Prognosis of extrahepatic biliary atresia

Implementing living-donor pediatric liver transplantation in Southern Vietnam: 15-year results and perspectives

BACKGROUND

ND2 in Ho Chi Minh City is currently the only public center that performs PLT in Southern Vietnam. In 2005, the first PLT was successfully performed, with support from Belgian experts. This study reviews the implementation of PLT at our center and evaluates the results and challenges.

METHODS

Implementation of PLT at ND2 required medico-surgical team building and extensive improvement of hospital facilities. Records of 13 transplant recipients from 2005 to 2020 were studied retrospectively. Short- and long-term complications, as well as the survival rates, were reported.

RESULTS

The mean follow-up time was 8.3 ± 5.7 years. Surgical complications included one case of hepatic artery thrombosis that was successfully repaired, one case of colon perforation resulting in death from sepsis, and two cases of bile leak that were drained surgically. PTLD was observed in five patients, of whom three died. There were no cases of retransplantation. The 1-year, 5-year, and 10-year patient survival rates were 84.6%, 69.2%, and 69.2%, respectively. There were no cases of complication or death among the donors.

CONCLUSION

Living-donor PLT was developed at ND2 for providing a life-saving treatment to children with end-stage liver disease. Early surgical complication rate was low, and the patient survival rate was satisfactory at 1 year. Long-term survival decreased considerably due to PTLD. Future challenges include surgical autonomy and improvement of long-term medical follow-up with a particular emphasis on prevention and management of Epstein-Barr virus-related disease.

Primary Prophylaxis for Gastrointestinal Bleeding in Children With Biliary Atresia and Portal Hypertension Candidates for Liver Transplantation: A Single-Center Experience

BACKGROUND

Cirrhosis for biliary atresia (BA) is associated with risk of gastrointestinal bleeding (GB) from gastroesophageal varices due to portal hypertension. Primary prophylaxis of GB is controversial in children who are candidates for liver transplantation (LT). The aim of the study was to define the management of gastroesophageal varices and to identify the benefit of primary prophylaxis for GB in BA children waiting for LT.

METHODS

A retrospective single-center study including all BA children listed for LT in 2008-2016. Clinical, endoscopical, and biochemical data were analyzed.

RESULTS

Of 82 children, 50 (61%) did not receive primary prophylaxis and did not present any episode of bleeding, 16 (19.5%) underwent primary prophylaxis, and 16 (19.5%) presented spontaneous GB and received secondary prophylaxis. Children without primary prophylaxis and GB were younger than patients with primary prophylaxis and those with GB (7.7 years [range, 4.1-37.9 years] vs 11.2 years [range, 5.1-43 years]; P = .03 vs 10.7 years [range, 6.9-39.9 years], respectively; P = .004). Seventy-five percent of GB occurred in children older than 8 months. Fifteen (93.8%) children with GB presented esophageal varices (grade III = 10 [62.5%]) and 10 (62.5%) required endoscopic treatments, consisting mainly of sclerotherapy. Median time to LT was similar for children with or without bleeding (2 months [range, 0-17.7 months] vs 2.2 months [0-17.9 months], respectively; P = .89). After 45.5 months (range, 13.7-105.5 months) of follow-up, the overall patient survival was 97.6%. At the intention-to-treat analysis, the survival rate was 100% for patients without bleeding episode and 87.5% for children with GB (P = .16).

CONCLUSIONS

Despite the risk of GB being not clinically predictable in children with BA waiting for LT, our experience suggests that primary prophylaxis of GB might be unnecessary in children younger than 6 months, while it should be considered in older children. Thus, the occurrence of GB does not delay the timing of transplantation.

Use of Lactobacillus casei rhamnosus to Prevent Cholangitis in Biliary Atresia After Kasai Operation

OBJECTIVES

Recurrent cholangitis may aggravate cholestatic liver cirrhosis in biliary atresia (BA) after the Kasai operation. This pilot study aimed to investigate whether Lactobacillus casei rhamnosus has the prophylactic efficacy for recurrent cholangitis in comparison with the conventional neomycin prophylaxis.

METHODS

Twenty jaundice-free patients with BA ages 0 to 3 years who underwent a Kasai operation were enrolled and randomized into 2 groups with 10 patients each: neomycin (25 mg · kg · day for 4 days/wk) and L casei rhamnosus (8 × 10 colony-forming unit per day) groups. The treatment duration was 6 months. Bacterial stool cultures were performed before treatment and 1, 3, and 6 months after starting treatment. In addition, 10 patients with BA with similar status but without prophylaxis served as the historical control group.

RESULTS

In the Lactobacillus group, 2 patients (20%, mean 0.03 ± 0.07 episodes per month) developed cholangitis during the study period, with the same frequency as in the neomycin group and significantly lower than that in the control group (80%, P = 0.005, mean 0.22 ± 0.16 episodes per month). The mean change in body weight z score during the 6 months in the Lactobacillus group was 0.97 ± 0.59, which was significantly better than that in the control group (-0.01 ± 0.79, P = 0.006). In bacterial stool cultures, the Lactobacillus and Escherichia coli populations significantly increased and decreased, respectively, in the Lactobacillus group.

CONCLUSIONS

The use of L casei rhamnosus was as effective as neomycin in preventing cholangitis in patients with BA who underwent Kasai operation, and therefore could be considered as a potential alternative prophylactic regimen.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic surveillance and primary prophylaxis sclerotherapy of esophageal varices in biliary atresia

OBJECTIVES

Evidence-based recommendations on endoscopic screening and prophylactic treatment of esophageal varices in patients with biliary atresia (BA) are scarce. We assessed the efficiency of endoscopic surveillance and risk factors of esophageal varices and associated upper gastrointestinal bleeding.

METHODS

A total of 47 consecutive children with BA and portoenterostomy underwent yearly endoscopies and prophylactic injection sclerotherapy of esophageal varices between 1987 and 2009. The median follow-up was 1.7 years (range 0.5-18.9) and overall 2-year survival 71%. Disease characteristics, clearance of jaundice, laboratory tests reflecting liver function and hypersplenism, as well as sonographic signs of portal hypertension were related to endoscopic findings and bleeding episodes.

RESULTS

Grade 2 to 3 varices developed with similar frequency after failed (18/28, 64%) and successful portoenterostomy (10/19, 53%) in 28 patients. Following failed portoenterostomy, esophageal varices were encountered significantly earlier (8 [4-23] vs. 19 [4-165] months, P = 0.004), and they reappeared after eradication more often (16/16 vs. 4/10, P = 0.001). Varices bled only after failed portoenterostomy (13/28 vs. 0/19, P < 0.001). Increased serum bilirubin concentration >40 μmol/L at 3 months after portoenterostomy was a risk factor of upper gastrointestinal bleeding (odds ratio [OR] 17, 95% confidence interval [CI] 1.7-175, P = 0.017).

CONCLUSIONS

In future studies as well as clinical surveillance of BA patients' varices, successful and failed portoenterostomy patients should be approached as separate groups with divergent prognoses. After failed portoenterostomy, surveillance should start early, for example, at 6 months.

Biliary atresia in the Netherlands: outcome of patients diagnosed between 1987 and 2008

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.

Twenty-year transplant-free survival rate among patients with biliary atresia

BACKGROUND & AIMS

Surgical treatment with Kasai portoenterostomy has improved the prognosis for patients with biliary atresia, although most patients ultimately require liver transplantation. Well-described patients with long-term, transplant-free survival are scarce; we assessed liver status and health perception among Dutch patients who survived 20 years after therapy and investigated whether the rate of transplant-free survival increases with time.

METHODS

By using the Dutch national database for biliary atresia, we identified 104 patients, born between 1977 and 1988. We collected data on clinical characteristics, liver biochemistry, and ultrasonography from all transplant-free patients who were alive at age 20 years (n = 28; 27% of the patients). General health perception data (RAND-36) were collected at the last examination.

RESULTS

The 20-year transplant-free survival rate increased from 20% (10 of 49) in the 1977 to 1982 cohort to 32% (18 of 55) in the 1983 to 1988 cohort (P = .03). Twenty-one percent of the long-term survivors (6 of 28) had normal liver biochemistry test results and no clinical or ultrasonographic signs of cirrhosis. The general health perception of female, but not male, patients, was lower, compared with controls (RAND-36 score, 54 ± 14 vs 74 ± 18; P = .005).

CONCLUSIONS

More than 25% of patients with biliary atresia survive at least 20 years without liver transplantation in The Netherlands. Women with biliary atresia have a reduced perception of their health, compared with control patients. Twenty percent of long-term survivors are symptom-free, without clinical or ultrasonographic signs of cirrhosis or portal hypertension.

Prevention of vitamin K deficiency bleeding in breastfed infants: lessons from the Dutch and Danish biliary atresia registries

OBJECTIVE

Newborns routinely receive vitamin K to prevent vitamin K deficiency bleeding. The efficacy of oral vitamin K administration may be compromised in infants with unrecognized cholestasis. We aimed to compare the risk of vitamin K deficiency bleeding under different prophylactic regimens in infants with biliary atresia.

PATIENTS AND METHODS

From Dutch and Danish national biliary atresia registries, we retrieved infants who were either breastfed and received 1 mg of oral vitamin K at birth followed by 25 microg of daily oral vitamin K prophylaxis (Netherlands, 1991-2003), 2 mg of oral vitamin K at birth followed by 1 mg of weekly oral prophylaxis (Denmark, 1994 to May 2000), or 2 mg of intramuscular prophylaxis at birth (Denmark, June 2000-2005) or were fed by formula. We determined the absolute and relative risk of severe vitamin K deficiency and vitamin K deficiency bleeding on diagnosis in breastfed infants on each prophylactic regimen and in formula-fed infants.

RESULTS

Vitamin K deficiency bleeding was noted in 25 of 30 of breastfed infants on 25 microg of daily oral prophylaxis, in 1 of 13 on 1 mg of weekly oral prophylaxis, in 1 of 10 receiving 2 mg of intramuscular prophylaxis at birth, and in 1 of 98 formula-fed infants (P < .001). The relative risk of a bleeding in breastfed compared with formula-fed infants was 77.5 for 25 microg of daily oral prophylaxis, 7.2 for 1 mg of weekly oral prophylaxis, and 9.3 for 2 mg of intramuscular prophylaxis at birth.

CONCLUSIONS

A daily dose of 25 microg of vitamin K fails to prevent bleedings in apparently healthy infants with unrecognized cholestasis because of biliary atresia. One milligram of weekly oral prophylaxis offers significantly higher protection to these infants and is of similar efficacy as 2 mg of intramuscular prophylaxis at birth. Our data underline the fact that event analysis in specific populations at risk can help to evaluate and improve nationwide prophylactic regimens.

Hepatocellular carcinoma complicating biliary atresia after Kasai portoenterostomy

Kasai portoenterostomy (PE) increases the survival for children with biliary atresia (BA) and consequently postpones subsequential liver transplantation. All long-term survivors, however, develop complications of biliary cirrhosis. We report a case of hepatocellular carcinoma (HCC) in a 19-year-old male patient with BA and Kasai PE. The preoperative abdominal ultrasound and magnetic resonance imaging showed a large hepatic mass (diameter 10 cm). The serum alpha-fetoprotein level was within normal range. Pathologic findings of the mass, after orthotopic liver transplantation, demonstrated a well-differentiated HCC (T1N0M0). HCC is a rare complication of BA, but will intensively impair the survival. Therefore, clinicians should be alert to the development of HCC in this very young patient group. Repeated sequential magnetic resonance imaging of the native liver in patients with Kasai PE is necessary to monitor possible malignant transformation of liver nodules that may potentially develop as a result of chronic cholestatic liver disease.

(13)C-phenylalanine breath test correlates with liver fibrosis in postoperative biliary atresia

BACKGROUND

Values derived from the (13)C-phenylalanine breath test (PBT) may serve as an index for liver fibrosis and clinically predictive readings for liver diseases in adults. In the present study the PBT was conducted in postoperative biliary atresia (BA) children to evaluate phenylalanine metabolism in the liver, and the results based on biochemical data, especially the index on liver fibrosis, were compared with PBT findings.

METHODS

Hepatofunctional evaluations were conducted in 10 postoperative BA children with moderate (group B; n = 4) and severe (group A; n = 6) liver dysfunction, and the PBT results were compared with those of 13 normal healthy children (group C). Subjects were orally given single-bolus (13)C-phenylalanine at 3.5 mg/kg (maximum dosing: 100 mg) in the morning. Time-related exhaled gas was periodically collected until 120 min after dosing. The (13)CO(2) levels were monitored with gas chromatography-mass spectrometry before and after administration, and the (13)C excretion rate, (13)C cumulative excretion and time of maximum (13)C excretion rate were monitored accordingly.

RESULTS

Total bile acid, hyaluronic acid, type IV collagen 7S, total bilirubin or albumin and the PBT findings were significantly correlated. The PBT findings in group A were significantly lower those of group B, indicating that phenylalanine metabolism was markedly attenuated in the former.

CONCLUSION

The PBT values correlated well with liver fibrosis in postoperative BA children. Because PBT is a non-invasive approach, results from this method may serve as a useful and reliable index for post-surgical monitoring of children operated on for liver fibrosis.

Short-term results of Kasai operation for biliary atresia: experience from one institution

BACKGROUND

The purpose of this study is to review the short-term outcome of patients with biliary atresia (BA) treated by the Kasai operation at our institution.

METHODS

Ninety-two BA patients treated by the Kasai operation between January 1996 and December 2002 were reviewed. The diagnosis of BA was confirmed by intraoperative cholangiography. The outcome of treatment was categorized into two groups: jaundice-free (total bilirubin < 2 mg%) and persistent jaundice (>or= 2 mg%). The outcome of Kasai operation was evaluated 1 year after surgery. Data are expressed as mean +/- SD.

RESULTS

Average age at the time of surgery was 90.26 +/- 36.44 days. Only 22.8% (21/92) of patients had Kasai operation before 60 days of age. Histologically, 49 patients (54.4%) had liver fibrosis at the time of surgery. Of 92 patients, 17 were not included in outcome evaluation as they were less than 1-year postsurgery. Therefore, 75 patients could be evaluated for the outcome. Thirty-eight patients (50.67%) were jaundice-free 1 year after surgery. Liver histology and age at the time of the Kasai operation did not influence early outcome. The most common complication was ascending cholangitis.

CONCLUSION

Half of our BA patients who underwent Kasai operation were jaundice-free 1 year after surgery. The lack of impact of age and liver pathology on outcome is presumably due to the briefness of the follow-up. In general, our patients underwent Kasai procedure too late. It is therefore important for us to conduct a campaign to highlight the plight of these patients and the urgency of referral for neonates with jaundice.

Fluordeoxyglucose positron emission tomography contributes to management of pediatric liver transplantation candidates with fever of unknown origin

Fever of unknown origin (FUO) frequently complicates the management of pediatric patients with terminal chronic liver failure during the pretransplantation period and may lead to increased morbidity and mortality. Nonhepatic origins of systemic infections may render the patient unsuitable for transplantation whereas infections within the liver may require organ resection for a cure. Therefore, accurate localization of the infection focus is critical for optimal management of children on the waiting list for liver transplantation. Here we report our experience using [18 F]fluordeoxyglucose (FDG)-positron emission tomography (PET) to detect the origin of infection in 11 children with biliary cirrhosis presenting with FUO during the waiting period for liver transplantation. In 5 children, positive intrahepatic FDG-PET signals correlated with bacterial cultures of the excised liver and/or anatomic or histologic signs of infection. Based on the FDG-PET findings, these patients underwent transplantation after continuous antibiotic treatment with ongoing, recurrent episodes of fever. In 6 children, no abnormal hepatic FDG-PET signals were found and no infections could be detected in the liver. Transplantation in these patients was performed only after becoming afebrile. Standard imaging techniques did not reveal abnormalities compatible with infection in any of the children. In conclusion, in children with biliary cirrhosis and FUO on the waiting list for liver transplantation, information obtained by FDG-PET imaging may be useful for decisions on therapy and suitability for liver transplantation.

Late-presenting cholangitis and Roux loop obstruction after Kasai portoenterostomy for biliary atresia

BACKGROUND/PURPOSE

Late-onset cholangitis is an uncommon complication after the Kasai operation for biliary atresia. Experience with 3 recent patients illustrates appropriate management.

METHODS

Retrospective review of patients with late unexplained deterioration in liver function attributed to cholangitis. All underwent quantitative radioisotope hepatobiliary scans to identify the Roux loop obstruction and confirm postoperative resolution. The role of percutaneous transhepatic cholangiography and computed tomography scanning was reviewed.

RESULTS

Three patients aged 8, 13, and 17 years were identified. All 3 had had a successful Kasai portoenterostomy for type 3 biliary atresia and presented after several virtually trouble-free years with late-onset cholangitis. The radioisotope scans in all 3 patients showed poor tracer uptake by the liver and pooling of the radioisotope at the porta hepatis. Laparotomy confirmed a proximal Roux loop obstruction at the level of the mesocolic window in all. This required mobilization and adhesiolysis and, in 1, correction of an actual stenosis within the wall of the intestine at this level. All patients had normalization of their liver function postoperatively. All are now well and anicteric at a follow-up of 6 to 12 months.

CONCLUSIONS

Long-term survivors of the Kasai portoenterostomy for biliary atresia with immediate deterioration in liver function warrant investigation for possible Roux loop obstruction. Resolution of the obstruction allows preservation of their native liver.

Surgical experience in children with biliary atresia treated with portoenterostomy

OBJECTIVE

Biliary atresia is the result of a fibrosing destructive inflammatory process affecting intrahepatic and extrahepatic bile ducts, which lead to cirrhosis and portal hypertension. Without surgical intervention, mortality reaches 100%. The 5-year survival rate after portoenterostomy ranges from 13% to 60%, with approximately 60% of patients requiring liver transplantation at a later stage because of insufficient bile flow.

METHODS

This retrospective analysis includes 30 consecutive patients undergoing portoenterostomy for biliary atresia at our hospital.

RESULTS

The 5-year actuarial survival of the 30 patients was 68%. Thirteen patients (43.3%) died 3 days to 7 years after portoenterostomy. Four patients (13.3%) underwent liver transplantation 3 to 24 months after the Kasai procedure with a 100% survival. In 65% of patients without presence of cirrhosis, the portoenterostomy was successful, compared with 35% of cases with liver cirrhosis (p = 0.0148). Liver cirrhosis with extrahepatic biliary atresia alone was present in 5 of 17 patients (29%) as compared with 8 of 12 patients (66%) with intrahepatic biliary hypoplasia in addition to extrahepatic biliary atresia and cirrhosis.

CONCLUSIONS

Portoenterostomy remains the treatment of choice for patients with extrahepatic biliary atresia. However, the presence of cirrhosis portends a poorer prognosis and may be an indication for early transplantation. Cirrhosis is more commonly present in the setting of intrahepatic biliary hypoplasia and may account for the lower success rates of portoenterostomy in this group of patients. Five-year survival of the female patients was 88% as compared with 55% of the male patients.

Five- and 10-year survival rates after surgery for biliary atresia: a report from the Japanese Biliary Atresia Registry

PURPOSE

The aim of this study was to elucidate the epidemiology and short- and long-term results of biliary atresia in Japan analyzing the data of the Japanese Biliary Atresia Registry (JBAR).

METHODS

In 1989, the Japanese Biliary Atresia Society started a nationwide registry, JBAR, to investigate all aspects of biliary atresia. A total of 1,381 patients, 863 girls, 507 boys, and 11 unknown, were registered between 1989 and 1999. JBAR includes an initial and follow-up questionnaires. Using these patients' data, the incidence, sex distribution, associated anomalies, the type of obstruction, the type of operation, and the surgical results were evaluated. The 5- and the 10-year results of 735 patients who were registered initially in or before 1994 also were analyzed.

RESULTS

The incidence of biliary atresia was 1 in 9,640 live births. One hundred sixty-four patients (11.9%) had type I atresia of the common bile duct, 34 (2.5%) had type II atresia of the hepatic ducts, and 1,162 (84.1%) had type III atresia at the porta hepatis. Congenital associated anomalies were found in 19.6% of the patients including 33 cases associated with polysplenia. Impact of the age at operation on bile flow was not clear until 90 days of age, and after 90 days the bile flow rate worsened. The original Roux-en-Y procedure had been used in more than 50% of the patients since 1995. In 1999, 96% of the patients underwent the original Roux-en-Y procedure or the Roux-en-Y with an intestinal valve, and only 3 patients (3.5%) underwent other modifications. There were no significant differences in either the rate of disappearance of jaundice or the incidence of cholangitis among these 3 procedures. Of the 735 patients registered in or before 1994, 19 patients (2.6%) were lost to follow-up. The 5-year survival rates of patients registered in 1989, 1990, 1991, 1992, 1993, and 1994 were 62%, 64.5%, 61.3%, 59.0%, 58.7%, and 52.7% without liver transplantation (LTx), and 69.4%, 74.2%, 75.2%, 79.5%, 78%, and 78.3% with LTx, respectively. Although the overall 5-year survival rate changed from 69.4% to 78.3%, the difference was not statistically significant. According to the 10-year follow-up results of the 108 patients initially registered in 1989, 72 (66.7%) and 57 (52.8%) survived with and without the aid of LTx, respectively.

CONCLUSIONS

The overall 5- and 10-year survival rates were 75.3% (553 of 734) and 66.7% (72 of 108), respectively. In spite of the increasing number of survivors after LTx, there was no significant improvement in the 5-year survival rate. It was shown that the JBAR system was functioning well with only 19 patients lost to follow-up among the 743 patients registered from 1989 to 1994.

Cholangitis after hepatic portoenterostomy for biliary atresia: a multivariate analysis of risk factors

Cholangitis occurred in 59% of 77 patients who underwent the portoenterostomy procedure for biliary atresia between 1980 and 2000. Good postoperative bile drainage was associated with a lower risk of cholangitis than partial (odds ratio, 5.72; 95% CI, 2.89-11.3) or poor (odds ratio, 3.29; 95% CI, 1.89-5.7) bile drainage. Cholangitis was not an independent risk factor for death or liver transplantation.

Prophylactic oral antibiotics in prevention of recurrent cholangitis after the Kasai portoenterostomy

PURPOSE

The aim of this study was to evaluate the efficacy of trimethoprim-sulfamethoxazole (TMP/SMZ) and neomycin as the prophylactic agents against the recurrence of cholangitis in children with biliary atresia (BA) after a Kasai portoenterostomy.

METHODS

Nineteen BA patients aged 0 to 2 years, who had one episode of cholangitis after a Kasai portoenterostomy, were recruited in this study. Patients were assigned randomly into 2 groups: one (9 cases) with TMP/SMZ (TMP 4 mg/kg/d and SMZ 20 mg/kg/d, divided in 2 doses) and the other (10 cases) with neomycin (25 mg/kg/d, qid, 4 days a week). Another 18 BA patients aged 0 to 2 years, with cholangitis but not put on long-term prophylaxis, served as the historical control group.

RESULTS

The mean prophylactic periods were 14.6 months and 14.7 months in the TMP/SMZ and neomycin groups. Patients who received prophylaxis with either TMP/SMZ or neomycin had lower recurrence rates of cholangitis than those in the control group (P =.042 and.011). There was no difference in the recurrence rates of cholangitis between the TMP/SMZ and neomycin groups (P =.641). The survival rates were higher in the TMP/SMZ and neomycin groups than in the control group (P =.09 and.018).

CONCLUSIONS

Use of TMP/SMZ or neomycin is effective as a prophylactic agent against the recurrence of cholangitis after the Kasai portoenterostomy, but there is no difference in efficacy between these 2 regimens.

A population-based study on the incidence and possible pre- and perinatal etiologic risk factors of biliary atresia

OBJECTIVE

To study the incidence, etiologic risk factors, and outcome of biliary atresia.

STUDY DESIGN

Register study using Swedish national health databases. The study population consisted of 1,204,791 children, corresponding to 99% of the entire cohort of Swedish children born between 1987 and 1997, with an end point of follow-up at 2 years of age. Cases with biliary atresia with and without major heart malformations were identified with indicators from various national health databases.

RESULTS

Eighty-five cases with biliary atresia were identified, the incidence being 1 in 14,000. A major heart malformation was found in 13 (15%) cases. In a multivariate analysis, 4 independent risk factors were identified: high maternal age (odds ratio [OR] = 3.0), parity of at least 4 (OR = 2.2), prematurity (OR = 2.9), and low birth weight for gestational age (OR = 4.7). No significant differences were found in the distribution of birth months. The outcome did not differ between the two groups with and without major heart malformations, nor with respect to any of the risk factors.

CONCLUSIONS

The Swedish incidence of biliary atresia is similar to that found in other European countries. The identified risk factors may suggest the existence of a maternal vulnerability and the importance of viral infections transmitted from mother to fetus/neonate.

Immunosuppression as adjuvant therapy for biliary atresia

BACKGROUND/PURPOSE

Despite improvements in the surgical management of biliary atresia, the long-term incidence of progressive liver failure remains high. Because chronic inflammation involving both bile ducts and liver parenchyma contributes to the pathology, the authors have hypothesized that the liver damage may be altered using immunosuppressive therapy. The aim of this study was to examine the safety and efficacy of long-term steroid therapy in patients with biliary atresia.

METHODS

A retrospective analysis of all patients with biliary atresia treated with an hepatoportoenterostomy and postoperative steroid therapy at our 3 institutions was undertaken. Patients were treated uniformly with immunosuppressive doses of oral steroids for a minimum of 6 weeks after surgery.

RESULTS

Twenty-five infants with biliary atresia were treated with steroid therapy. Overall survival rate was 22 patients (88%) with a mean follow-up period of 50 months. Nineteen patients (76%) became jaundice free with native liver function. Four patients (16%) did not respond to treatment and required transplantation. Age less than 12 weeks was a crucial predictor of success of adjuvant steroid therapy. Cholangitis developed in 8 patients (32%). There were no complications caused by steroid therapy.

CONCLUSIONS

Steroid administration at immunosuppressive doses markedly improves the clinical outcome within the first 5 years after surgery as measured by jaundice-free status and survival without liver transplantation when compared with concurrent reports. These results suggest that immunosuppressive therapy is safe and has a positive impact on the clinical course of this disease. However, a randomized study is needed to ultimately prove such an hypothesis.

The frequency and outcome of biliary atresia in the UK and Ireland

BACKGROUND

Biliary atresia is an obliterative cholangiopathy of infancy that is fatal if untreated. Surgical treatment, the Kasai portoenterostomy, may restore bile flow and clear jaundice, and, if successful, achieve a 10-year survival of 90% with a native liver. The outcome of a 2-year cohort of children with biliary atresia in the UK and Ireland was assessed to find the current frequency, the factors influencing outcome, and the medium-term need for liver transplantation.

METHODS

Cases diagnosed between March, 1993, and February, 1995, were notified by paediatricians to the British Paediatric Surveillance Unit via a monthly reporting system. Confirmed cases were followed up by postal questionnaires to notifying paediatricians.

FINDINGS

93 cases were confirmed, a frequency of 1/16700 livebirths. Primary surgery was done in 91 children in 15 surgical centres with an early success rate for clearing jaundice of 55% overall. Centres were grouped according to caseload; group A had more than 5 cases/year and group B fewer than 5 cases/year. Early success was higher in group-A centres, odds ratio 2.02 (95% CI 0.86-4.73), but this did not reach statistical significance. Of 41 children in whom surgery was unsuccessful in clearing jaundice 9 (22%) died and 30 (73%) underwent liver transplantation. Survival without liver transplantation and overall survival were both significantly greater in group-A centres, rate ratios 0.48 (95% CI 0.27-0.86) and 0.32 (0.11-0.94). Actuarial 5-year survival without transplantation was 61.3% in group-A centres and 13.7% in groupB centres. Actuarial 5-year overall survival was 91.2% in group A and 75% in group B. Once centre size was taken into account, no other factor, including age at surgery, was predictive of survival without transplantation or overall survival.

INTERPRETATION

The outcome of children with biliary atresia is related to the caseload of the surgical centre where they have their primary surgery. Children with biliary atresia should be managed in surgical centres with a caseload of more than five cases annually.

Prognostic value of serum procollagen III peptide and type IV collagen in patients with biliary atresia

BACKGROUND/PURPOSE

Progressive hepatic fibrosis, in spite of a successful Kasai procedure, is a major problem in patients with biliary atresia (BA). Early identification of patients at risk would be of great value. N-terminal procollagen-III peptide (PIIIP) (which is a marker of fibrogenesis and, therefore, of on going inflammation), and type IV collagen (found in basement membrane extracellular matrix), were measured in patients with BA to determine their potential as prognostic markers.

METHODS

Thirty-three postoperative BA patients (11.0+/-3.7 years old) and 20 normal controls (10.5+/-2.8 years old) were studied. The BA patients were classified on the basis of their current liver function test results into three outcome groups. Group I (n = 9) had severe liver dysfunction, group II (n = 13) had moderate, and group III (n = 11) had good liver function. Serum P-III-P and type IV collagen values were determined by radioimmunoassays and one step sandwich enzyme immunoassay.

RESULTS

In group I, serum PIIIP (1.93+/-0.64 U/mL) and type IV collagen levels (363.5+/-69.5 ng/mL) were significantly higher than in group II (PIIIP [1.32+/-0.25 U/mL], type IV collagen [225.3+/-45.4 ng/mL]; P < .01). There were increased levels in serum PIIIP and serum type IV collagen in group II compared with group III (PIIIP [1.01+/-0.25 U/mL], type IV collagen [171.3+/-47.2 ng/mL]; P < .01). There were no significant differences in serum PIIIP and type IV collagen levels between group III and controls.

CONCLUSION

The authors conclude that serum levels of PIIIP and type IV collagen may be useful in the long-term follow-up of BA patients after Kasai's portoenterostomy.

Impact of the development of a liver transplant program on the treatment of biliary atresia in an institution in Japan

Kasai operation for biliary atresia (BA) and living-related liver transplantation (LRLT) for failed Kasai cases have been performed by the same team in our hospital. Outcome of the treatment for BA in the pretransplantation and posttransplantation era in our institution were compared. As the "pre" group, 35 children first underwent the Kasai operation between 1982 and 1989. The "post" group consisted of 25 patients who underwent Kasai after introduction of the LRLT program in our hospital (1990). As for the reconstruction procedure after portal dissection during Kasai, jejunal interposition hepatic portoduodenostomy for the pre group was intentionally changed to Roux-en-Y procedure for the post group to decrease the risk of duodenal leakage after LRLT. Patients who needed revision of the Kasai decreased from 57% for the pre group to 28% for the post group. There was only one re-revision in the post group compared with seven in the pre group. In the pre group, 10 patients (28.6%) died at age 6 to 16 (mean, 8.5) months before the transplantation program was initiated. In the pre group, three patients could receive a cadaveric liver transplantation in other countries, and seven had LRLT in our hospital. Ten patients (40%) in the post group had LRLT at 7 to 22 (mean, 9.3) months old, and no deaths occurred in this group. When the patients who had liver dysfunction were excluded, the percentage of the patients who could be expected to survive and accomplish growth without undergoing liver transplantation was similar for the two groups, (31.4% v 36%). The change in the reconstruction procedure and the tendency for fewer revisions of Kasai procedure were effects of the start of the liver transplant program. As a general strategy for BA, Kasai operation should be the initial procedure, followed by liver transplantation for failed Kasai. In the late-diagnosed patients, primary LRLT can be considered if the liver has already been cirrhotic. LRLT in the infantile period is a significant component of this strategy for helping all patients to survive.

Biliary atresia: the King's College Hospital experience (1974-1995)

The survival experience of 338 infants born with biliary atresia between January 1973 and December 1995 was analyzed. All the infants had their initial surgery at a single UK centre. These infants were divided into three groups based on year of birth; group 1 (1970s, n = 38); group 2 (1980s, n = 182), and group 3 (1990s, n = 118). The data from group 1 were incomplete and selected, and comparisons with the remaining groups were therefore restricted. However, all infants who had been treated since 1980 underwent portoenterostomy or hepaticojejunostomy and were included.

RESULTS

In the whole cohort there were 89 deaths (26%), 79 children (23%) who underwent liver transplantation and 170 children (50%) who were alive at last follow-up. The 5- and 10-year actuarial survival for group 2 was 50% and 41%, respectively and the 5-year actuarial survival for group 3 was 60%. Overall, 57 children have survived to 10 years after surgery for biliary atresia. There has been a progressive fall in the age at surgery from a median of 77 days in group 1, through 69 days in group 2 to 56 days in group 3 (P < .0001). However, there was no significant difference in outcome to 5 years between the age cohorts (< 40 days, 41 to 60 days, 61 to 99 days, and > or = 100 days; P > .1) for the infants treated since 1980 (n = 200).

CONCLUSIONS

Portoenterostomy is an effective long-term procedure for biliary atresia in about 40% to 50% of infants. The remaining 50% to 60% will require transplantation mostly within 2 years of age, although there is also a continuing need beyond 5 and 10 years. The age at surgery has limited usefulness as a predictor of survival after portoenterostomy and certainly should not be used to dictate primary treatment.

Treatment of biliary atresia by portoenterostomy and liver transplantation: The Queen Mary Hospital, Hong Kong experience

Ninety three out of 96 patients with biliary atresia (BA) underwent Kasai 1 portoenterostomy and 11 children subsequently underwent 12 liver transplantation (LTX) procedures which included 8 living related liver transplants (LRLT), 3 reduced-size liver transplants (RSLT) and 1 orthotopic liver transplantation (OLT). During a follow-up period of 3-206 months (mean, 73 months) after portoenterostomy and 3-63 months after LTX, 50% of 96 patients are alive and well with total clearance of jaundice while 12% are mildly jaundiced, 10% are deeply jaundiced and 28% have died. Two of the 3 patients who did not undergo portoenterostomy and 25 from the portoenterostomy group have died. Of the latter group, 22 deaths occurred before, and 3 after the introduction of LTX therapy respectively. Of the 68 long-term survivors, 32 are less than 5, and 36 are 6-17 years old. Complete clearance of jaundice was achieved in 55% of patients irrespective of whether portoenterostomy was initially performed at < 10 or between 10 and 12 weeks. Portoenterostomy performed beyond 13 weeks was associated with declining results. We conclude that (1) portoenterostomy combined with liver transplantation, when indicated, has given patients with BA a much better prognosis and (2) pediatric LTX in our institute is a well established procedure with 100% patient and 88% primary graft survival.

The treatment of biliary atresia in Europe 1969-1995

European studies of biliary atresia have suggested that the aetiology is heterogeneous. Histological studies of the liver and biliary remnants excised at portoenterostomy have failed to identify any prognostic features except for the size of bile ductules in the porta hepatis. Most of the major series have confirmed that there is a relationship between age at portoenterostomy and clearance of jaundice which has been achieved in more than 67% of infants under 10 weeks of age. Cholangitis reduced survival and bleeding from esophageal varices has occurred in more than 19% of long-term survivors. The 5-year jaundice-free survival rate after portoenterostomy is 37% and the 10 year rate is 18%. It is predicted that these survival rates will improve. Orthotopic transplantation now results in long-term survival in 70% of patients who fail the portoenterostomy operation and long-term survival is now achieved in a majority of children born with biliary atresia.

Is early response to portoenterostomy predictive of long-term outcome for patients with biliary atresia?

PURPOSE

Therapy for biliary atresia (BA) typically involves portoenterostomy (PE). In light of the development of liver transplantation (LT) as an option for therapy in infancy, the authors reviewed their experience to determine factors that might predict the requirement for LT.

METHODS

Cases of BA diagnosed between September 1980 and September 1994 were reviewed. Responses to PE were rated as poor (PR; death or LT by 3 years), temporary (TR; LT > 3 years), or good (GR; anicteric).

RESULTS

Twenty-nine patients were identified; 24% were native indian or Inuit. Twenty-three had PE; 11 responded. Seven (32%) became anicteric and continue to do well (GR). Four (18%) required LT after age 3 (TR). Twelve patients had PR; 3 underwent LT (average age, 1.3 years), 4 are listed for LTX, and 5 died by age 2.8 years. (Six patients did not have PE; 2 died in infancy and 4 had LT.) All transplant recipients are well. Factors associated with PR were older age at time of surgery (67 +/- 7 days v 51 +/- 4 days in the GR group), nadir of AST (273 +/- 84 U/Lv 70 +/- 26 U/L in the GR group), and number of post-PE complications (3.6 v per patient v 1 per patient in the GR group). TR was differentiated from GR by bilirubin nadir (46 +/- 10 mumol/Lv 14 +/- 3 mumol/L, respectively) and rate of bilirubin decline (2.6 +/- 1.5 mumol/L/d v 10.8 +/- 3.0 mumol/L/d, respectively). (P < .05 for all comparisons.)

CONCLUSION

Outcomes are comparable to those of North American series, but the incidence is lower overall and is higher among natives. Factors that correlate with outcome include age at time of surgery, post-PE complications, postoperative decline and rate of decline of bilirubin and AST. The latter had not been reported previously and may prove useful in planning therapy for partial responders after PE.

Periodic bile cultures and irrigation of the external jejunostomy for cholangitis in biliary atresia

We retrospectively investigated the use of periodic bile cultures and irrigation of the external jejunostomy for prevention or treatment of postoperative cholangitis in 11 infants who had undergone the Suruga II modification with external jejunostomy for biliary atresia. Periodic cultures obtained from bile in the external jejunostomy were done weekly in all patients. Staphylococci were first cultured 1 week after operation, followed by intestinal flora such as enterococci, Pseudomonas, Klebsiella, or Enterobacter. Most of the cultures revealed two or more microorganisms. Susceptibility testing indicated the effective antibiotics for the treatment of each case of cholangitis. Therefore, periodic bile cultures and irrigation of the external jejunostomy provide important information for prevention or treatment of postoperative cholangitis, especially in the early postoperative period.

Timely referral of infants with jaundice: case report

Family physicians should see all infants between 2 and 4 weeks of age to exclude persistent jaundice. Early identification of infants with jaundice due to liver disease might lead to better outcomes not only for infants with extrahepatic biliary atresia but for all infants with neonatal liver diseases. The case illustrates the consequences of late identification.

Calculation of biliary atresia prognostic index using a multivariate linear model

The purpose of this study was to determine the relative value of liver function markers in predicting the magnitude of morbidity and to develop a quantitative estimate of the prognostic risk using a multivariate regression model in patients who have been operated on for biliary atresia. The study sample consisted of 37 patients who had undergone a Kasai portoenterostomy; the jaundice disappeared in 32 and persisted in five. A computer-based stepwise regression procedure produced the linear predictive models by the equation: biliary atresia prognostic index (BAPI) = 9.2 Cu:Zn + 1.0 ZTT + 3.2 TB - 0.05 ChE + 9.9 for infants under 1 year of age, and BAPI = 10.3 Cu:Zn + 0.8 ZTT + 0.03 GGTP - 0.12 ChE + 25.6 for children over 1 year of age. In validation of these models, the indexes fluctuated from -17 to 122, and the degree of morbidity increased linearly with the increase in BAPI. Postoperatively the patients were classified into four categories according to the dynamics of their postoperative course: A (BAPI < 25), successful cases that should not require liver transplantation (40.5%); B (25 < or = BAPI < or = 50), improved cases that have extended survival with their native liver (29.7%); C (50 < BAPI < or = 75), cases that improved in terms of disappearance of jaundice but ultimately will require liver transplantation (8.1%); and D (BAPI > 75), cases that require early referral for transplantation (21.6%). (The percentages indicate the distribution rate of patients at the time of final follow-up evaluation.) These models allow quantification of the risk of morbidity from progressive liver cirrhosis in the individual patient, permitting the clinician to consider whether such patients should be considered for liver transplantation.

The Kasai procedure in the treatment of biliary atresia

From 1978 to 1992, 62 patients were diagnosed as having extrahepatic biliary atresia (EHBA) at Childrens Hospital Los Angeles. The patients presented with either persistent jaundice, alcoholic stools, and/or hepatomegaly. Hepatobiliary IDA scans were performed in 47 of the patients; 46 had results typical of EHBA. Fifty-nine of the 62 patients underwent a Kasai portoenterostomy; three patients were more than 4 months of age at initial presentation and were referred directly for liver transplantation. The preoperative total bilirubin level for all patients averaged 8.6 mg/dL (range, 4.1 to 18.1). All patients underwent a standardized Kasai procedure using a 40-cm Roux-en-Y intestinal segment performed in the end-to-side fashion. Postoperative management included oral antibiotics and fat-soluble vitamins for at least 9 months. Long-term complications included cholangitis in 20 cases and portal hypertension in 25, which led to variceal hemorrhage in 12 cases. Growth rates were at or above the 50th percentile for age in 59% of the Kasai patients. Forty-one of the 59 Kasai patients survived (69.5%); six deaths occurred within 2 years after the Kasai procedure. Twelve patients were lost to follow-up within 2 years after surgery, and for calculation of mortality were presumed dead. Seventeen patients had follow-up for 5 or more years, 13 had follow-up for 2 to 5 years, and 29 had follow-up for less than 2 years. The average total bilirubin level for the patients with less than 2 years of follow-up was 7.9 mg/dL (0.3 to 20.8), and that for the patients with more than 2 years of follow-up was 1.6 mg/dL (0.3 to 18.1). Orthotopic liver transplantation was performed in 11 Kasai patients, in whom chronic liver failure eventually developed. Rejection occurred in one of these patients, which required retransplantation. Based on these results, the Kasai portoenterostomy procedure continues to offer palliation, if not long-term success, in a large percentage of patients with EHBA.

Outcomes of ileocolic conduit for biliary drainage in infants with biliary atresia; comparison with Roux-en-Y type reconstruction

This study was undertaken to define the role of an ileocolic conduit that was devised as anti-reflux procedure in comparative study with Roux-en-Y type reconstruction in infants with biliary atresia treated at a single institution. The ileocolic conduit (IC) consisted of 30 cm of distal ileum anastomosed to the portahepatis and a 10-cm segment of ascending colon vented through the abdominal wall, which was later anastomosed to the second portion of the duodenum. In the Roux-en-Y type reconstruction (RY), 40 to 60 cm of jejunum was used for the hepatic limb. Twenty-three infants in group IC and 16 infants in group RY were entered in this study. Mean ages at definitive surgery were 65.3 +/- 23.1 days for group IC and 65.0 +/- 19.5 days for group RY. The two groups were compared for the postoperative outcomes in terms of bile excretion, incidence of cholangitis, esophageal varices, survival rate, and the effects on physical development. The follow-up ranged from 4 to 15 years. Bile excretion was obtained in all infants in both groups. Twenty infants (87.0%) in group IC and 10 infants (62.5%) in group RY became anicteric. Cholangitis occurred in 60.9% of group IC, compared with 83.3% for group RY, in which 6 infants required revision to complete diversion of Roux-en-Y limb (Suruga II). There was the same occurrence rate of esophageal varices for both groups. However, the varices tended to develop later in group IC (53.0 +/- 18.4 months) than in group RY (12.7 +/- 6.0 months) (P < .02).(ABSTRACT TRUNCATED AT 250 WORDS)

Sequential treatment of biliary atresia with Kasai portoenterostomy and liver transplantation: a review

Biliary atresia is the most frequent cause of chronic cholestasis in infants. When left untreated, this condition leads to death from liver insufficiency within the first 2 yr of life. The modern therapeutic approach consists of a sequential strategy with Kasai portoenterostomy as a first step and, in case of failure, liver transplantation. After portoenterostomy, no more than 20% to 30% of patients will live jaundice-free into adulthood. Illness in another third will be palliated, and these patients have extended survival, delaying liver transplantation to later childhood (2 to 15 yr). The remaining 30% to 40% will not benefit from the Kasai operation and will die of liver failure in infancy. The annual need of liver transplantation for biliary atresia is one case per million people. This indication represents 35% to 67% of the reported series of pediatric liver transplantation and between 5% and 10% of the indications for liver transplantation, all ages included. Approximately four of five children transplanted for biliary atresia will become long-term survivors with good physical and mental development; recurrence of the disease after transplantation has not been observed. Because most candidates are young children (< 3 yr) of small size (< 10 kg), there is a shortage of size-matched donors (which has been alleviated by the use of innovative techniques such as reduced and split livers). The resulting redistribution of the adult donor liver pool is ethically justified by the equal quality of the results after transplantation of a full-size or partial graft.

Use of neomycin as the prophylaxis against recurrent cholangitis after Kasai portoenterostomy

Ascending cholangitis after portoenterostomy for biliary atresia often leads to significant morbidity. The long-term prognosis also involves recurrent and frequently recalcitrant bouts of cholangitis. Attempts at prophylaxis with use of oral antibiotics are frequently unsuccessful. The authors describe three patients who, after successful portoenterostomies, were plagued with recurrent bouts of cholangitis, despite the use of a variety of antibiotics. The authors instituted oral neomycin as prophylaxis and nearly eliminated this serious complication.

Current concept of the treatment of biliary atresia

Hepatic portoenterostomy (Kasai operation) for the patient with biliary atresia (BA) can restore the bile flow in approximately 80% of children operated on before 60 days of life [1]. However, in terms of long-term survival, according to a recent nationwide survey among the major pediatric centers in Japan, only 325 of 2013 patients had more than 10 years' survival, and only 157 patients (7.8%) remained jaundice-free with normal liver function [2]. About 20% of BA cases without jaundice are generally able to survive for long periods; and most of those patients have portal hypertension or abnormal liver function [3-5]. As the results of liver transplantation have improved, controversy has arisen over the optimal care of these children [4, 6, 7]. Some investigators have claimed that transplantation is the favored primary therapy for most patients with BA [8]. We are thus at a turning point concerning the primary therapy of BA, which makes it necessary to determine the exact indications for the Kasai portoenterostomy and the timing of liver transplantation. This paper describes our strategy for the optimal treatment of BA patients based on our 117 patients who have had various form of portoenterostomy.

Simultaneous correction of biliary atresia and small bowel atresia in the neonate

The coexistence of biliary atresia and small bowel atresia has been described. However, attempts to correct the biliary atresia at the same time as small bowel atresia repair have not been detailed. In 1986, a 2,170-g female was delivered at 36 weeks' gestation. Postpartum, duodenal obstruction was suspected after oral feedings were not tolerated. At 37 hours after birth, laparotomy showed unsuspected biliary atresia in addition to intestinal malrotation, duodenal web, and type IIIb jejunal atresia with an apple-peel configuration of the upper jejunum and mesentery supplied by the superior mesenteric artery with normal small bowel length and normal ileal mesentery. A modified Roux-en-Y hepatic portoenterostomy was performed using the blind end of the apple-peel configuration of jejunum, with a side-to-side duodenojejunostomy 25 cm from the portoenterostomy. Microscopic examination of the fibrous extrahepatic biliary tissue showed a disarray of small bile ductules. The maximal ductal size at the portoenterostomy site was 600 microns. A liver biopsy specimen showed normal architecture with eosinophils infiltrating the portal triads and periductal areas. Postoperatively, she has maintained normal growth and development with no episodes of cholangitis. Liver biopsies at 1 year and 3 years were normal. At 4 years, total and conjugated bilirubin, serum proteins, liver enzymes, coagulation factors, and trace elements were normal. We conclude that simultaneous correction of biliary atresia and small bowel atresia can be accomplished in the neonate with excellent early results.

Paediatric liver transplantation: life after portoenterostomy in biliary atresia

Seventy-five percent to 80% of patients with biliary atresia (BA) will be candidates for paediatric liver transplantation (PLTx) throughout the first 14 years of life. They form the main group of recipients in our Paediatric Liver Transplant Unit. Of 48 children transplanted, 21 (44%) had BA. These patients present particular features, average weight of 12 kg, mean age of 3 years, and severe malnutrition prior to PLTx, which distinguish them from other paediatric candidates. With the advent of PLTx, portoenterostomy (PE) has ceased to be the only recourse for treating the majority of patients with BA. Different factors converge in these patients: some, including haemorrhage and adhesions, may present technical difficulties, and others, such as infections (19% in this series) due to severe malnutrition and malabsorption and consequent chronic rejection (14% in this series), often lead to death in the postoperative period (33% in this series). BA is treated by all paediatric surgeons, but the overall success rate now depends not only on PE but also on PLTx. In an attempt to facilitate possible later PLTx in pts with BA, the authors as paediatric surgeons performing PE or PLTx present surgical modifications and emphasize the most important medical aspects conducive to the improved general status of these pts. Our aim was to establish guidelines for taking full advantage of PE while preventing posterior problems and facilitating future transplant surgery.

The efficacy of Kasai operation for biliary atresia: a single institutional experience

To assess the efficacy of Kasai operation for biliary atresia, 60 cases during a 14-year period (1976 to 1989) at this institution were reviewed. Thirty-four (56.7%) underwent operation within 90 days of life, 11 (18.3%) between 90 and 120 days and 15 (25.0%) beyond 120 days. Fifty-six underwent hepaticoportojejunostomy and 4 underwent hepaticoportocholecystostomy. Follow-up was 1 to 14 years (mean, 7.2 years). The postoperative follow-up of these 60 patients was categorized into five groups: group A (16 patients, 26.7%) was characterized by survival greater than 3 years and without jaundice; group B (3 patients, 5.0%) was defined as survival greater than 3 years, but with jaundice; group C (11 patients, 18.3%) was defined by survival but follow-up less than 3 years, (this group was further divided into C1 [7 patients, 11.7%] if anicteric and C2 [4 patients, 6.7%] if icteric); group D (2 patients, 3.3%) was patients who underwent liver transplantation; and group E (28 patients, 46.7%) was the group of patients who died at time of review. Group A and group C1 were interpreted as success after Kasai operation; hence, the potential success rate in this series was 38.3% (23 patients). They were long-term survivers, and most of them performed normal activities appropriate for their ages. We conclude that approximately one third of patients with biliary atresia would benefit from or be cured by this operation, which should be the first attempt in the treatment of this disease entity.

Intrahepatic bile duct loss in biliary atresia despite portoenterostomy: a consequence of ongoing obstruction?

The histological and immunohistochemical characteristics of the liver in 44 children (28 boys, 16 girls) with extrahepatic biliary atresia at different stages of the clinical course were studied. Thirty-four wedge liver biopsy specimens taken during Kasai operations (25 specimens) and relaparotomy (9 specimens) and 20 hepatectomy explants taken at the time of transplantation were examined. Routine histological stains and monoclonal antibodies against different molecular weight cytokeratins and HLA-DR were used. The histopathological changes and the pattern of cytokeratin expression observed during the course of the disease were suggestive of persistent or recurrent extrahepatic biliary obstruction that occurred despite the Kasai operation and eventually led to cirrhosis and liver failure. Quantitative studies showed a progressive loss of intrahepatic bile ducts over the time course of the disease. This destruction of bile ducts had a geographic anatomical distribution in hepatectomy specimens, and in two livers it occurred predominantly in only one lobe. This geographic distribution of the vanishing bile ducts probably indicates an unpredictable and uneven obliteration of bile ducts in the porta hepatis during portoenterostomy wound healing and scarring.

Update of pediatric liver transplantation

Liver transplantation is an effective and widely accepted therapy for children with end-stage liver disease. Major indications include primary liver disease, resulting in hepatic insufficiency, or severe morbidity secondary to chronic non-progressive liver disease and metabolic diseases of the liver. Liver replacement should not be considered if there is an acceptable alternative therapy. Relative contraindications to transplantation include irreversible impairment of other organ systems, major systemic infection and diseases expected to recur after transplantation. Early referral for pre-transplant evaluation is important to confirm the proper diagnosis and determine priority for transplantation, to identify potential contraindications, and to assist in supportive care of the patient with chronic liver disease. Innovations such as reduced-sized liver grafts and most recently, living related liver transplantation have increased the donor supply of organs for small infants and significantly reduced pre-transplant mortality. In addition, living donor transplantation allows infants to benefit from transplantation before developing severe complications of end-stage liver disease and reduces the incidence of primary graft non-function and rejection. Immunosuppression following transplantation is maintained with methylprednisolone, azathioprine and cyclosporine. Acute rejection is treated with short bursts of high-dose corticosteroids and when necessary OKT3. With this approach, 90% of the episodes of rejection can be successfully controlled. Survival after transplantation has steadily improved and survival rates of 70%-90% are routine. Following transplantation, children experience rapid nutritional restoration, increased muscle strength, marked progress in gross motor development and improved general health.

A valved hepatic portoduodenal intestinal conduit for biliary atresia

Forty-six consecutive patients with biliary atresia were operated on at our institution during the 11-year period between 1978 and 1989. Their ages at operation ranged from 18 to 153 days (mean, 59 days). After dissecting the porta hepatis structures by Kasai operation, a biliointestinal anastomosis was constructed with a valved hepatic portoduodenal intestinal conduit in all cases. The intestinal valve is an intussuscepted muscular valve. Valvular function was examined radiologically. The upper gastrointestinal series demonstrated no reflux of contrast material into the conduit proximal to the valve and liver scintigraphy demonstrated that radioactive isotope drained readily into the duodenum through the valve. Thirty-nine of the forty-six patients (85%) had bile drainage after initial operation. At present 30 patients (65%) are alive without jaundice, 6 (13%) are alive with jaundice, and 10 (22%) are dead. The 5-year jaundice-free survival rate was 64%. Cholangitis occurred in 9 of 39 patients (23%) who had obtained apparent bile drainage: 5 had tractable cholangitis and 4 had refractory cholangitis. Reoperation restored bile flow in 2 of 8 patients who abruptly ceased to have bile drainage without cholangitis. In conclusion, with a valved hepatic portoduodenal intestinal conduit, the incidence of cholangitis was decreased, its medical control became easier, and the survival rate was improved.

Long-term outcome after surgery for biliary atresia. Study of 40 patients surviving for more than 10 years

To define long-term prognosis of children who underwent surgery for biliary atresia, a retrospective study was undertaken in 122 children who underwent one of the Kasaï procedures between 1968 and 1977. Forty of the 122 children (32.7%) were alive after 10 years. Firm hepatomegaly was present in 31 and splenomegaly in 29 children. Serum bilirubin or all liver function tests were normal in 21 and 11 children, respectively; survival rate decreased with the age at operation, but no significant difference was observed in the rate of children surviving with normal serum bilirubin whether they underwent surgery before age 2 months or between 2 and 3 months. Twenty-four had esophageal varices and 15 experienced gastrointestinal bleeding. Normal liver-function tests and absence of portal hypertension were observed in 11 of 122 children. These results indicate that Kasaï's procedures were helpful in a significant proportion of children with biliary atresia who underwent surgery during this period. However, 80% of children who initially underwent surgery with Kasaï's procedures should eventually undergo liver transplantation.