Biliary atresia

Liver transplant for biliary atresia is associated with a worse outcome - Myth or fact?

BACKGROUND

Liver transplant for biliary atresia (BA) has been reported to be associated with worse outcome, but this remains controversial. The objective of this study is to compare the outcomes of BA and non-BA recipients.

METHODS

Recipients with age <18years were reviewed except cases of retransplantation. Intratransplant and posttransplant complications as well as survivals were evaluated.

RESULTS

119 patients, with median follow-up period 8.5years, were studied (DDLT=33; LDLT=86/M:F=56:63), and 68% (n=81) were BA patients. While demographic data were comparable between two groups of recipients, BA patients had a worse pretransplant PELD/MELD score (15.2 vs 4.0, p=0.021). Transplantation takes a longer time in the BA group (580min vs 400min, p=0.065) with more blood loss (720ml vs 500ml, p=0.072). The incidence of transplant-related complications was 30.3% (36/119) (Table 1). There was no significant difference between incidences of vascular complication, but biliary complication was more common in the BA group. Overall, the survivals between the two groups were comparable.

CONCLUSIONS

Liver transplant is an effective surgical treatment for BA patients. When compared to other indications, results are not inferior. Previous Kasai operation is not necessarily associated with adverse outcomes.

Newborn Screening for Biliary Atresia

Biliary atresia is the most common cause of pediatric end-stage liver disease and the leading indication for pediatric liver transplantation. Affected infants exhibit evidence of biliary obstruction within the first few weeks after birth. Early diagnosis and successful surgical drainage of bile are associated with greater survival with the child's native liver. Unfortunately, because noncholestatic jaundice is extremely common in early infancy, it is difficult to identify the rare infant with cholestatic jaundice who has biliary atresia. Hence, the need for timely diagnosis of this disease warrants a discussion of the feasibility of screening for biliary atresia to improve outcomes. Herein, newborn screening for biliary atresia in the United States is assessed by using criteria established by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Published analyses indicate that newborn screening for biliary atresia by using serum bilirubin concentrations or stool color cards is potentially life-saving and cost-effective. Further studies are necessary to evaluate the feasibility, effectiveness, and costs of potential screening strategies for early identification of biliary atresia in the United States.

Impact of Kasai portoenterostomy on liver transplantation outcomes: A retrospective cohort study of 347 children with biliary atresia

Biliary atresia (BA) is the main diagnosis leading to liver transplantation (LT) in children. When diagnosed early in life, a Kasai portoenterostomy (Kasai-PE) can prevent or postpone LT. Instances of previous operations can result in difficulties during the LT. We hypothesized that a previous Kasai-PE could affect LT outcomes. A retrospective cohort study of 347 BA patients submitted to LT between 1995 and 2013 at Hospital Sírio-Libanês and A. C. Camargo Cancer Center was conducted. Patients were divided into those with a previous Kasai portoenterostomy early failure (K-EF), Kasai portoenterostomy late failure (K-LF), and those with no Kasai portoenterostomy (No-K). Primary outcomes were patient and graft survival. A total of 94 (27.1%) patients had a K-EF, 115 (33.1%) had a K-LF, and 138 (39.8%) had No-K before LT. Children in the K-LF group were older and had lower Pediatric End-Stage Liver Disease (PELD) scores. Patients in both K-EF and K-LF groups had more post-LT biliary complications. After Cox-multivariate analysis adjusting for confounding factors to determine the influence of Kasai-PE on patient and graft survival, the K-LF group had an 84% less probability of dying and a 55% less chance to undergo retransplantation. The K-LF group had a protective effect on posttransplant patient and graft survival. When properly performed, the Kasai procedure can postpone LT and positively affect outcomes. Having a K-EF and having not performed a Kasai-PE had the same effect in patient and graft survival; however, a previous Kasai-PE can increase post-LT complications as biliary complications and bowel perforations.

Can neonatal hepatitis be more fatal than biliary atresia?

BACKGROUND/AIMS

The basic problem in diagnosis of neonatal cholestasis (NC) is to differentiate biliary atresia (BA) from other non-obstructive disorders. Because if bile flow cannot be provided by surgery, BA leads to cirrhosis and death within the first year of life. The aim of the present study is to determine histopathological features that may help to differentiate BA from neonatal hepatitis (NH).

MATERIAL AND METHODS

This retrospective study was carried out on 105 liver biopsy specimens of 74 infants with NC who were diagnosed between 2003 and 2012.

RESULTS

The mean age was 76.5 ± 40.64 days. The most valuable biopsy findings for the discrimination between NH and BA, in decreasing order of importance, were ductular proliferation (p < 0.001), cholestasis in neoductuli (p < 0.001), fibrosis (p = 0.002), and extramedullar hematopoiesis (p = 0.02). While Kasai operations were performed in 19 cases, liver transplantation was performed in 10 cases. Survival rate among the death cases with BA was longer than the survival time of the death cases with NH (p = 0.023). Currently more children live with a close to normal quality of life with portoenterostomy and/or liver transplantation. On the contrary, NH can be more fatal with associated disorders such as growth retardation, specific infections, respiratory distress, and metabolic or endocrine diseases.

Hemorrhagic diathesis as the presenting symptom of neonatal cholestasis

A 4-week-old infant presented with a coagulation disorder resulting from a vitamin K deficiency. The vitamin K deficiency was caused by neonatal cholestasis due to biliary atresia. Jaundice, hepatomegaly and pale stools are the predominant presenting symptoms of biliary atresia, none of which were recognized in our patient before admission. However, the patient presented with bleeding caused by vitamin K deficiency. She was fully breastfed and had received adequate doses of vitamin K at birth and from the age of 1 week. In case of a hemorrhagic diathesis due to neonatal cholestasis, timely identification of treatable underlying disorders, in particular biliary atresia, is important because an early surgical intervention results in a better prognosis. Meticulous history taking and a thorough physical exam can be decisive for an early diagnosis and subsequent intervention.

Medical status of 219 children with biliary atresia surviving long-term with their native livers: results from a North American multicenter consortium

OBJECTIVES

To examine the medical status of children with biliary atresia (BA) with their native livers after hepato- portoenterostomy (HPE) surgery.

STUDY DESIGN

The Childhood Liver Disease Research and Education Network database was utilized to examine subjects with BA living with their native livers 5 or more years after HPE and to describe the prevalence of subjects with BA with an "ideal" outcome, defined as no clinical evidence of chronic liver disease, normal liver biochemical indices (aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase, platelet count, total bilirubin, international normalized ratio, and albumin), and normal health-related quality of life 5 or more years after HPE.

RESULTS

Children with BA (n = 219; 43% male) with median age 9.7 years were studied. Median age at HPE was 56 (range 7-125) days. Median age- and sex-adjusted height and weight z-scores at 5-year follow-up were 0.487 (IQR -0.27 to 1.02) and 0.00 (IQR -0.74 to 0.70), respectively. During the 12 preceding months, cholangitis and bone fractures occurred in 17% and 5.5%, respectively. Health-related quality of life was reported normal by 53% of patients. However, only 1.8% met the study definition of "ideal" outcome. Individual tests of liver synthetic function (total bilirubin, albumin, and international normalized ratio) were normal in 75%, 85%, and 73% of the study cohort.

CONCLUSION

Cholangitis and fractures in long-term survivors underscore the importance of ongoing medical surveillance. Over 98% of this North American cohort of subjects with BA living with native livers 5 or more years after HPE have clinical or biochemical evidence of chronic liver disease.

[Prenatal diagnosis of gallbladder abnormalities: a review]

OBJECTIVES

Our objective was to review the possible consequences and management possibilities of fetal gallbladder abnormalities.

MEANS AND METHODS

A search through publications was conducted using the Pubmed database.

RESULT

The majority of fetal gallbladder abnormalities are benign (absence, malformation, cholelithiasis, sludge...). When the absence of gallbladder is isolated, biliary tract atresia, that is a rare but severe disease, must be evoked.

CONCLUSION

An extensive morphological analysis of the fetus is required in cases with gallbladder abnormalities. An amniocentesis for caryotype analysis must be proposed when an absent gallbladder is associated with other fetal abnormalities and in all cases of absent gallbladder for digestive enzymes evaluation to rule out a biliary atresia.

Identification of the plasma metabolomics as early diagnostic markers between biliary atresia and neonatal hepatitis syndrome

Early detection is the most effective way to improve the clinical outcome of biliary atresia (BA). Emerging metabolomics provides a powerful platform for discovering novel biomarkers and biochemical pathways to improve early diagnosis. The aim of this study is to find the potential biomarkers to distinguish BA from neonatal hepatitis syndrome (NHS) by using a metabolomics method. We comprehensively analyzed the serum metabolites in a total of 124 blood samples from patients with BA or neonatal hepatitis syndrome (NHS) and from normal individuals using advanced metabolomic approaches, and found that the levels of glutarylcarnitine (C5DC) significantly increased in the BA group while the levels of threonine (Thr) significantly rose in the NHS group comparing with the other groups. The levels of glutamic acid (Glu) in the BA group were significantly elevated compared to those in the NHS group, but still lower than the hyperbilirubinemia and normal controls. The levels of propionyl carnitine (C3), isovaleryl carnitine (C5) and glutamine (Gln) were reduced in the BA group compared to those in the NHS group, but still higher than the hyperbilirubinemia and normal controls. This study demonstrates the possibility of metabolomics as non-invasive biomarkers for the early detection of BA and also provides new insight into pathophysiologic mechanisms for BA.

A study to demonstrate the use of FNA cytology rather than biopsy in the diagnosis of neonatal biliary atresia

OBJECTIVE

To study the use of fine needle aspiration (FNA) cytology in neonatal biliary atresia (BA).

METHODS

Twelve female and nine male patients (age range, 3-7 months; mean age, 4.5 months) with a pre-operative diagnosis of BA, who were scheduled for Kasia portoenterostomy and selected for intraoperative FNA, were studied.

RESULTS

Cholestasis, bile deposits, bile infarcts, hepatitic rosettes enclosing bile plugs, feathery degeneration of hepatocytes and inflammatory cells were seen in the cytological slides. Bile infarcts, rosette formation and inflammatory cells were mainly noticed in type 3 BA. Bile infarcts and hepatitic rosettes are surrogate findings for the diagnosis of the obstructive type of cholestasis.

CONCLUSION

With the help of imaging studies, FNA in a multidisciplinary setting can be diagnostic of neonatal BA when cytological features suggest the obstructive nature of cholestasis, but this procedure cannot replace completely liver biopsy for this diagnosis.

Value of hepatic subcapsular flow by color Doppler ultrasonography in the diagnosis of biliary atresia

BACKGROUND AND AIM

Diagnosis of biliary atresia (BA), particularly distinguishing it from other causes of neonatal cholestasis (NC), is challenging. Ultrasonography is a helpful investigation when evaluating NC. The aim was to determine the value of color Doppler ultrasound, particularly hepatic subcapsular flow, as a possible tool in early discrimination of BA from other causes of NC.

METHODS

Ultrasonographic and color Doppler findings of 27 BA patients were compared with that in 27 non-BA cholestasis patients and a control group of 22 non-hepatic neonates.

RESULTS

Hepatic artery diameter was significantly higher in BA (2.48 ± 0.55 mm) than that in non-BA group (1.91 ± 0.63 mm) (P = 0.001) and the control group (1.6 ± 0.47 mm) (P < 0.0001), while there were no statistically significant difference between BA and non-BA groups as regards portal vein diameter and flow, hepatic vein flow, and hepatic artery resistance index. The frequency of hepatic subcapsular flow was significantly higher in BA than that in non-BA group (96.3% vs 3.7%; P < 0.0001), while it was not detected in any of the non-hepatic control group. The presence of hepatic subcapsular flow had 96.3% sensitivity and specificity in predicting BA.

CONCLUSIONS

Color Doppler ultrasound findings could help significantly in discriminating BA from other causes of NC, among which hepatic subcapsular flow had the best performance. Considering the young age of BA patients (61.8 ± 15.1 days), hepatic subcapsular flow can help in early diagnosis of BA and prevent the delay in surgical correction.

Developmental assessment of infants with biliary atresia: differences between boys and girls

OBJECTIVE

The aim of the present study was to investigate whether male and female infants with biliary atresia (BA) differ cognitively and to confirm previously documented developmental lags in infants with BA before liver transplantation.

METHODS

With the Mullen Scales of Early Learning, we examined 21 female and 12 male infants (ages 3-20 months) with BA, comparing scores across indices by sex and correlating Mullen Scales of Early Learning scores with standard clinical and biochemical parameters.

RESULTS

Overall, both boys and girls were found to be vulnerable to developmental lags in the areas of expressive language (EL) and gross motor skills. In comparison with their male peers, girls were found to be weaker in the area of visual reception skills (P=0.05) with a trend found for EL (P=0.08). Girls were also found to have higher C-bilirubin levels and to be of shorter length. Growth parameters were found to be correlated with EL scores. International normalized ratio was found to be correlated with gross motor performance and with a trend also noted for fine motor skills. Age at Kasai predicted receptive language skills.

CONCLUSIONS

As has been shown, infants with BA appear to be vulnerable to developmental lags before transplantation. In particular, female infants appear to be vulnerable to cognitive and skill delays in comparison with their male peers. C-bilirubin levels may play a role in this increased vulnerability for females.

Intestinal synthesis and secretion of bile salts as an adaptation to developmental biliary atresia in the sea lamprey

Bile salt synthesis is a specialized liver function in vertebrates. Bile salts play diverse roles in digestion and signaling, and their homeostasis is maintained by controlling input (biosynthesis) and intestinal conservation. Patients with biliary atresia (i.e., obliteration of the biliary tree) suffer liver fibrosis and cirrhosis. In contrast, sea lamprey thrives despite developmental biliary atresia. We discovered that the sea lamprey adapts to biliary atresia through a unique mechanism of de novo synthesis and secretion of bile salts in intestine after developmental biliary atresia, in addition to known mechanisms, such as the reduction of bile salt synthesis in liver. During and after developmental biliary atresia, expression of cyp7a1 in intestine increased by more than 100-fold (P < 0.001), whereas in liver it decreased by the same magnitude (P < 0.001). Concurrently, bile salt pools changed in similar patterns and magnitudes in these two organs and the composition shifted from C24 bile alcohol sulfates to taurine-conjugated C24 bile acids. In addition, both in vivo and ex vivo experiments showed that aductular sea lamprey secreted taurocholic acid into its intestinal lumen. Our results indicate that the sea lamprey, a jawless vertebrate, may be in an evolutionarily transitional state where bile salt synthesis occurs in both liver and intestine. Understanding the molecular basis of these mechanisms may shed light on the evolution of bile salt synthesis and possible therapy for infant biliary atresia.

Bone metabolism in cholestatic children before and after living-related liver transplantation--a long-term prospective study

Bone disorders are common in children with end-stage liver diseases, especially those associated with cholestasis. Abnormal hepatocyte function, disordered vitamin D metabolism and calcium-phosphorous homeostasis, malnutrition, and immunosuppressive treatment are potential risk factors of bone tissue pathology before and after transplantation. The aim of the study was to analyze the long-term effect of successful living-related liver transplantation (LRLTx) on skeletal status and bone metabolism in cholestatic children. Eighteen cholestatic children (1.4±0.5yr old; 12 females [F]/6 males [M]) qualified for LRLTx were analyzed; 16 (5F/11M) of them participated in long-term observation (V4). Serum levels of osteocalcin (OC), procollagen type 1 N-terminal propeptide (P1NP), cross-linked telopeptide of type 1 collagen (CTx), insulin-like growth factor I (IGF-I), IGF-I binding protein 3 (IGFBP-3), parathyroid hormone (PTH), 25-hydroxyvitamin D (25(OH)D), and 1,25-dihydroxyvitamin D (1,25(OH)(2)D) were assayed before (V0) and 6mo (V1), 12mo (V2), 18mo (V3), and 4.4yr (V4) after LRLTx. Total body bone mineral content (TBBMC) and total body bone mineral density (TBBMD) were measured by dual-energy X-ray absorptiometry (DXA) at the same pattern. Before LRLTx, the OC, P1NP, CTx, IGF-I, and IGFBP-3 levels as well as TBBMC and TBBMD were decreased compared with age-matched control group. The mean serum levels of 25(OH)D and 1,25(OH)(2)D were within reference ranges from V0 to V4. After LRLTx, the OC, P1NP, CTx, IGF-I, and IGFBP-3 as well as TBBMC and TBBMD reached the age-matched reference values. At V4, the level of P1NP decreased below and the PTH increased above the reference range that coincided with reduced Z-scores of both TBBMC (-1.11±1.24) and TBBMD (-1.00±1.19). P1NP and CTx, both measured at V3, correlated with IGF-I at V2 (R=0.86, p=0.014 and R=0.78, p=0.021, respectively) and PTH at V3 for P1NP and V1 for CTx (R=0.64, p=0.048 and R=0.54, p=0.038, respectively). The TBBMC changes between V0 and V4 correlated with IGF-I (R=0.68, p=0.015) and 1,25(OH)(2)D (R=0.54, p=0.025), both assayed at V1. The change of TBBMC Z-scores between V0 and V4 correlated with P1NP at V1 (R=0.69, p=0.002). The TBBMD changes between V0 and V4 correlated with CTx at V1 (R=0.54, p=0.027) and P1NP change between V0 and V1 (R=0.51, p=0.038). In short-term observation, successful LRLTx led to bone metabolism normalization triggered by probable anabolic action of IGF-I and PTH and manifested by TBBMC and TBBMD increases. In long-term horizon, moderately impaired DXA assessed bone status coincided with disturbances in bone metabolism. Bone metabolism markers, especially P1NP and CTx, appeared to be good predictors of changes in bone status evaluated by DXA.

Association of X-prolyl aminopeptidase 1 rs17095355 polymorphism with biliary atresia in Thai children

AIM

  To investigate XPNPEP1 rs17095355 polymorphism in biliary atresia (BA) patients and to determine whether there is an association between XPNPEP1 gene polymorphism and susceptibility to BA in a Thai population.

METHODS

  A total of 124 cases of BA and 114 controls were genotyped for XPNPEP1 rs17095355 polymorphism. The XPNPEP1 rs17095355 C/T genotype was determined by polymerase chain reaction (PCR) and direct sequencing. Allele and genotype frequencies were established by directed counting from the sequences.

RESULTS

  Genotype distributions for the XPNPEP1 rs17095355 polymorphism tested were in Hardy-Weinberg equilibrium for both control and study groups. There were no significant differences in genotype and allele frequencies of the single nucleotide polymorphism between controls and Thai children with BA. Genotype frequencies of rs17095355 of T/T in BA were higher than those of controls (34.68% and 16.67%, P < 0.002). Also, the T allele frequencies of BA were higher than those of controls (56.85% and 42.98%, P < 0.003).

CONCLUSION

  The association between XPNPEP1 rs17095355 polymorphism and BA has been demonstrated, particularly with the T allele. We hypothesize that the XPNPEP1 rs17095355 polymorphism confers increased susceptibility to the disease.

Diagnostic value of hepatic intercellular adhesion molecule-1 expression in Egyptian infants with biliary atresia and other forms of neonatal cholestasis

AIM

  The diagnosis of biliary atresia (BA) is challenging as no single preoperative test is 100% accurate, especially for distinguishing it from other causes of neonatal cholestasis (NC). Intercellular adhesion molecule (ICAM) elevation was reported in BA as a part of the immune-mediated inflammatory process. The use of ICAM-1 as a discriminative tool between BA and other causes of NC has never been addressed before. This study was to evaluate the diagnostic potentials of ICAM-1 in BA versus other forms of NC.

METHODS

  For this purpose, serum ICAM-1 (sICAM-1) and ICAM-1 expression, in liver biopsy using immunohistochemistry, were estimated in 30 patients with BA and compared to that in 20 patients with other forms of NC. sICAM-1 levels were compared to that in 20 healthy controls.

RESULTS

  sICAM-1 levels were significantly higher in BA (1055.9 ± 230.2 ng/mL) than that in cholestasis (604.8 ± 194.8 ng/mL) and the control groups (158.9 ± 78.7 ng/mL) (P < 0.0001). A cut-off value of 793.8 ng/mL had 86.7% sensitivity and 95% specificity in discriminating the BA from the cholestasis group. The biliary expression score of ICAM-1 at a cut-off value of 110 could discriminate between BA and other causes of NC with 100% sensitivity and specificity. Neither serum levels nor liver expression of ICAM-1 scores correlated with disease severity or with fibrosis stage.

CONCLUSION

  These results suggest that ICAM-1 has a diagnostic value in patients with BA and would be a promising helpful tool when investigating patients with NC.

[Biliary atresia: a condition requiring urgent diagnosis and treatment]

Every neonatal jaundice lasting more than 2 weeks needs urgent investigations, beginning with examination of stools colour, and blood tests with total and conjugated serum bilirubin. If neonatal cholestasis (NC) is confirmed, vitamin K should be immediately injected, and the child should be referred to a specialised centre for investigations and treatment. Biliary atresia (BA) is the first cause of NC. Its diagnosis is urgent, since the chance of success of the conservative surgical treatment (Kasai operation or variants) decreases rapidly as the age at surgery increases. Normal ultrasound scans cannot rule out BA. After prompt work-up looking for the main other causes of NC, BA can often be strongly suspected before surgery, and is confirmed by operative findings and cholangiogram if needed. In case of failure to restore the biliary drainage, biliary cirrhosis progresses and leads to liver transplantation, generally in the first years of life. Currently, more than 90 % of children with BA can live, with a close to normal quality of life for most of them. Early diagnosis and treatment of BA contribute to decrease the needs for liver transplantation in infancy and childhood.

Clinical practice: management of biliary atresia

Biliary atresia is a rare, serious and challenging disease in newborn children. Its aetiology remains unknown. Optimal management at specialist centres with resultant better overall outcomes is achieved through a multidisciplinary team approach. The Kasai portoenterostomy performed early in life remains the only surgical repair procedure. Two thirds of patients will clear their jaundice after a Kasai procedure, but only about one third will retain their livers after the first decade of life. Failure of this procedure leaves liver transplantation as the only chance for survival, and this disease is the commonest indication for liver transplantation in children. With modern medical care and refinements in surgical techniques, survival after either or both of these procedures is about 90%. Early referral to specialist centres and long-term specialist care remains the key to successful treatment of this condition.

Long-term results of percutaneous bilioenteric anastomotic stricture treatment in liver-transplanted children

The purpose of this study was to evaluate the mid- and long-term results of percutaneous transhepatic cholangiography (PTC) and biliary drainage in children with isolated bilioenteric anastomotic stenosis (BAS) after pediatric liver transplantation. Sixty-four children underwent PTC from March 1993 to May 2008. Nineteen cholangiograms were normal; 10 showed intrahepatic biliary stenosis and BAS, and 35 showed isolated BAS. Cadaveric grafts were used in 19 and living donor grafts in 16 patients. Four patients received a whole liver, and 31 patients received a left lobe or left lateral segment. Roux-en-Y hepaticojejunostomy was performed in all patients. Indication for PTC was based on clinical, laboratory, and histopathologic findings. In patients with isolated BAS, dilation and biliary catheter placement, with changes every 2 months, were performed. Patients were separated into 4 groups according to number of treatment sessions required. The drainage catheter was removed if cholangiogram showed no significant residual stenosis and normal biliary emptying time after a minimum of 6 months. The relationship between risk factors (recipient's weight <10 kg, previous exposure to Cytomegalovirus, donor-recipient sex and weight relations, autoimmune disease as indication for transplantion, previous Kasai's surgery, use of reduced liver grafts, chronic or acute rejection occurrence) and treatment was evaluated. Before PTC, fever was observed in 46%, biliary dilation in 23%, increased bilirubin in 57%, and increased gamma-glutamyltransferase (GGT) in 100% of patients. In the group with BAS, 24 of 35 (69%) patients had histopathologic findings of cholestasis as did 9 of 19 (47%) patients in the group with normal PTC. Of the 35 patients, 23 (65.7%) needed 1 (group I), 7 needed 2 (group II), 4 needed 3 (group III), and 1 needed 4 treatment sessions (group IV). The best results were observed after 1 treatment session, and the mean duration of catheter placement and replacement was 10 months. The primary patency rate was 61.2%, and the recurrence rate was 34.3% (group I). Seven patients (7 of 35; 20%) had their stricture treated with a second treatment session (group II). The average drainage time in group II was 24 months. During a period >20 months, 4 patients (4 of 35; 11.4%) required 1 additional treatment session (group III), and 1 patient (1 of 35; 2.9%) had a catheter placed at the end of the study period (group IV). Drainage time in group I was significantly shorter than those in groups II, III, and IV (p < 0.05). There was no statistically significant relation between therapeutic response and the selected risk factors (p > 0.05). The majority of complications, such as catheter displacement and leakage, were classified as minor; however, 2 patients (5.7%) with hemobilia were noted. Complications increased according to the need for reintervention. In conclusion, balloon dilation and percutaneous drainage placement is safe and effective, and it has long-term patency for children with BAS after liver transplantation. Because of prolonged treatment time, reintervention may be necessary, thereby increasing the complication rate. Balloon dilation and percutaneous drainage placement should be considered as the first treatment option because of its minimally invasive nature.

Biliary atresia: Swiss national study, 1994-2004

OBJECTIVES

To determine the epidemiology of biliary atresia (BA) in Switzerland, the outcome of the children from diagnosis, and the prognostic factors.

PATIENTS AND METHODS

The records of all patients with BA born in Switzerland between January 1994 and December 2004 were analyzed. Survival rates were calculated with the Kaplan-Meier method, and prognostic factors evaluated with the log rank test. Median follow up was 58 months (range, 5-124).

RESULTS

BA was diagnosed in 48 children. Incidence was 1 in 17,800 live births (95% confidence interval 1/13,900-1/24,800), without significant regional, annual, or seasonal variation. Forty-three children underwent a Kasai portoenterostomy (PE) in 5 different Swiss pediatric surgery units. Median age at Kasai PE was 68 days (range, 30-126). Four-year survival with native liver after Kasai PE was 37.4%. Liver transplantation (LT) was needed in 31 in 48 children with BA, including 5 patients without previous Kasai PE. Four patients (8%, all born before 2001) died while waiting for LT, and 29 LT were performed in 27 patients (28 in Geneva and 1 in Paris). All of the transplanted patients are alive. Four-year overall BA patient survival was 91.7%. Four-year survival with native liver was 75% in patients who underwent Kasai PE before 46 days, 33% in patients operated on between 46 and 75 days, and 11% in patients operated on after 75 days (P = 0.02).

CONCLUSIONS

Overall survival of patients with BA in Switzerland compares favorably with current international standards, whereas results of the Kasai operation could be improved to reduce the need for LTs in infancy and early childhood.

Biliary atresia: interdisciplinary initiatives focus on a rare disease

During the last decade, biliary atresia (BA) has attained more interest and the frequency of BA-related publications has increased continuously. Pediatric hepatologists and pediatric surgeons are very active in improving diagnosis and treatment modalities of BA patients, in order to prolong the survival rate of their native liver. Together with transplant surgeons, the bridging of BA patients to liver transplantation (LTx) becomes optimized and as a consequence of this interdisciplinary approach, the overall survival of babies with BA has already reached 90%. Furthermore, basic research into the still unknown origin of BA has advanced, and numerous scientific programs have already linked together. The overriding interest is to discover at least BA's etiology and to turn the treatment of BA patients from a symptomatic to a causative approach. Interdisciplinary and international programs are mandatory and already existing initiatives in Europe, the United States and Japan are going to coordinate their registries, clinical trials and basic research studies for the benefit of the patients and solve the riddle of BA.