Three-color risk stratification for improving the diagnostic accuracy for biliary atresia

A convenient nomogram for predicting early death or liver transplantation after the Kasai procedure in patients with biliary atresia

PURPOSE

Many patients with biliary atresia (BA) after the Kasai procedure (KP) progress to death or require liver transplantation to achieve long-term survival; however, most cases of death/liver transplantation (D/LT) occur in the early period after KP (usually within 1 year). This study was designed to construct a convenient nomogram for predicting early D/LT in patients with BA after KP.

METHODS

A BA cohort was established in May 2017, and up to May 2023, 112 patients with 1-5 years of follow-up were enrolled in the study and randomly (ratio, 3:1) divided into a training cohort for constructing a nomogram (n = 84) and a validation cohort (n = 28) for externally validating the discrimination and calibration. The training cohort was divided into two groups: the early D/LT group (patients who died or had undergone LT within 1 year after KP [n = 35]) and the control group (patients who survived through the native liver more than 1 year after KP [n = 49]). Multivariate logistic regression and stepwise regression were applied to detect variables with the best predictive ability for the construction of the nomogram. The discrimination and calibration of the nomogram were internally and externally validated.

RESULTS

The Kaplan-Meier (K-M) curve showed an actual 1-year native liver transplantation (NLS) rate of 57.1% and an estimated 2-year NLS rate of 55.2%. By multivariate regression and stepwise regression, age at KP, jaundice clearance (JC) speed 1 month after KP, early-onset PC (initial time < 36.5 days) after KP, sex, aspartate aminotransferase-to-platelet ratio index (APRI), and weight at KP were identified as the independent variables with the best ability to predict early D/LT and were used to construct a nomogram. The developed nomogram based on these independent variables showed relatively good discrimination and calibration according to internal and external validation.

CONCLUSION

Most D/LTs were early D/LTs that occurred within 1 year after KP. The established nomogram based on predictors, including sex, weight at the KP, the APRI, age at the KP, JC speed 1 month after the KP, and early PC, may be useful for predicting early D/LT and may be helpful for counseling BA patients about patient prognosis after KP. This study was retrospectively registered at ClinicalTrials.gov (NCT05909033) in June 2023.

Diagnostic Efficacy of Advanced Ultrasonography Imaging Techniques in Infants with Biliary Atresia (BA): A Systematic Review and Meta-Analysis

The early diagnosis of biliary atresia (BA) in cholestatic infants is critical to the success of the treatment. Intraoperative cholangiography (IOC), an invasive imaging technique, is the current strategy for the diagnosis of BA. Ultrasonography has advanced over recent years and emerging techniques such as shear wave elastography (SWE) have the potential to improve BA diagnosis. This review sought to evaluate the diagnostic efficacy of advanced ultrasonography techniques in the diagnosis of BA. Six databases (CINAHL, Medline, PubMed, Google Scholar, Web of Science (core collection), and Embase) were searched for studies assessing the diagnostic performance of advanced ultrasonography techniques in differentiating BA from non-BA causes of infantile cholestasis. The meta-analysis was performed using Meta-DiSc 1.4 and Comprehensive Meta-analysis v3 software. Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Fifteen studies consisting of 2185 patients (BA = 1105; non-BA = 1080) met the inclusion criteria. SWE was the only advanced ultrasonography technique reported and had a good pooled diagnostic performance (sensitivity = 83%; specificity = 77%; AUC = 0.896). Liver stiffness indicators were significantly higher in BA compared to non-BA patients (p < 0.000). SWE could be a useful tool in differentiating BA from non-BA causes of infantile cholestasis. Future studies to assess the utility of other advanced ultrasonography techniques are recommended.

Use of shear wave elastography for the diagnosis and follow-up of biliary atresia: A meta-analysis

BACKGROUND

Timely differentiation of biliary atresia (BA) from other infantile cholestatic diseases can impact patient outcomes. Additionally, non-invasive staging of fibrosis after Kasai hepatoportoenterostomy has not been widely standardized. Shear wave elastography is an ultrasound modality that detects changes in tissue stiffness. The authors propose that the utility of elastography in BA can be elucidated through meta-analysis of existing studies.

AIM

To assess the utility of elastography in: (1) BA diagnosis, and (2) post-Kasai fibrosis surveillance.

METHODS

A literature search identified articles that evaluated elastography for BA diagnosis and for post-Kasai follow-up. Twenty studies met criteria for meta-analysis: Eleven for diagnosis and nine for follow-up post-Kasai. Estimated diagnostic odds ratio (DOR), sensitivity, and specificity of elastography were calculated through a random-effects model using Meta-DiSc software.

RESULTS

Mean liver stiffness in BA infants at diagnosis was significantly higher than in non-BA, with overall DOR 24.61, sensitivity 83%, and specificity 79%. Post-Kasai, mean liver stiffness was significantly higher in BA patients with varices than in patients without, with DOR 16.36, sensitivity 85%, and specificity 76%. Elastography differentiated stage F4 fibrosis from F0-F3 with DOR of 70.03, sensitivity 96%, and specificity 89%. Elastography also differentiated F3-F4 fibrosis from F0-F2 with DOR of 24.68, sensitivity 85%, and specificity 81%.

CONCLUSION

Elastography has potential as a non-invasive modality for BA diagnosis and surveillance post-Kasai. This paper’s limitations include inter-study method heterogeneity and small sample sizes. Future, standardized, multi-center studies are recommended.

Ultrasound elastography in the diagnosis of biliary atresia in pediatric surgery: a systematic review and meta-analysis of diagnostic test

BACKGROUND

Biliary atresia (BA) is one of the most fatal hepatobiliary diseases in infants and young children, and is easy to cause obstructive jaundice in infants and children, and liver transplantation in children. BA and infantile hepatitis syndrome are the main causes of cholestatic jaundice. The early clinical manifestations are extremely similar, and timely identification is difficult. Therefore, early and differential diagnosis of BA is crucial. At present, there are many imaging diagnosis methods for BA, such as ultrasound examination and nuclear magnetic resonance. Ultrasound elastography (USE) is the most popular method. However, the application of USE in BA is still in the exploratory stage.

METHODS

PubMed, Web of Science, Embase, Cochrane Library, and other databases were searched for articles on USE diagnosis of pediatric surgical BA. Later, the articles were screened, and the included articles should meet the following requirements: the research objects were children with BA; the intervention measures were USE diagnosis; the control group was diagnosed by other methods than USE. RevMan5.3 was adopted for quality assessment, and forest maps and summary receiver operating characteristic (SROC) curves were constructed.

RESULTS

Finally, seven articles covering 490 patients were included. There were 120 patients in the control group. The included articles showed good quality and there was no obvious bias. The area under the SROC curve (AUC) for USE diagnosis of BA was 0.93, the sensitivity was 0.93 (95% CI: 0.72-1.00), and the specificity was 0.95 (95% CI: 0.74-1.00).

DISCUSSION

USE showed high diagnostic value for pediatric surgical biliary tract closure.

Ultrasound for the Diagnosis of Biliary Atresia: From Conventional Ultrasound to Artificial Intelligence

Biliary atresia is an aggressive liver disease of infancy and can cause death without timely surgical intervention. Early diagnosis of biliary atresia is critical to the recovery of bile drainage and long-term transplant-free survival. Ultrasound is recommended as the initial imaging strategy for the diagnosis of biliary atresia. Numerous ultrasound features have been proved helpful for the diagnosis of biliary atresia. In recent years, with the help of new technologies such as elastography ultrasound, contrast-enhanced ultrasound and artificial intelligence, the diagnostic performance of ultrasound has been significantly improved. In this review, various ultrasound features in the diagnosis of biliary atresia are summarized. A diagnostic decision flow chart for biliary atresia is proposed on the basis of the hybrid technologies, combining conventional ultrasound, elastography and contrast-enhanced ultrasound. In addition, the application of artificial intelligence in the diagnosis of biliary atresia with ultrasound images is also introduced.

Practical approach for the diagnosis of biliary atresia on imaging, part 2: magnetic resonance cholecystopancreatography, hepatobiliary scintigraphy, percutaneous cholecysto-cholangiography, endoscopic retrograde cholangiopancreatography, percutaneous liver biopsy, risk scores and decisional flowchart

We aim to present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses to biliary cirrhosis, end-stage liver failure and death within the first years of life. Differentiating biliary atresia from other nonsurgical causes of neonatal cholestasis is difficult as there is no single method for diagnosing biliary atresia and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. In this second part, we discuss the roles of magnetic resonance (MR) cholecystopancreatography, hepatobiliary scintigraphy, percutaneous biopsy and percutaneous cholecysto-cholangiography. Among imaging techniques, ultrasound (US) signs have a high specificity, although a normal US examination does not rule out biliary atresia. Other imaging techniques with direct opacification of the biliary tree combined with percutaneous liver biopsy have roles in equivocal cases. MR cholecystopancreatography and hepatobiliary scintigraphy are not useful for the diagnosis of biliary atresia. We propose a decisional flowchart for biliary atresia diagnosis based on US signs, including elastography, percutaneous cholecysto-cholangiography or endoscopic retrograde cholangiopancreatography and liver biopsy.

Variability in age at Kasai portoenterostomy for biliary atresia across US children's hospitals

BACKGROUND/PURPOSE

The purpose of this study was to assess variability in age at Kasai portoenterostomy (KP) in infants with biliary atresia (BA) across children's hospitals in the United States.

STUDY DESIGN

A multi-institutional retrospective study was performed examining infants with BA undergoing KP within 6 months of birth from 2016-2019, utilizing the Pediatric Health Information System (PHIS). Multivariable negative binomial mixed effects regression was performed for age at KP, and inter-hospital variability was examined.

RESULTS

Across 46 hospitals, 470 infants with BA underwent KP at a median age of 57 days (IQR 42-72), with 212 (45.1%) undergoing KP at ≥60 days of age. There was significant inter-hospital variability in age at KP ranging from 38 days (95% CI: 31d, 47d) to 76 days (95% CI: 63d, 91d) (p<0.0001). Factors associated with later KP were black or African-American race, urgent/emergent admission, and treatment at a hospital in the Pacific-West region. Predictors of earlier KP included later year, history of neonatal comorbidity, and admission to an intensive care service (all p<0.05).

CONCLUSION

There is significant variability in the age at KP in infants with BA across children's hospitals in the United States.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Diagnostic performance and prognostic value of elastography in patients with biliary atresia and after hepatic portoenterostomy: protocol for a systematic review and meta-analysis

INTRODUCTION

Biliary atresia (BA) is a life-threatening disease with persistent neonatal cholestasis and progressive liver fibrosis. Timely non-invasive diagnosis of BA can result in early hepatic portoenterostomy (HPE) and better prognosis. Quantitative elastography enables the non-invasive measurement of liver stiffness. However, the studies on elastography methods in the diagnosis of BA and the prediction of post-HPE outcomes vary in their results and have small sample sizes. Thus, we propose this systematic review and meta-analysis to obtain comprehensive evidence on the value of elastography in BA.

METHODS AND ANALYSIS

We will search the PubMed, Embase and the Cochrane Central Register of Controlled Trials databases for studies evaluating the diagnostic performance of elastography in patients with BA and the prognostic value of postoperative elastography, from inception to 31 December 2020. We plan to use the Quality Assessment of Diagnostic Accuracy Studies-2 list and the Quality In Prognosis Studies tool to assess the risk of bias in the included studies and the study quality. We will evaluate the diagnostic performance of elastography by synthesising the pooled sensitivity, pooled specificity, pooled positive likelihood ratio, pooled negative likelihood ratio, pooled diagnostic OR and summary receiver operating characteristic curve using Meta-Disc V.1.4. We will evaluate the predictive value of elastography after HPE by synthesising the pooled correlation coefficient and pooled OR of prognostic outcomes using STATA V.14. The funnel plot and Egger's test will be used to evaluate the potential publication bias. Sensitivity analysis will be conducted by examining the estimated effects of individual studies.

ETHICS AND DISSEMINATION

As this study is a meta-analysis based on previously published literature, ethical approval is not necessary according to the ethics committee of West China Hospital, Sichuan University. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020162055.

Development and Assessment of Screening Nomogram for Biliary Atresia Based on Hepatobiliary Ultrasonographic Features

Objectives: Biliary atresia (BA) is a rare neonatal liver disease of which the early diagnosis remains a challenge for clinicians. Our center has established a nomogram diagnostic model based on clinical characteristics and liver function characteristics. We aim to develop and validate a nomogram that includes additional ultrasound and finds hepatobiliary abnormality with better BA early screening performance. Methods: In this single-center, retrospective cohort analysis, 1,001 neonatal obstructive jaundice (NOJ) patients between 2012 and 2015 were enrolled. Multivariable analysis was used to identify clinical characteristics, laboratory liver function characteristics, and ultrasonic features that may early screen BA. A nomogram was developed to predict the probability of BA using multiple logistic regression analysis. This nomogram was subsequently validated using another cohort of 501 NOJ patients between 2015 and 2017. Calibration curve analysis and decision curve analyses were performed to evaluate and interpret the nomogram's clinical benefits. Results: Gender, direct bilirubin (DB), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), fasting gallbladder visibility, fasting gallbladder filling, and common bile duct visibility were found to have profound statistical significance between the BA and non-BA groups (P < 0.05). The significant features were used to build the nomogram. The area under the receiver operating characteristic (ROC) curve (AUC) value of the novel nomogram (0.87) was superior to those of the former nomogram (0.83) and GGT alone (0.81) in the prediction of BA. The calibration curve revealed a close resemblance between the predicted and actual BA probabilities. Also, the net benefit from the decision curve analysis (DCA) of the nomogram (0.54) was superior to those of the former nomogram (0.49) and GGT alone (0.45) at 80% of threshold possibility. Conclusions: The nomogram has demonstrated better performance for BA screening by including additional information of the US finding, holding a promising future as a non-invasive method for BA patients.