normal (ULN) for ALT (median 2.11 × ULN) and 9 × the ULN for ALP (median 2.02 × ULN). Six patients had a serum bilirubin > 50 μmol/l. Pruritus and jaundice were noted in 8 of 20 patients (40%) and 11 of 22 patients (50%) respectively. Thirteen patients (59.1%) were shown to have imaging features of sclerosing cholangitis, with strictures of intrahepatic bile duct(s) (IHBD), dilatation of IHBD (n = 8), or stone(s) within the IHBD (n = 5). A history of presumed bacterial cholangitis was present in 11 patients (50%). Successful pregnancies were recorded in three of fourteen female patients. Four patients underwent transplant between the ages of 20-27 years. Twenty-one patients (95.5%) were alive, including 18 (81.8%) with their native liver at the time of last follow-up. CONCLUSIONS Some patients treated for biliary atresia will survive into adulthood with their native liver, but commonly with secondary biliary disease including cholangitis and portal hypertension.
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Lampela H, Ritvanen A, Kosola S, Koivusalo A, Rintala R, Jalanko H, Pakarinen M. National centralization of biliary atresia care to an assigned multidisciplinary team provides high-quality outcomes. Scand J Gastroenterol 2012; 47:99-107. [PMID: 22171974 DOI: 10.3109/00365521.2011.627446] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Effects of caseload and organization of care on outcomes of biliary atresia (BA) remain unclear. We compared outcomes before and after national centralization of BA treatment in Finland with a population of 5.4 million people and 60,000 live births/year. METHODS All children born in Finland from 1987 to 2010 with BA were included. Complete patient identification was ascertained from the national Register of Congenital Malformations. Hospital records were reviewed for confirmation of the diagnosis, treatment, and follow-up data. Clearance of jaundice (serum bilirubin ≤ 20 μmol/l) and survival modalities were compared before and after centralization from five centers to Helsinki. RESULTS The incidence of BA was 1 in 20,100 live births. A total of 72 BA patients of whom 64 had undergone surgery for BA were identified. After centralization, the median caseload per center increased from 0 (range, 0-3) to 4 (2-5) patients/year (p < 0.001), clearance of jaundice rate increased from 27% to 75% (p = 0.001), 2-year jaundice-free native liver survival from 25% to 75% (p = 0.002), transplant-free survival from 27% to 75% (p = 0.005), and overall survival from 64% to 92% (p = 0.082). Baseline patient characteristics including type of BA and age at portoenterostomy remained unaltered. In a logistic regression analysis including treatment era, operating center, BA splenic malformation syndrome, and age at portoenterostomy as variables, only treatment in Helsinki after centralization predicted clearance of jaundice (odds ratio 4.2; 95% confidence interval 1.05-16.5; p = 0.043). CONCLUSIONS In small countries, BA treatment should be centralized to appointed multidisciplinary teams allowing high quality results with a median of four cases/year.
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Affiliation(s)
- Hanna Lampela
- Pediatric Surgery, Children's Hospital, Helsinki University and Helsinki University Central Hospital, Helsinki, Finland.
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Does adjuvant steroid therapy post-Kasai portoenterostomy improve outcome of biliary atresia? Systematic review and meta-analysis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:440-4. [PMID: 21912769 DOI: 10.1155/2011/125610] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of adjuvant steroid therapy in the postoperative management of patients with biliary atresia (BA) is unclear. OBJECTIVE To systematically review the literature and perform a meta-analysis to determine the efficacy of adjuvant steroid therapy post-Kasai portoenterostomy (KP) on BA outcome. METHODS A systematic review and meta-analysis of randomized trials and⁄or observational studies that examined the role of steroids on BA outcomes published between January 1969 and June 2010 was conducted. Studies were identified using the Medline, PubMed, EMBASE and Cochrane databases. RESULTS Sixteen observational studies and one randomized controlled trial (RCT) were found. Four of the 16 observational studies (160 participants) and the RCT (73 participants) met the entry criteria and were eligible to be included in the analysis. There was no statistically significant difference in the effect of steroids either on normalizing serum bilirubin levels at six months (pooled OR 1.48 [95% CI 0.67 to 3.28]) or in delaying the need for early liver transplantation (within the first year post-KP (pooled OR 0.59 [95% CI 0.21 to 1.72]). CONCLUSION The present meta-analysis did not find a significant effect of steroid over standard therapy, either in normalizing serum bilirubin levels at six months or at delaying the need for early liver transplantation post-KP. RCT studies of sufficient size and comprehensive design using high-dose steroids are needed to determine the effectiveness of steroids on the short and intermediate post-KP outcomes for BA patients.
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Davenport M, Ong E, Sharif K, Alizai N, McClean P, Hadzic N, Kelly DA. Biliary atresia in England and Wales: results of centralization and new benchmark. J Pediatr Surg 2011; 46:1689-94. [PMID: 21929975 DOI: 10.1016/j.jpedsurg.2011.04.013] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 04/14/2011] [Accepted: 04/16/2011] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Biliary atresia (BA) is a rare, potentially life-threatening condition of the newborn presenting with conjugated jaundice. Typically, it is treated by an initial attempt to restore bile flow (the Kasai portoenterostomy [KP]) as soon as possible after diagnosis and, if this fails, liver transplantation. Since 1999, the treatment of BA has been centralized to 3 centers in England and Wales able to offer both treatment options. The aim of this study was to review the outcome of this policy change and provide a national benchmark. METHODS The management of all infants born within England and Wales during the period January 1999 to December 2009 was assessed using 3 key performance indicators such as median time to KP, percentage clearance of jaundice (≤20 mol/L) post-KP, and 5- and 10-year native liver and true survival estimates. Data are quoted as median (range), and P < .05 was considered significant. RESULTS A total of 443 infants had confirmed BA; and of these, most were isolated BA (n = 359), with 84 having other significant anomalies (but predominantly BA splenic malformation syndrome). Four infants died before any biliary intervention. Kasai portoenterostomy was performed in 424 infants (median age, 54 [range 7-209] days), and a primary liver transplant was performed in 15. Clearance of jaundice post-KP was achieved in 232 (55%). There were 41 deaths, including 4 (10%) without any intervention, 24 (58%) post-KP usually because of end-stage liver disease and mostly on a transplant waiting list, and 13 (32%) post-LT usually because of multiorgan failure. Overall, the 5- and 10-year native liver survival estimates were 46% (95% confidence interval [CI], 41-51) and 40% (95% CI, 34-46), respectively. The 5- and 10-year true patient survival estimates were 90% (95% CI, 88-93) and 89% (95% CI, 86-93), respectively. Outcome was worse for those with other anomalies (lower clearance of jaundice post-KP [43% vs 57%; odds ratio, 1.7; 95% CI, 1.04-2.8]; P = .02) and an increased mortality overall (eg, at 5 years, 72 [95% CI, 64-83] vs 94 [95% CI, 91-96]; χ(2) = 33; P < .0001). CONCLUSIONS National outcome measures in BA appear better than those from previously published series from comparable countries and may be attributed to centralization of surgical and medical resources.
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Affiliation(s)
- Mark Davenport
- Paediatric Liver Centre, Kings College Hospital, SE5 9RS London, UK.
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