Liver transplantation for biliary atresia: a systematic review

Butyrate inhibits histone deacetylase 2 expression to alleviate liver fibrosis in biliary atresia

BACKGROUND

Previous studies have found a reduction in butyrate-producing bacteria in the gut microbiota of infants with biliary atresia (BA). Butyrate is also an important inhibitor of histone deacetylase 2 (HDAC2). This study aims to explore how butyrate alleviates liver fibrosis in BA through HDAC2.

METHODS

Fibrosis-related pathways associated with butyrate were analyzed using the GSE46960 database. BA liver sections were used to validate factor expression. The effects of HDAC2 and butyrate and the pathway were performed in vitro experiments. Butyrate intervention was performed in bile duct ligation (BDL) mice, and alterations in the gut microbiota were analyzed using fecal 16S rRNA sequencing. The impact of butyrate and related pathways on liver fibrosis in BDL mice was further evaluated.

RESULTS

The IL-6/STAT3 pathway showed a clear correlation with butyrate in BA. HDAC2 promoted LX-2 activation via the IL-6/STAT3 pathway, while butyrate inhibited LX-2 activation by suppressing HDAC2. Butyrate not only alleviated liver fibrosis but also improved the gut microbiota structure in BDL mice.

CONCLUSION

Butyrate may improve liver fibrosis in BA by regulating HDAC2 expression and modulating the IL-6/STAT3 pathway. Therefore, butyrate could serve as a promising therapeutic option for mitigating liver fibrosis in BA.

Impact of follow-up liver biopsy on long-term outcomes post-Kasai procedure in patients with biliary atresia

PURPOSE

Patients with biliary atresia (BA) suffer from progressive liver damage, even after successful Kasai portoenterostomy (KPE). The purpose of this study is to analyze the relevance of follow-up percutaneous liver biopsy (LBx) and long-term prognosis of patients with BA.

METHODS

This study included patients with BA who were born between 1983 and 2005 and survived with their native liver until 10 years of age. Patient characteristics, laboratory data and Child-Pugh score at the time of LBx, and native-liver survival (NLS) and complication-free survival (CFS) in patients with mild (F0-F2) or severe fibrosis (F3, F4) on follow-up LBx were retrospectively analyzed.

RESULTS

Forty-three patients were gathered in this study and the most recent LBx was performed at age 21.1 ± 2.9 years. Thirty-three patients had mild fibrosis and ten patients had severe fibrosis on follow-up LBx. Long-term NLS and CFS were significantly worse in patients with severe fibrosis. Among those patients, 18 patients had follow-up LBx between the ages of 6 and 12 years, and CFS were significantly worse in patients with severe fibrosis.

CONCLUSIONS

We found that patients with BA with severe liver fibrosis on follow-up LBx had worse long-term survival and a higher rate of progression of complications of BA.

Perioperative comparison of whether the liver was lifted out of the abdominal cavity in Kasai surgery

Objective

To compare the perioperative effect of whether the liver is lifted out of the abdominal cavity during Kasai surgery in patients with biliary atresia type III.

Methods

We retrospectively analyzed 29 males and 33 females aged 2.2 ± 0.6 months who underwent kasai surgery from June 2019 to December 2022 at Fujian Provincial Children's Hospital. Among the 62 children with the liver not lifted out of the abdominal cavity into the experimental group (n = 31), and those with the liver lifted out of the abdominal cavity into the control group (n = 31). We compared the operation time, surgical incision length, intraoperative blood pressure and body temperature fluctuations, average daily peritoneal drainage, postoperative length of hospital stay, postoperative complications, postoperative total bilirubin level, and autologous liver survival rate between the two groups.

Results

The length of the surgical incision in the control group (7.5 ± 1.2 cm) was longer than that in the experimental group (6.7 ± 1.1 cm), and the difference was statistically significant (t = 2.88, P = 0.005). The fluctuations in blood pressure in the control group (before and after the liver was lifted out of the abdominal cavity) (24.3 ± 7.7 mmHg) were greater than that in the experimental group (before and after hooking to expose the hilar area) (20.2 ± 6.0 mmHg), which was a statistically significant difference (t = 2.32, P = 0.023). The temperature fluctuations in the control group (before and after the liver was lifted out of the abdominal cavity) (0.3 ± 0.1°C) was greater than that in the experimental group (before and after the liver was lifted out of the abdominal cavity) (0.1 ± 0.1°C), showing a statistically significant difference (t = 8.19, P = 0.000). The average daily abdominal drainage in the control group was 71.3 ± 33.5 ml, which was greater than that in the experimental group (49.2 ± 49.6 ml), and the difference was statistically significant (t = 2.06, P = 0.044). The number of days of postoperative hospital stay in the control group (18.2 ± 4.8 days) was significantly more than that in the experimental group (15.8 ± 3.8 days), with a statistically significant difference (t = 2.18, P = 0.033).

Conclusion

In children with biliary atresia type III, the liver is not lifted out of the abdominal cavity during Kasai surgery increases the safety of surgery and reduces the length of hospital stay.

Polymeric immunoglobulin receptor promotes Th2 immune response in the liver by increasing cholangiocytes derived IL-33: a diagnostic and therapeutic biomarker of biliary atresia

BACKGROUND

Biliary atresia (BA) is a devastating neonatal cholangiopathy with an unclear pathogenesis, and prompt diagnosis of BA is currently challenging.

METHODS

Proteomic and immunoassay analyses were performed with serum samples from 250 patients to find potential BA biomarkers. The expression features of polymeric immunoglobulin receptor (PIGR) were investigated using human biopsy samples, three different experimental mouse models, and cultured human biliary epithelial cells (BECs). Chemically modified small interfering RNA and adenovirus expression vector were applied for in vivo silencing and overexpressing PIGR in a rotavirus-induced BA mouse model. Luminex-based multiplex cytokine assays and RNA sequencing were used to explore the molecular mechanism of PIGR involvement in the BA pathogenesis.

FINDINGS

Serum levels of PIGR, poliovirus receptor (PVR), and aldolase B (ALDOB) were increased in BA patients and accurately distinguished BA from infantile hepatitis syndrome (IHS). Combined PIGR and PVR analysis distinguished BA from IHS with an area under the receiver operating characteristic curve of 0.968 and an accuracy of 0.935. PIGR expression was upregulated in the biliary epithelium of BA patients; Th1 cytokines TNF-α and IFN-γ induced PIGR expression in BECs via activating NF-κB pathway. Silencing PIGR alleviated symptoms, reduced IL-33 expression, and restrained hepatic Th2 inflammation in BA mouse model; while overexpressing PIGR increased liver fibrosis and IL-33 expression, and boosted hepatic Th2 inflammation in BA mouse model. PIGR expression promotes the proliferation and epithelial-mesenchymal transition, and reduced the apoptosis of BECs.

INTERPRETATION

PIGR participated in BA pathogenesis by promoting hepatic Th2 inflammation via increasing cholangiocytes derived IL-33; PIGR has the value as a diagnostic and therapeutic biomarker of BA.

FUNDING

This study was financially supported by the National Natural Science Foundation of China (82170529), the National Key R&D Program (2021YFC2701003), and the National Natural Science Foundation of China (82272022).

Pre-operative Serum Albumin Predicts Native Liver Survival in Biliary Atresia

BACKGROUND

To predict native liver survival (NLS) after Kasai portoenterostomy (KP) for biliary atresia (BA) using pre-operative clinical data.

MATERIALS AND METHODS

Pre-operative data were collected from 29 patients with BA who underwent KP at our department between 1989 and 2017 and were analysed including serum albumin, bilirubin, prothrombin time-international normalised ratio, body height, body weight, age at KP, paediatric end-stage liver disease score calculated using the pre-operative data and the period of NLS.

RESULTS

The 10-year NLS rate of all patients was 51%. A multivariate analysis revealed that among all factors, the pre-KP serum albumin level was the only independent predictor of NLS ( P = 0.04, hazard ratio = 0.269, 95% confidence interval = 0.077-0.934). The area under the receiver operating characteristic curve for NLS, determined using pre-KP serum albumin was 0.760 and 3.75 mg/dl was selected as the cut-off value. There was a significant difference in NLS between patients with high (≥3.8 mg/dl) and low (≤3.7 mg/dl) pre-KP serum albumin (90.0% vs. 31.5%, P < 0.01).

CONCLUSIONS

Decreased pre-KP serum albumin may reflect not only functional impairment of the liver, but also the inflammatory process, which is hypothesized to occur during its advancement. The pre-KP serum albumin level may be a good prognostic factor for NLS in post-KP BA patients.

Eicosapentaenoic acid administration ameliorates the progression of liver fibrosis after laparoscopic Kasai portoenterostomy

PURPOSE

Biliary atresia (BA) poses a persistent challenge characterized by ongoing liver inflammation and subsequent fibrosis even after the clearance of jaundice (COJ). This study aimed to evaluate the therapeutic potential of eicosapentaenoic acid (EPA) in alleviating liver inflammation and limiting fibrosis during the post-COJ phase of BA.

METHODS

Among the BA patients undergoing laparoscopic Kasai portoenterostomy (lapKP) between December 2016 and October 2021, EPA (20-40 mg/kg/day) was administered orally to those whose parents consented. The study included patients from January 2014 to October 2021, classifying them into two groups: EPA-treated (Group E) and untreated (Group N). Their liver fibrosis and clinical course at 1 and 2 years post-lapKP were compared.

RESULTS

Group E consisted of 25 patients, while Group N comprised 32 patients. Twenty-one patients in Group E and 25 patients in Group N achieved COJ (p = 0.74). Among jaundice-free patients at 1 and 2 years post-lapKP, Group E exhibited significantly lower M2BPGi levels and platelet counts, and Group E showed a significant reduction in Aminotransferase-to-Platelet Ratio Index (APRI) at 2 years post-lapKP.

CONCLUSION

Although EPA administration did not improve COJ, it attenuated the progression of liver fibrosis during the 2 years following lapKP in jaundice-free patients. (200/200Words).

Factors predicting the need for liver transplantation in biliary atresia patients after 18 years of age

PURPOSE

We aimed to identify factors predicting the need for future liver transplantation (LT) at 18 years of age in patients with biliary atresia (BA).

METHODS

BA patients with native liver survival at > 18 years of age were retrospectively reviewed. The clinical characteristics, outcomes, hepatobiliary function, and liver fibrosis markers of native liver survivors (NLS group) were compared with patients who subsequently underwent LT (LT group).

RESULTS

The study population included 48 patients (NLS, n = 34; LT, n = 14). The male-to-female ratio, age at Kasai procedure, and type of BA in the two groups did not differ to a statistically significant extent. There was no significant difference in the MELD scores between the groups at 18 years of age. The aspartate aminotransferase-to-platelet ratio index (APRI), albumin-bilirubin (ALBI), and BA liver fibrosis (BALF) scores at 18 years of age were significantly higher in the LT group. The AUCs for APRI, ALBI, and BALF were 0.91, 0.79, and 0.85, respectively.

CONCLUSION

Adult BA patients have limited options for LT owing to the lack of donor candidates and the low prevalence of deceased donors. The elucidation of prognostic factors for LT in adulthood is important. APRI was the most useful marker in this study.

Stable two- and three-dimensional cholangiocyte culture systems from extrahepatic bile ducts of biliary atresia patients: use of structural and functional bile duct epithelium models for in vitro analyses

We herein report two- (2D) and three-dimensional (3D) culture methods of cholangiocytes originating from extrahepatic bile ducts of biliary atresia (BA) patients. Cells were stabilized for in vitro analyses, and 3D culture by two different methods showed the structural and functional features of cholangiocytes in the gel scaffold. First, cells were obtained from gallbladder contents or resected tissues of patients at surgery and then cultured in our original conditioned medium with a cocktail of signaling inhibitors that maintains the immaturity and amplification of cells. Cells were immortalized by inducing SV40T and hTERT genes using lentivirus systems. Immunostaining with CK19 and Sox9 antibodies confirmed the cells as cholangiocytes. 3D organoids were formed in Matrigel in two different ways: by forming spheroids or via vertical growth from 2D cell sheets (2 + 1D culture). Organoids generated with both methods showed the uptake and excretion of rhodamine-123, and duct-like structures were also found. Our culture methods are simpler than previously reported methods and still show the structural and functional characteristics of cholangiocytes. Thus, this system is expected to be useful for the in vitro investigation of cholangiocyte damage or regeneration in BA patients.

The systemic immune-inflammation index at kasai portoenterostomy: related to clinical outcomes

BACKGROUND

Systemic Immune-Inflammation Index (SII), known as an easy, economical and useful marker, correlates with the balance of inflammation and immune response. However, the usefulness of SII in biliary atresia (BA) remains unclear. Therefore, we evaluated the relationship of SII level and postoperative clinical outcomes of BA.

METHODS

Retrospective review of 168 patients with BA was conducted with assessments of demographic information, histological findings, laboratory parameters, and clinical outcomes. The LASSO logistic regression analysis was established using the "glmnet" software package to explore the influencing factors related to native liver survival time. Numerical variables were dichotomized based on the receiver operating characteristic (ROC) curve and Youden index yielding the best performance of prediction. R software was used for statistical analysis.

RESULTS

Overall, the 24 month native liver survival rate was 43.5% (73 cases) after Kasai portoenterostomy. LASSO logistic regression analysis show that preoperative malnutrition (OR = 0.032, 95%CI 0.001-0.424), gamma-glutamyltransferase (GGT, OR = 0.994, 95%CI 0.987-0.998), lymphocyte count (LY, OR = 2.426, 95%CI 1.467-4.604), SII (OR = 0.977, 95%CI 0.960-0.989), and liver fibrosis grading (LFG, reference: Grade 1, Grade 3, OR = 0.076, 95%CI 0.007-0.614) were the independent influencing factors for 24 month native liver survival. ROC curve analysis showed that the area under the curve of SII level (0.919) was larger than that of preoperative malnutrition (0.690), LFG (0.759), GGT (0.747), and Ly (0.773). A SII < 140.09 was found to be a significant marker in the prediction of 24-month native liver survival, with 90.41% sensitivity and 93.68% specificity. Furthermore, the rates of 24-month native liver survival (33.1% vs. 72.7%), jaundice clearance (46.8% vs. 75.0%), and good liver function recovery (46.8% vs. 65.9%) were lower in the SII ≥ 140.09 group than that in the SII < 140.09 group (all P < 0.05), but there was no difference in the occurrence of cholangitis (P > 0.05).

CONCLUSION

Preoperative malnutrition, GGT, Ly, SII, and LFG were independent influencing factors for postoperative 24-month native liver survival of BA. The SII level, as a routine haematological marker, has better universality and simplicity and is related to clinical outcomes after Kasai portoenterostomy.

Cognitive function of children with biliary atresia after primary living donor liver transplantation

BACKGROUND

The survival rate of children with biliary atresia (BA) after liver transplantation (LT) is significantly improved, and their quality of life has attracted much attention.This study aimed to investigate the cognition and its influencing factors in children with BA after primary living donor LT (BA-pLDLT) during infancy.

METHODS

Children with BA were recruited 6 months after pLDLT at Children's Hospital of Chongqing Medical University (2018-2022). Demographic and clinical data were collected from the health information system. Cognition was assessed using the Chinese version of the Griffiths Mental Development scale (GMDS-C). Multivariate linear regression were used to analyze the influencing factors of their cognitive function.

RESULTS

In total, 57 children with BA-pLDLT, aged 5.00(3.90-9.30) months at transplantation and 25.00(14.00-60.80) months at evaluation were included. The general developmental quotient (89.02 ± 12.07) and motor, language, eye-hand coordination, performance, and practical reasoning quotients of these children were significantly lower than the normative mean values of GMDS-C(P < 0.05). Of the 57 children, 16 (28.07%) had borderline developmental delay (DQ between 70 and 84), 3 (5.26%) had developmental delay (DQ < 70), and 11(19.29%) had language delay. Reoperation for biliary or vascular complications after pLDLT was a risk factor for decreased general development quotient and motor quotient and lower ZW at assessment was associated with decline motor quotient.

CONCLUSION

Children with BA-pLDLT have varying degrees of developmental delays in early life. Reoperation and nutritional deficiencies had adverse effects on cognitive development.

Postoperative outcomes of acute-on-chronic liver failure in infants and children with biliary atresia

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is associated with increased mortality and morbidity in patients with biliary atresia (BA). Data on impact of ACLF on postoperative outcomes, however, are sparse.

METHOD

We performed a retrospective analysis of patients with BA aged <18 years who underwent LT between 2011 and 2021 at our institution. ACLF was defined using the pediatric ACLF criteria: ≥1 extra-hepatic organ failure in children with decompensated cirrhosis.

RESULTS

Of 107 patients (65% female; median age 14 [9-31] months) who received a LT, 13 (12%) had ACLF during the index admission prior to LT. Two (15%) had Grade 1; 4 (30%) had Grade 2; and 7 (55%) had Grade ≥3 ACLF. ACLF cohort was younger at time of listing (5 [4-8] vs. 9 [6-24] months; p < .001) and at LT (8 [8-11] vs. 16 [10-40] months, p < .001) compared to no-ACLF group. Intraoperatively, ACLF patients had higher blood loss (40 [20-53] vs. 10 [6-19] mL/kg; p < .001) and blood transfusion requirements (33 [21-69] vs. 18 [7-25] mL/kg; p = .004). Postoperatively, they needed higher vasopressor support (31% vs. 10.6%; p = .04) and had higher total hospital length of stay (106 [45-151] vs. 13 [7-30] days; p = .023). Rate of return to the operating room, hospital readmission rates, and 1-year post-LT survival rates were comparable between the groups.

CONCLUSION

Despite higher perioperative complications, survival outcomes for ACLF in BA after LT are favorable and comparable to those without ACLF. These encouraging data reiterate prioritization during organ allocation of these critically ill children for LT.

Predicting Cirrhosis and Poor Outcomes of Bile Drainage Surgery for Biliary Atresia: A Multicentric Observational Study in Japan

OBJECTIVE

To identify patients with biliary atresia (BA) with extremely poor outcomes of bile drainage surgery using the infant BA liver fibrosis (iBALF) score, a liver fibrosis marker based on standard blood analysis.

BACKGROUND

Although primary liver transplantation is beginning to be considered as an alternative to bile drainage surgery in patients with BA, those most likely to benefit from this procedure have not yet been identified.

METHODS

The medical records of 380 patients with BA with bile drainage surgery between 2015 and 2019 were collected for retrospective analysis from 60 participating hospitals. To predict native liver survival at age 1 year, a receiver operating characteristic curve was drawn for the iBALF score. The cutoff value was determined as the point indicating >99% sensitivity.

RESULTS

The median age at surgery was 56 days (range: 4-183 days), and native liver survival at age 1 year was achieved in 258 (67.9%) patients. An iBALF score of 5.27 was chosen as the cutoff, and 18 patients (4.7%) were found to have an iBALF score >5.27; of these, only 2 (95% CI: 1.4%-34.7%) had native liver survival at age 1 year, indicating a significantly poorer outcome than in the other patients (95% CI: 65.7%-75.4%). Moreover, patients with an iBALF score >5.27 had significantly higher mortality and younger age at salvage liver transplantation.

CONCLUSIONS

Patients with BA having a preoperative iBALF score >5.27 had extremely poor outcomes of bile drainage surgery and may be considered candidates for primary LTx.

Small Intestinal Adenocarcinoma Arising at the Anastomotic Site after Kasai Operation for Biliary Atresia: A Case Report and Literature Review

Biliary atresia is an obliterative cholangiopathy of unknown etiology. Hepatic portoenterostomy, in which obliterated extrahepatic bile ducts are resected and bile flow is restored, known as Kasai operation, is performed within 3 months after birth. While this operation enhances long-term survival of patients, the occurrence of primary malignant hepatic tumors has been increasing. We report a case of small intestinal adenocarcinoma arising at the anastomotic site after Kasai operation. A 49-year-old man, who underwent Kasai operation for biliary atresia when he was 2 months old, experienced rapidly progressive jaundice and liver dysfunction. Deceased-donor liver transplantation was performed for liver failure. Macroscopically, there was a white-yellow tumor located at the anastomotic site of hepatic portoenterostomy of the resected liver. Pathological examination revealed a well-differentiated adenocarcinoma with some Paneth cells in the neoplastic lesion. Immunohistochemically, the tumor cells were negative for cytokeratin 7 (CK7) but positive for cytokeratin 20 (CK20) and a homeobox domain-containing transcription factor (CDX2). Mucin expression in tumor cells was negative for mucin 1 (MUC1) and mucin 6 (MUC6) and positive for mucin 2 (MUC2) and mucin 5AC (MUC5AC). The pathological diagnosis was small intestinal adenocarcinoma originating from the jejunum. The patient was discharged 48 days after the operation. The patient had not experienced recurrence at 10 months after the operation. This is the first report of small intestinal adenocarcinoma arising at the anastomotic site after Kasai operation for biliary atresia. Special care should be taken for the patients after Kasai operation with acute progressive jaundice and liver dysfunction because there is a possibility of malignancy in their native liver.

Pure laparoscopic versus open left lateral hepatectomy in pediatric living donor liver transplantation: a review and meta-analysis

PURPOSE

The meta-analysis was conducted to evaluate the safety and feasibility of pure laparoscopic left lateral hepatectomy in comparison with open approach for pediatric living donor liver transplantation (LDLT).

METHODS

A systemic literature survey was performed by searching the PubMed, EMBASE and Cochrane Library databases for articles that compared pure laparoscopic left lateral living donor hepatectomy (LLDH) and open left lateral living donor hepatectomy (OLDH) by November 2021. Meta-analysis was performed to assess donors' and recipients' perioperative outcomes using RevMan 5.3 software.

RESULTS

A total of five studies involving 432 patients were included in the analysis. The results demonstrated that LLDH group had significantly less blood loss (WMD = -99.28 ml, 95%CI -152.68 to -45.88, p = 0.0003) and shorter length of hospital stay (WMD = -2.71d, 95%CI -3.78 to -1.64, p < 0.00001) compared with OLDH group. A reduced donor overall postoperative complication rate was observed in the LLDH group (OR = 0.29, 95%CI 0.13-0.64, p = 0.002). In the subgroup analysis, donor bile leakage, wound infection and pulmonary complications were similar between two groups (bile leakage: OR = 1.31, 95%CI 0.43-4.02, p = 0.63; wound infection: OR = 0.38, 95%CI 0.10-1.41, p = 0.15; pulmonary complications: OR = 0.24, 95%CI 0.04-1.41, p = 0.11). For recipients, there were no significant difference in perioperative outcomes between the LLDH and OLDH group, including mortality, overall complications, hepatic artery thrombosis, portal vein and biliary complications.

CONCLUSION

LLDH is a safe and effective alternative to OLDH for pediatric LDLT, reducing invasiveness and benefiting postoperative recovery. Future large-scale multi-center studies are expected to confirm the advantages of LLDH in pediatric LDLT.

Biliary atresia and liver transplantation in the United States: A contemporary analysis

BACKGROUND

Biliary atresia (BA) remains the number one indication for paediatric liver transplantation (LT) worldwide but is an uncommon indication for older LT recipients. The impact of recent donor allocation changes, pervasive organ shortage and evolving LT practices on the BA LT population is unknown.

METHODS

We identified patients who underwent LT between January 2010 and December 2021 using the UNOS database. We compared clinical outcomes between patients with BA and those with non-BA cholestatic liver disease. Groups were stratified by age, <12 years (allocated via PELD system) and ≥12 years (allocated via MELD system). Waitlist outcomes were compared using competing-risk regression analysis, graft survival rates were compared using Kaplan-Meier time-to-event analysis and Cox proportional hazards modelling provided adjusted estimates.

RESULTS

There were 2754 BA LT waitlist additions and 2206 BA LTs (1937 <12 years [younger], 269 ≥12 years [older]). There were no differences in waitlist mortality between BA and non-BA cholestatic patients. Among BA LT recipients, there were 441 (20.0%) living-donor liver transplantations (LDLT) and 611 (27.7%) split deceased-donor LTs. Five-year graft survival was significantly higher among BA versus non-BA cholestatic patients in the older group (88.3% vs. 79.5%, p < .01) but not younger group (89.3% vs. 89.5%). Among BA LT recipients, improved graft outcomes were associated with LDLT (vs. split LT: HR: 2, 95% CI: 1.03-3.91) and higher transplant volume (volume >100 vs. <40 BA LTs: HR: 3.41, 95% CI: 1.87-6.2).

CONCLUSION

Liver transplant outcomes among BA patients are excellent, with LDLT and higher transplant centre volume associated with optimal graft outcomes.

Risk Assessment of Liver Transplantation After Kasai Portoenterostomy in Children and Adults

INTRODUCTION

Reports of liver transplantation (LT) after Kasai portoenterostomy (KPE) in adult patients with biliary atresia are scarce. The aim of this study was to evaluate the outcomes and investigate the risk factors of LT after KPE in both pediatric and adult patients.

METHODS

We retrospectively reviewed a prospective database of patients with biliary atresia who underwent LT after KPE. Eighty-nine consecutive patients were included, and risk factors for in-hospital mortality after LT were assessed.

RESULTS

The median age of the patients was 2 y (range, 0-45 y). Forty-six patients (51.7%) had a history of upper abdominal surgery after KPE. The in-hospital mortality rate was 5.6% (5 patients). Of these, 80% of patients with mortality were aged ≥17 y, and all patients with mortality had a history of two or more upper abdominal surgeries. In the univariate and receiver operating characteristic curve analyses, age ≥17 y and the number of previous upper abdominal surgeries ≥2 were identified as possible risk factors.

CONCLUSIONS

Our study suggests that older age and multiple previous upper abdominal surgeries are important risk factors for mortality after LT following KPE. We believe that these findings will serve as indications for safe LT in future patients.

Advances in pediatric liver transplantation from the pediatric surgeon's perspective

Pediatric liver transplantation is a lifesaving state-of-the-art operation for children with various liver diseases, including cholestatic diseases, metabolic disorders, acute liver failure, and primary malignant liver tumors. Among these indications, transplantation for biliary atresia and hepatoblastoma is discussed in this review because pediatric surgeons are usually involved in their initial treatments. For biliary atresia, pediatric surgeons are advised to keep dissection of the hilar structures to a minimum during Kasai portoenterostomy in order to make total hepatectomy easier at transplantation. Early referral to a transplant team is recommended when worrisome signs of liver dysfunction, cirrhosis, portal hypertension and growth retardation are noted. Hepatoblastoma with multiplicity or located close to major vessels may indicate unresectability, and the transplant team needs to be consulted early after neoadjuvant chemotherapy is started. The graft size, including its thickness, needs to be evaluated before transplantation for small children, as tailoring the shape of the partial graft may be necessary during the transplant procedure.

Development of liver inflammatory injury in biliary atresia: from basic to clinical research

Biliary atresia (BA) is a severe cholangiopathy in infants. It is characterized by inflammatory fibro-obliteration of the intra- and extrahepatic bile ducts. Although the restoration of bile flow can be successful after Kasai operation, the rapid progression of liver fibrosis can continue, leading to cirrhosis. It is believed that the progression of liver fibrosis in BA is exacerbated by complicated mechanisms other than the consequence of bile duct obstruction. The fibrogenic cascade in BA liver can be divided into three stages, including liver inflammatory injury, myofibroblast activation, and fibrous scar formation. Recent studies have revealed that the activation of an immune response following bile duct injury plays an important role in promoting the inflammatory process, the releasing of inflammatory cytokines, and the development of fibrogenesis in BA liver. In this article, we summarized the evidence regarding liver inflammatory injury and the possible mechanisms that explain the rapid progression of liver fibrosis in BA.

Prognostic Factors Related to In-hospital Death in Children with Biliary Atresia: Analysis of a Nationwide Inpatient Database

BACKGROUND AND AIMS

Patients with biliary atresia (BA) are prone to hepatic decompensation, which might eventually lead to death. This study aimed to identify the possible risk factors affecting in-hospital death in BA patients in China.

METHODS

We collected data from the Hospital Quality Monitoring System, a national inpatient database. All patients aged up to 2 years old with a diagnosis of BA were included. The subjects were divided to three groups, including Kasai portoenterostomy (KP), liver transplantation (LT), and no surgery. Logistic regression with Firth's method was performed to identify potential influencing variables associated with in-hospital death.

RESULTS

During the year 2013 to 2017, there were 14,038 pediatric admissions with a diagnosis of BA. The proportion of in-hospital death in pediatric BA admissions was 1.08%. Compared with patients under six months, there was a higher risk of in-hospital death for children aged six months to 1 year and 1-2 years old. Clinical signs, including cirrhosis, variceal bleeding, and hepatic encephalopathy, were significantly associated with the risk of in-hospital death. In no surgery group, compared to those in Beijing and Shanghai, BA patients admitted in other districts had a lower risk of in-hospital death (OR=0.39, 95% CI: 0.21, 0.70). However, in the LT group, patients admitted in other districts had a higher risk of in-hospital death (OR=9.13, 95% CI: 3.99, 20.87).

CONCLUSIONS

In-hospital survival remains unsatisfactory for pediatric BA patients with severe complications. Furthermore, more resources and training for BA treatment, especially LT, are essential for districts with poor medical care in the future.

Liver-Spleen Volume Ratio as a Predictor of Native Liver Survival in Patients with Biliary Atresia

BACKGROUND

The appropriate timing of liver transplantation (LT) in patients with biliary atresia (BA) who survived with their native livers until adolescence remains controversial. The liver-spleen volume ratio (LSR) has been reported to be efficacious in predicting the prognosis of chronic liver disease. We investigated whether LSR could predict long-term native liver prognosis and serve as an indication for LT in patients with BA.

METHODS

Patients with BA who survived with their native liver until the age of 15 years were included. These patients were classified into 2 groups. The unfavorable prognosis group included patients who underwent or were awaiting LT or developed complications such as refractory cholangitis or gastrointestinal bleeding due to esophagogastric or intestinal varices. The favorable prognosis group included patients who survived with their native liver without complications. We compared the 2 groups regarding LSR, hematological, and histologic data.

RESULTS

Of 19 patients, 8 were in the unfavorable prognosis group, and 11 were in the favorable prognosis group. LSR was significantly lower in the unfavorable prognosis group (P = .009). Analysis of the receiver operating characteristic curve showed that the area under the curve of the LSR was 0.891, which was higher than the area under the curve of liver fibrosis markers. The optimal LSR cut-off value for predicting poor native liver prognosis was 1.97, with a sensitivity of 75.0% and a specificity of 87.5%.

CONCLUSIONS

The LSR reflects splenomegaly and liver atrophy. The LSR might be a reliable predictor of native liver prognosis and could guide decisions about LT in patients with BA.

Association between serum HMGB1 elevation and early pediatric acute respiratory distress syndrome: a retrospective study of pediatric living donor liver transplant recipients with biliary atresia in China

BACKGROUND

High mobility group box 1 (HMGB1) protein is one of the main risk factors for pediatric acute respiratory distress syndrome (PARDS) after living donor liver transplantation (LDLT). However, studies of the relationship between HMGB1 and PARDS are lacking. We evaluated the link between anomalies of intraoperative serum HMGB1 and PARDS in pediatric LDLT recipients with biliary atresia during the first week after transplant.

METHODS

Data for 210 pediatric patients with biliary atresia who underwent LDLT between January 2018 and December 2021 were reviewed retrospectively. The main measure was serum HMGB1 levels 30 min after reperfusion, while the outcome was early PARDS after LDLT. Data including pretransplant conditions, laboratory indexes, variables of intraoperation, clinical complications, and outcomes after LDLT were analyzed for each patient. Univariate analysis of PARDS and multivariate logistic regression analyses of serum HMGB1 levels at 30 min in the neohepatic phase in the presence of PARDS were conducted to examine the potential associations. Subgroup interaction analyses and linear relationships between intraoperative serum HMGB1 levels and PARDS were also performed.

RESULTS

Among the participants, 55 had PARDS during 7 days after LDLT, including four in the first HMGB1 tertile (4.3-8.1 pg/mL), 18 in the second tertile (8.2-10.6 pg/mL), and 33 in the third tertile (10.6-18.8 pg/mL). The nonadjusted association between intraoperative HMGB1 levels and PARDS was positive (odds ratio 1.41, 95% confidence intervals 1.24-1.61, P < 0.0001). The association remained unchanged after adjustment for age, weight, pretransplant total bilirubin, albumin, graft cold ischemia time, and intraoperative blood loss volume (odds ratio 1.28, 95% confidence interval 1.10-1.49, P = 0.0017). After controlling for potential confounders, the association between intraoperative HMGB1 levels and PARDS remained positive, as well as in the subgroup analyses.

CONCLUSIONS

Serum HMGB1 levels at 30 min after reperfusion were positively associated with early PARDS among pediatric patients with biliary atresia who had undergone LDLT. Identifying such patients early may increase the efficacy of perioperative respiratory management.

Advances in the Treatment of Neonatal Biliary Disease

This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.

[New advances in the diagnosis and treatment of biliary atresia]

The diagnosis of biliary atresia (BA) is mainly based on clinical manifestations, screening, and related biochemistry tests. In recent years, the development of blood biomarkers and the improvement in ultrasound examination have made it possible for BA to be diagnosed at a younger age. In particular, matrix metalloproteinase-7 shows high sensitivity and specificity and has a higher diagnostic efficiency than existing biochemical parameters, thereby holding a promise for clinical application. Sound touch elastography can increase the diagnostic efficiency for BA in terms of diagnosis and prognostic evaluation. Surgery is still the only method for the treatment of BA at present, with the preferred surgical treatment regimen of Kasai portoenterostomy combined with pharmacotherapies for alleviating infection and inflammation, and the patients who fail Kasai portoenterostomy or have liver dysfunction may require liver transplantation to save their lives. Therefore, the current research on BA should focus on the biomarkers for early diagnosis, specifically targeted drugs, and drugs for preventing progressive liver fibrosis. This article reviews the current diagnosis and treatment methods for BA and discusses the potential research directions.

Impact of allograft types on outcomes after pediatric liver transplantation due to biliary atresia

BACKGROUND

Several surgical strategies, including split donor transplantation and living donor transplantation, have been used to increase the donor liver pool. This report focuses on the effects of whole, split, and LDLT on recipient outcomes.

METHODS

We retrospectively analyzed the records of all patients with biliary atresia at Tianjin First Central Hospital between April 2013 and December 2019.

RESULTS

A total of 882 patients were included and divided into three groups by graft type, with 198 in the whole-liver-transplantation group, 78 in the split liver transplantation group, and 606 in the LDLT group. The median follow-up time was 39 months, patient survival rates of three groups were 94.4%, 88.5%, and 95.0%, respectively, and graft survival rates were 90.2%, 83.3%, and 94.7%, respectively. We divided the split liver transplantation group into two subgroups according to the donor's age, and patient survival rates exhibited a significant difference only in the group whose donor age was over 45 years. The postoperative complication rates were significantly higher with respect to hepatic artery thrombosis, portal stenosis, and AR; and lower in hepatic venous stenosis, PTLDs, CMV virus, and EBV infection in the WLT group. Our multivariate model showed that donor age ≥45 years, RBC transfusion, pneumonia, and HAT were the independent predictors of allograft loss.

CONCLUSIONS

The survival of split liver transplantation group was slightly lower. The types of complications are different from different graft types. Therefore, postoperative monitoring and treatment need to be adjusted according to the different graft types used.

Accumulation of Postoperative Unexpected Events Assessed by the Comprehensive Complication Index® as Prognostic Outcome Parameters for Kasai Procedure

Introduction The Kasai procedure in children with biliary atresia (BA) is associated with several complications in the short-term. The Comprehensive Complication Index (CCI®) is a validated metric in adult surgery for the analysis of complications and morbidity in surgical patients. We aimed to analyze the CCI® for the first time in BA infants and to correlate its association with outcomes. Material and Methods We conducted a retrospective review of medical records of infants with type III BA undergoing the Kasai procedure between January 2011 and December 2021 at our institution. All unexpected events were ranked according to the Clavien−Dindo classification, and the CCI® per patient was subsequently calculated. Clavien−Dindo grades, individual events, CCI®, and total event numbers per patient were correlated with one- and two-year outcomes post-surgery. Results A total of 131 events were identified in 101 patients (ranging 0−11 per patient). Forty-four Grade I (33.6%), 67 Grade II (51.1%), 18 Grade III (13.7%), and two sentinel events [>Grade IV] (1.5%) were documented according to Clavien−Dindo, including one death in a cardiac-associated BA patient. None of the complications significantly correlated with a poor outcome. Sixty-three (62.4%) CCI® scores were calculated (range 0−100). The mean CCI® score during the in-patient treatment post-surgery was significantly higher in patients with a poorer outcome than patients with native liver survival at one- and two-year follow-up (22.7 ± 21.7 vs. 13.2 ± 18.1; p = 0.02). Conclusion Not the severity of complications, but the accumulation of numerous events related to Kasai procedure were associated with a poorer outcome. Therefore, the CCI® is an excellent instrument for the postoperative morbidity assessment of BA patients.

A multi-disciplinary, comprehensive approach to management of children with heterotaxy

Heterotaxy (HTX) is a rare condition of abnormal thoraco-abdominal organ arrangement across the left-right axis of the body. The pathogenesis of HTX includes a derangement of the complex signaling at the left-right organizer early in embryogenesis involving motile and non-motile cilia. It can be inherited as a single-gene disorder, a phenotypic feature of a known genetic syndrome or without any clear genetic etiology. Most patients with HTX have complex cardiovascular malformations requiring surgical intervention. Surgical risks are relatively high due to several serious comorbidities often seen in patients with HTX. Asplenia or functional hyposplenism significantly increase the risk for sepsis and therefore require antimicrobial prophylaxis and immediate medical attention with fever. Intestinal rotation abnormalities are common among patients with HTX, although volvulus is rare and surgical correction carries substantial risk. While routine screening for intestinal malrotation is not recommended, providers and families should promptly address symptoms concerning for volvulus and biliary atresia, another serious morbidity more common among patients with HTX. Many patients with HTX have chronic lung disease and should be screened for primary ciliary dyskinesia, a condition of respiratory cilia impairment leading to bronchiectasis. Mental health and neurodevelopmental conditions need to be carefully considered among this population of patients living with a substantial medical burden. Optimal care of children with HTX requires a cohesive team of primary care providers and experienced subspecialists collaborating to provide compassionate, standardized and evidence-based care. In this statement, subspecialty experts experienced in HTX care and research collaborated to provide expert- and evidence-based suggestions addressing the numerous medical issues affecting children living with HTX.

Living-Related Liver Retransplantation in a Child: When it Seems Impossible (A Clinical Case)

The objective: to show the possibility of anesthesia during liver retransplantation in a child in the absence of adequate vascular access.

A clinical case of liver retransplantation in a 10-year-old patient with liver transplant dysfunction and acquired thrombophilia is considered. In 2011, the child underwent Kasai portoenterostomy, and in 2012, living-related transplantation of the left lateral liver bisegment from a related donor was performed due to liver cirrhosis as an outcome of biliary atresia. Also, the child had multiple surgical interventions due to perforations of the small intestine with underlying segmental venous mesenteric thrombosis. In the long term after the transplantation, irreversible transplant dysfunction developed with manifestations and worsening of hepatocellular insufficiency, encephalopathy, as well as recurrent bleeding from varicose veins of the esophagus and cardiac orifice. The clinical situation was complicated by the lack of adequate vascular access due to total thrombosis of the venous system, thrombosis of the superior and inferior vena cava. The only possible option for ensuring adequate venous access was the implantation of a tunneled catheter into the right atrium of the right atrium for prolonged standing in conditions of single-lung ventilation through right-sided thoracotomy.  

Comprehensive Analysis of Gut Microbiota and Fecal Bile Acid Profiles in Children With Biliary Atresia

Background

Biliary atresia (BA) is the most common cholestatic liver disease in neonates. Herein, we aimed at characterizing the gut microbiota and fecal bile acid profiles of BA patients, defining the correlations between them, and evaluating the relationship between the clinical pathogenesis and changes in the gut microbiota and bile acid profiles.

Methods

A total of 84 fecal samples from BA patients (n = 46) and matched healthy controls (HCs, n = 38) were subjected to sequencing by 16S rRNA gene amplification, and fecal bile acid were analyzed by targeted metabolomics.

Findings

Compared with the controls, a structural separation of the intestinal flora of BA patients was uncovered, which was accompanied by changes in the composition of fecal bile acids. In the BA group, Actinobacillus, Monoglobus, and Agathobacter were enriched in patients without cholangitis (p &lt; 0.05). Selenomonadaceae and Megamonas were more abundant in patients without recurrent cholangitis episodes (p &lt; 0.05), while Lachnospiraceae and Ruminococcaceae were enriched in patients with multiple recurrences of cholangitis (p &lt; 0.05). Postoperative jaundice clearance was associated with Campylobacter and Rikenellaceae (p &lt; 0.05), and tauroursodeoxycholic acid was associated with jaundice clearance (p &lt; 0.001).

Conclusion

BA patients are characterized by different compositions of gut microbiota and bile acids, and their interaction is involved in the process of liver damage in BA, which may be closely related to the occurrence of postoperative cholangitis and jaundice clearance.

Centralization of Biliary Atresia: Has Germany Learned Its Lessons?

INTRODUCTION

 The majority of pediatric surgeons and hepatologists recommend the centralization of biliary atresia (BA) treatment within experienced liver units. We aimed to investigate whether voluntary self-restriction and acceptance of the need for this change in practice changed the BA referral policy in Germany during the last decade.

MATERIALS AND METHODS

 In cooperation with pediatric surgeons, gastroenterologists or hepatologists, and pediatric liver transplant units, the 2-year follow-up data of infants with BA born in Germany between 2010 and 2014 were collected using www.bard-online.com or pseudonymized data transfer. Results were compared with our previous analysis of the outcome data of infants with BA born between 2001 and 2005 in Germany.

RESULT

 Overall, 173 infants with BA were identified, of whom 160 underwent Kasai portoenterostomy (KPE; 92.5%) and 13 (7.5%) underwent primary liver transplantation at 21 German centers. At 2-year follow-up, overall survival was 87.7% (vs. 81.9% in 2001-2005 [p = 0.19]), survival with native liver post-KPE was 29.2% (vs. 22.8% in 2001-2005 [p = 0.24]), and jaundice-free survival with native liver post-KPE was 24.0% (vs. 20.1% in 2001-2005 [p = 0.5]). Compared with the 2001-2005 analysis, all criteria showed improvement but the differences are statistically not significant.

CONCLUSION

 Our observation shows that KPE management requires improvement in Germany. Centralization of BA patients to German reference liver units is not yet mandatory. However, European and national efforts with regard to the centralization of rare diseases support our common endeavor in this direction.

Variability of Care and Access to Transplantation for Children with Biliary Atresia Who Need a Liver Replacement

Background & Aims: Biliary atresia (BA) is the commonest single etiology indication for liver replacement in children. As timely access to liver transplantation (LT) remains challenging for small BA children (with prolonged waiting time being associated with clinical deterioration leading to both preventable pre- and post-transplant morbidity and mortality), the care pathway of BA children in need of LT was analyzed—from diagnosis to LT—with particular attention to referral patterns, timing of referral, waiting list dynamics and need for medical assistance before LT. Methods: International multicentric retrospective study. Intent-to-transplant study analyzing BA children who had indication for LT early in life (aged < 3 years at the time of assessment), over the last 5 years (2016−2020). Clinical and laboratory data of 219 BA children were collected from 8 transplant centers (6 in Europe and 2 in USA). Results: 39 patients underwent primary transplants. Children who underwent Kasai in a specialist -but not transplant- center were older at time of referral and at transplant. At assessment for LT, the vast majority of children already were experiencing complication of cirrhosis, and the majority of children needed medical assistance (nutritional support, hospitalization, transfusion of albumin or blood) while waiting for transplantation. Severe worsening of the clinical condition led to the need for requesting a priority status (i.e., Peld Score exception or similar) for timely graft allocation for 76 children, overall (35%). Conclusions: As LT currently results in BA patient survival exceeding 95% in many expert LT centers, the paradigm for BA management optimization and survival have currently shifted to the pre-LT management. The creation of networks dedicated to the timely referral to a pediatric transplant center and possibly centralization of care should be considered, in combination with implementing all different graft type surgeries in specialist centers (including split and living donor LTs) to achieve timely LT in this vulnerable population.

Neonatal diagnosis of biliary atresia: a practical review and update

Biliary atresia is challenging to diagnose because many of the clinical and imaging features of this condition overlap with those of other causes of cholestasis in newborns. When jaundice persists beyond 2 weeks of age, the neonate should be evaluated for cholestasis, and biliary atresia - the most common cause of neonatal cholestasis - should be considered. It is critical to diagnose biliary atresia early because failure to treat can result in hepatic fibrosis and death in less than 1 year. In this paper, we review the current diagnostic imaging methods, differential considerations and treatment options for biliary atresia.

Characteristics of SOX9-positive progenitor-like cells during cholestatic liver regeneration in biliary atresia

Background

The progression of Biliary Atresia (BA) is associated with the number of reactive ductular cells (RDCs) whose heterogeneity in origin and evolution in humans remains unknown. SOX9-positive liver progenitor-like cells (LPLCs) have been shown to participate in RDCs and new hepatocyte formation during cholestatic liver regeneration in an animal model, which implies the possibility that hepatocyte-reprogrammed LPLCs could be a source of RDCs in BA. The present study aimed to elucidate the characteristics of SOX9-positive LPLCs in BA for exploring new possible therapeutic targets by manipulating the bi-differentiation process of LPLCs to prevent disease progression.

Methods

Twenty-eight patients, including 24 patients with BA and 4 patients with Congenital Choledochal Cyst as the control group, were retrospectively recruited. Liver biopsy samples were classified histologically using a 4-point scale based on fibrosis severity. LPLCs were detected by SOX9 and HNF4A double positive staining. Single immunohistochemistry, double immunohistochemistry, and multiple immunofluorescence staining were used to determine the different cell types and characteristics of LPLCs.

Results

The prognostic predictors of BA, namely total bile acid (TBA), RDCs, and fibrosis, were correlated to the emergence of LPLCs. SOX9 and HNF4A double-positive LPLCs co-stained rarely with relevant markers of portal hepatic progenitor cells (portal-HPCs), including CK19, CK7, EPCAM, PROM1 (CD133), TROP2, and AFP. Under cholestasis conditions, LPLCs acquired superior proliferation and anti-senescence ability among hepatocytes. Moreover, LPLCs arranged as a pseudo-rosette structure appeared from the periportal parenchyma to the portal region, which implied the differentiation from hepatocyte-reprogrammed LPLCs to RDCs with the progression of cholestasis.

Conclusions

LPLCs are associated with disease progression and prognostic factors of BA. The bipotent characteristics of LPLCs are different from those of portal-HPCs. As cholestasis progresses, LPLCs appear to gain superior proliferation and anti-senescence ability and continually differentiate to RDCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-02795-2.

Efficacy and tolerance of enteral nutrition in children with biliary atresia awaiting liver transplantation

OBJECTIVES

Malnutrition is common in children with biliary atresia (BA) awaiting liver transplantation (LT). Few studies have evaluated the effectiveness of enteral nutrition (EN) in these patients. The objective of this work was to assess the efficacy and tolerance of EN in children with BA awaiting LT.

METHODS

A total of 31 patients with BA followed between 1995 and 2018 were retrospectively included. Anthropometric indicators (weight, length, and head circumference) and adverse effects of EN were noted at the start (T0) and the end (T1) of EN. The z-scores for anthropometric indicators were compared between T0 and T1.

RESULTS

The median age at T0 was 7 months (interquartile range [IQR] 5-9), and the median duration of EN was 9 months (IQR 3-17). The z-scores for anthropometric variables improved from T0 to T1: -1.6 (IQR -2.5 to -1.0) to -0.5 (IQR -1.8 to 0.3) for median weight for age; -1.3 (IQR -2.4 to 0) to -0.4 (IQR -2.0 to 0.7) for length for age; -0.9 (IQR -2.3 to -0.3) to -0.3 (IQR -1.2 to 0.1) for weight for length; and -1.2 (IQR -2.1 to -0.6) to -0.2 (IQR -1.6 to 0.4) for body mass index (p < 0.05 for all comparisons). Nearly all (94%) of the patients had a weight-for-length z-score > -2 at the end of EN; 23% had adverse effects and 10% had complications leading to the cessation of EN.

CONCLUSION

EN is effective and well tolerated in infants with BA awaiting LT.

Sound touch elastography for assessing cirrhosis preoperatively in infants with biliary atresia: Comparison with serum fibrosis biomarkers

INTRODUCTION

The accurate assessment of the stages of hepatic fibrosis in children with biliary atresia (BA) before performing Kasai portoenterostomy (KPE) is of utmost importance. Some studies demonstrated that ultrasound elastography can be used to assess the stages of hepatic fibrosis by detecting liver stiffness. Therefore, the aim of this work was to explore the usefulness of sound touch elastography (STE) for preoperatively assessing liver cirrhosis in infants with BA.

METHODS

A total of 189 children from the Hunan Children's Hospital with highly suspected BA were selected for this study, and their preoperative liver STE values and related clinical data were collected. The pathological results of the liver stages were considered as the gold standard. Spearman correlation was used to analyze the correlation between each parameter and the stage of hepatic fibrosis, and the receiver operator characteristic (ROC) curve was used to analyze the diagnostic performance for cirrhosis of each parameter.

RESULTS

Among the selected 189 patients with suspected BA, 159 were included in this study and were composed of 3 at hepatic fibrosis stage F1, 45 at stage F2, 41 at stage F3, and 70 at stage F4, while no patients at stage F0 were present. Spearman correlation analysis showed that the liver STE value had the highest correlation with the stage of hepatic fibrosis, with a correlation coefficient of 0.813 (P < 0.001). The liver STE value had the highest diagnostic performance for hepatic cirrhosis compared to other biomarkers of serum fibrosis; the area under the ROC curve was 0.899 when the best cut-off value was 14.57 kPa. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 78.6, 84.3, 79.7, 83.3, and 81.8%, respectively.

CONCLUSION

The liver STE value has a high correlation with the stage of hepatic fibrosis in children with BA. STE has a good diagnostic performance in evaluating cirrhosis before KPE in children with BA.

Association of Gut Microbiota and Metabolites With Disease Progression in Children With Biliary Atresia

Background and Aims

Biliary atresia is the most common cause of liver disease and liver transplantation in children. The accumulation of bile acids in hepatocytes and the stimulation of the intestinal microbiome can aggravate the disease progression. This study investigated changes in the composition of the gut microbiota and its metabolites in biliary atresia and the possible effects of these changes on disease progression.

Methods

Stool samples of biliary atresia at different disease stages and matched control individuals were collected (early stage: 16 patients, 16 controls; later stage: 16 patients, 10 controls). Metagenomic sequencing was performed to evaluate the gut microbiota structure. Untargeted metabolomics was performed to detect and analyze the metabolites and bile acid composition.

Results

A disturbed gut microbiota structure occurred in the early and later stages of biliary atresia. Klebsiella, Streptococcus, Veillonella, and Enterococcus have always been dominant. The abundance of V. atypica displayed significant changes between the early and later stages of biliary atresia. Combined with clinical indicators, Spearman’s analysis showed that Klebsiella and Veillonella atypica strongly correlated with liver enzymes. Enterococcus faecium had an enormously positive relationship with lithocholic acid derivatives. Metabolites involved in tryptophan metabolism were changed in the patients with biliary atresia, which had a significant association with stool V. atypica and blood total bilirubin (p < 0.05).

Conclusions

The liver damage of biliary atresia was directly or indirectly exacerbated by the interaction of enriched Klebsiella (K. pneumoniae), Veillonella (V. atypica), and Enterococcus (E. faecium) with dysmetabolism of tryptophan and bile acid.

Extended Adhesion-Sparing Liver Eversion during Kasai Portoenterostomy for Infants with Biliary Atresia

Background: Despite the fact that Kasai portoenterostomy (KPE) is the primary treatment for biliary atresia (BA), liver transplantation (LT) remains the ultimate surgery for two-thirds of these patients. Their true survival rate with the native liver reflects the original KPE and the burden of post-operative complications. We report an original modification of the adhesion-sparing liver eversion (ASLE) technique during KPE that facilitates the total native hepatectomy at time of transplantation. Methods: All consecutive patients with BA who underwent KPE at our department and subsequent LT at Paediatric Liver Transplant Centre at Papa Giovanni XXIII Hospital between 2010–2018 were retrospectively enrolled. All patients underwent ASLE during KPE. Patients’ demographic data, type of KPE, total transplant time (TTT), hepatectomy time (HT), intra-operative packed red blood cells and plasma transfusions, intra- and post-operative complications were noted. Results: 44 patients were enrolled. Median TTT and HT were 337 and 57 min, respectively. The median volume of packed red blood cell transfusion was 95 mL. No patients presented bowel perforation during the procedure or in the short post-operative course. No mortality after LT was recorded. Conclusions: In addition to the well-known advantages of the standard liver eversion technique, ASLE reduces the formation of intra-abdominal adhesions, lowering significantly the risk of bowel perforation and bleeding when liver transplantation is performed for failure of KPE.

The Prognosis of Type III Biliary Atresia with Hilar Cyst

OBJECTIVE

To compare the outcome of biliary atresia (BA) patients with and without hilar cyst on preoperative ultrasound.

METHODS

A single center retrospective review of patients of BA with (n = 27) and without hilar cyst (n = 27) over a 5 y period was done. The patients were analyzed using propensity score matching to reduce selection bias. All patients were diagnosed as type III BA by histologic examination and cholangiograms. Clinicopathological characteristics and survival outcomes were compared between the two groups.

RESULTS

There were no significant intergroup differences between baseline characteristics and outcomes after Kasai portoenterostomy surgery in two groups. BA with hilar cyst group showed comparable survival outcomes to the BA without cyst group (cumulative 1-y, 2-y and 5-y overall survival rates with native liver 61.4% vs. 65.8%, P = 0.041; 45.0% vs. 49.0%, P = 0.57; 45.0% vs. 49.0%, P = 0.57). And the Kaplan-Meier survival curves showed no significant difference in cumulative survival with native liver between the two groups (P = 0.58).

CONCLUSIONS

Type III BA with hilar cyst had no better prognosis compared with Type III BA without cyst.

Characteristics of Gut Microbiota in Children With Biliary Atresia After Liver Transplantation

Background and Aims

Biliary atresia (BA) is an idiopathic neonatal cholestasis and is the most common indication in pediatric liver transplantation (LT). Previous studies have suggested that the gut microbiota (GM) in BA is disordered. However, the effect of LT on gut dysbiosis in patients with BA has not yet been elucidated.

Methods

Patients with BA (n = 16) and healthy controls (n = 10) were recruited. In the early life of children with BA, Kasai surgery is a typical procedure for restoring bile flow. According to whether BA patients had previously undergone Kasai surgery, we divided the post-LT patients into the with-Kasai group (n = 8) and non-Kasai group (n = 8). Fecal samples were collected in both the BA and the control group; among BA patients, samples were obtained again 6 months after LT. A total of 40 fecal samples were collected, of which 16 were pre-LT, 14 were post-LT (8 were with-Kasai, 6 were non-Kasai), and 10 were from the control group. Metagenomic sequencing was performed to evaluate the GM.

Results

The Kruskal-Wallis test showed a statistically significant difference in the number of genes between the pre-LT and the control group, the pre-LT and the post-LT group (P < 0.05), but no statistical difference between the post-LT and the control group. Principal coordinate analysis also showed that the microbiome structure was similar between the post-LT and control group (P > 0.05). Analysis of the GM composition showed a significant decrease in Serratia, Enterobacter, Morganella, Skunalikevirus, and Phifllikevirus while short chain fatty acid (SCFA)-producing bacteria such as Roseburia, Blautia, Clostridium, Akkermansia, and Ruminococcus were increased after LT (linear discriminant analysis > 2, P < 0.05). However, they still did not reach the normal control level. Concerning functional profiles, lipopolysaccharide metabolism, multidrug resistance, polyamine biosynthesis, GABA biosynthesis, and EHEC/EPEC pathogenicity signature were more enriched in the post-LT group compared with the control group. Prior Kasai surgery had a specific influence on the postoperative GM.

Conclusion

LT partly improved the GM in patients with BA, which provided new insight into understanding the role of LT in BA.

Bile Acids Impair Vaccine Response in Children With Biliary Atresia

Background

Vaccination is the best way to protect children under 5 years from death or disability. Children with biliary atresia (BA), which is the most common pediatric cholestatic end-stage liver disease (PELD), are more vulnerable to infectious diseases. However, the vaccination coverage and factors modulating vaccine responses in children with BA are largely unknown.

Methods

In this study, 288 children (median age: 7 months) diagnosed with BA before liver transplantation were enrolled for the evaluation of vaccination status and the factors affecting the immune response to the hepatitis B (HBV) vaccine. Moreover, 49 BA children (median age: 4 months) were enrolled for flow cytometric analysis of CD4⁺ T cells and CD19⁺ B cell subsets and correlations with serum bile acid levels.

Results

Generally, these children had very low routine vaccination rates for the meningococcal serogroup AC (Men AC) (41.2%), measles-mumps-rubella (MMR) (31.3%), poliomyelitis (Polio) (25.3%), hepatitis A (HAV) (25.0%), Japanese encephalitis (JE) (15.0%), diphtheria-tetanus-pertussis (DTP) (14.2%), meningococcal serogroup A (Men A) (13.5%) and varicella (VAR) (10.8%) vaccines, but not for the HBV (96.2%) and bacillus Calmette-Guérin (BCG) (84.7%) vaccines. Remarkably, 19.8% (57/288) of the patients had HBV infection. Out of 220 patients vaccinated for HBV, 113 (51.4%), 85 (38.6%) and 22 (10%) had one, two or three doses of the HBV vaccine, respectively. Furthermore, logistic regression analysis revealed that the bile acid level was an independent factor associated with poor HBV vaccine response (p = 0.03; OR = 0.394; 95% CI = 0.170-0.969). Immunophenotyping showed that bile acids were only negatively correlated with the CD19⁺CD27⁺IgG⁺ post-class-switched memory B cell ratio (p = 0.01).

Conclusion

This study reveals the overall vaccination rates of routine vaccines in Chinese BA children are very low and the poor HBV vaccine responses are associated with bile acids, possibly via the inhibition of CD19⁺CD27⁺IgG⁺ post-class-switched memory B cell response.

Clinical Trial Registration

http://www.chictr.org.cn, identifier ChiCTR1800019165.

Pure Laparoscopic Living Donor Left Lateral Sectionectomy Using Glissonean Approach and Original Bridging Technique

BACKGROUND

Living donor liver transplantation (LDLT) is the final treatment for children with end-stage liver disease. Congenital biliary atresia (CBA) is the most common disease requiring LDLT in Japan, and a left lateral sector graft is preferably procured owing to its anatomic predictivity and identical graft volume for preschool recipients. Laparoscopic left lateral sectionectomy (L-LLS) for LDLT has been recently established; however, there is no report about the innovative technique in L-LLS. The aim of this study was to introduce our L-LLS using the Glissonean approach and bridging technique for pediatric LDLT.

MATERIALS AND METHODS

From September 2017 to September 2020, 5 cases of L-LLS for pediatric LDLT because of CBA were performed and we performed L-LLS using the original technique on their donors. In this novel procedure, the left Glissonean pedicle was encircled at the parenchymal side of the Laennec capsule after mobilization of the lateral sector and visualization of the left hepatic vein. Then, we passed 2 tapes through the encircled Glissonean pedicle at the hepatic side and the duodenal side, as the caudate lobe branch is enclosed like a bridge. By virtue of this bridging technique, we encircled the caudate lobe branch alone by switching the tape, and we clipped and divided it; this technique secured an adequately long hepatic duct on the graft side to perform a hepaticojejunostomy. The left hepatic duct was divided after indocyanine green fluorescence cholangiography, and the left hepatic artery and portal vein were divided as well. Finally, the left hepatic vein was transected and procured from an extended intraumbilical incision.

RESULTS

We achieved L-LLS by using the Glissonean approach and the bridging technique in the 5 donors. The median operating time and blood loss were 282 (268 to 332) minutes and 34 (25 to 75) mL, respectively. There was no conversion to hybrid or open LLS and no postoperative complications. Regarding recipient outcomes, hepatic artery thrombosis occurred on postoperative day 4 in a 5-year-old female. All grafts function well and all recipients are alive after discharge (range of observation period, 3 to 26 mo).

CONCLUSIONS

We herein present standardized L-LLS using the Glissonean approach and bridging technique for pediatric LDLT. Our technique can secure a longer margin of the left hepatic duct for recipients' hepaticojejunotomy. Our results have demonstrated the advantage in pediatric LDLT, especially in patients with CBA after the Kasai procedure.

Liver Transplantation in Children: An Overview of Organ Allocation and Surgical Management

Liver transplantation is the standard treatment for children with end-stage liver disease, primary hepatic neoplasms, or liver-localized metabolic defects. Perioperative mortality is almost absent, and long-term survival exceeds 90%. Organ shortage is managed thanks to advances in organ retrieval techniques; living donation and partial liver transplantation almost eliminated waiting list mortality, thus leading to expanding indications for transplantation. The success of pediatric liver transplantation depends on the prompt and early referral of patients to transplant Centers and on the close and integrated multidisciplinary collaboration between pediatricians, hepatologists, surgeons, intensivists, oncologists, pathologists, coordinating nurses, psychologists, and social workers.

Portal vein reconstruction using side-to-side unification technique for infant-to-infant deceased donor whole liver transplantation

Backgrounds/Aims

Infant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. We analyze clinical sequences of our 7 cases of I2I-WLT and present evolution of surgical techniques to prevent PV stenosis.

Methods

A total of 7 cases of I2I-WLT were performed at our institution during last 13 years, which represented 0.1% of our LT volume. Patient perioperative profiles and clinical sequences were analyzed with focusing on portal vein (PV) complications.

Results

Donor ages were 6-17 months and graft weights were 140-525 g. Recipient ages were 7-16 months and body weights were 6-10.1 kg and Primary diagnoses were biliary atresia in 6 and progressive familial intrahepatic cholestasis in 1. The first case underwent PV stenting 2 months after I2I-WLT, and underwent retransplantation 6 years later. The second case underwent intraoperative PV stenting, but died 32 days later. The third case underwent repeated PV dilatation. The fourth, fifth and seventh cases experienced no surgical complications, and PV reconstruction was performed using a side-to-side unification venoplasty technique. The sixth case had poor development of the PV system, so customized PV venoplasty was performed, but PV occlusion requiring PV stenting occurred. Early retransplantation was performed, but scanty PV flow was detected despite no obvious PV stenosis, resulting in graft failure. Serious PV complications developed in 4, but none experienced after adoption of side-to-side unification venoplasty.

Conclusions

As PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty.

Perihilar cholangiocarcinoma in an explanted liver after Kasai operation for biliary atresia: A case report and literature review

Kasai operation is widely performed for biliary atresia (BA), as it improves the prognosis. Biliary tract cancer has rarely been reported as a complication after Kasai operation. A 17-year-old man underwent liver transplantation for progressive jaundice and liver dysfunction after Kasai operation for BA. A macroscopic examination of the explanted liver revealed a 3.6-cm-diameter mass in the hilus of the explanted liver. The tumor consisted of an atypical proliferation of glandular cells in the collagenous stroma. The differential diagnosis included a florid ductular reaction and primary adenocarcinoma. Immunohistochemistry revealed that the glandular cells were diffusely positive for IGF2BP3 and S100P, but negative for CDX2. A diagnosis of extrahepatic cholangiocarcinoma arising from the liver hilus was made. To our knowledge, this is the third case of perihilar cholangiocarcinoma after Kasai operation for BA. The previously reported cases had a poor prognosis, but the current case did not recur during a 15-year follow-up. Cholangiocarcinoma and hepatocellular carcinoma can occur as a late complication of BA after Kasai operation, and early detection and liver transplantation may improve the prognosis.

Side-to-side portal vein reconstruction for infant-to-infant deceased donor whole liver transplantation: Report of 2 cases with video

Infant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. Unlike living donor liver transplantation or split liver transplantation, the donor graft portal vein (PV) in I2I-WLT is very small in diameter, so risk of PV complications increases significantly. We present two cases of I2I-WLT with application of side-to-side unification venoplasty for secure PV reconstruction. The first case recipient was a 10-month-old female baby who weighed 6.0 kg. She was diagnosed with progressive familial intrahepatic cholestasis. The deceased donor was a 12-month-old boy. The graft weight was 245 g, so the graft-recipient weight ratio (GRWR) was 4.1%. PV was reconstructed using side-to-side unification venoplasty. The function of graft liver recovered uneventfully and there was no evidence of PV complications. She is currently doing well for 4 years. The second case recipient was a 10-month-old female baby who weighed 8.8 kg. She had also undergone Kasai operation for biliary atresia. GRWR was 6.0%. Because the graft liver was much larger than the native liver, we designed the length of the extrahepatic PV more redundant than the precedent cases to avoid extrinsic compression by the large-sized caudate lobe. The PV was reconstructed using side-to-side unification venoplasty. The function of the graft liver recovered uneventfully. There was no evidence of PV complications. She is currently doing well for 2 years. As the PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty. Three supplementary video clips are provided.

Key imaging features for differentiating cystic biliary atresia from choledochal cyst: prenatal ultrasonography and postnatal ultrasonography and MRI

Purpose

This study compared clinical and radiologic differences between cystic biliary atresia (cBA) and choledochal cyst (CC) type Ia/b.

Methods

Infants (≤12 months old) who were diagnosed with cBA or CC type Ia/b from 2005 to 2019 were retrospectively reviewed. Imaging features on preoperative ultrasonography (US) and magnetic resonance imaging (MRI) were compared between the cBA and CC groups. Logistic regression and area under the receiver operating characteristic curve (AUC) analyses were performed for the diagnosis of cBA. Changes in cyst size were also evaluated when prenatal US exams were available.

Results

Ten patients (5.5% of biliary atresia cases) with cBA (median age, 48 days) and 11 infants with CC type Ia/b (Ia:Ib=10:1; median age, 20 days) were included. Triangular cord thickness on US (cutoff, 4 mm) showed 100% sensitivity and 90.9% specificity (AUC, 0.964; 95% confidence interval [CI], 0.779 to 1.000) and cyst size on MRI (cutoff, 2.2 cm) had 70% sensitivity and 100% specificity (AUC, 0.900; 95% CI, 0.690 to 0.987) for diagnosing cBA. Gallbladder mucosal irregularity on US and an invisible distal common bile duct on MRI were only seen in the cBA group (10 of 10). Only the CC group showed prenatal cysts exceeding 1 cm with postnatal enlargement.

Conclusion

Small cyst size (<1 cm) on prenatal US, triangular cord thickening (≥4 mm) and gallbladder mucosal irregularity on postnatal US, and small cyst size (≤2.2 cm) and an invisible distal common bile duct on MRI can discriminate cBA from CC type Ia/b in infancy.

Hepatic expression of HGF/C-met and native liver survival in biliary atresia

BACKGROUND

The prognosis of biliary atresia (BA) remains difficult to predict. This study evaluated the roles of hepatocyte growth factor (HGF) and its receptor (C-met) towards clinical outcome and native liver survival.

METHODS

Hepatic HGF and C-met expression were determined using immunohistochemistry from liver biopsies of 41 BA patients during Kasai operation, and 17 non-cholestatic patients. The HGF and C-met expression was visually scored as per its intensity and percentage of stained area. BA patients were classified as high- and low-HGF and C-met receptor status. Native liver survival was compared between the two groups at 3-year follow-up. Data are shown as median and range.

MAIN RESULTS

Median age of BA patients was 2 (1-6) months. Hepatic HGF and C-met staining scores of BA patients were higher than those of non-cholestatic patients (P < 0.0001). There was a correlation between HGF and C-met staining scores (spearman r = 0.77, P < 0.0001). However, there was no association between their expression and early outcome at 6 months post-op. Mean follow-up time was 68.6 months. Survival analysis revealed that native liver survival at 1 year and 3 years were 88% and 77%, respectively. Additionally, 82.6% (19/23) of patients in the low-HGF group survived with native liver, compared with 66.7% (10/15) of those in high-HGF group (P = 0.436). For C-met expression, 78.6% (22/28) of low-score and 70% (7/10) of high score groups survived with native liver (P = 0.673).

CONCLUSIONS

Strong expression of hepatic HGF and its receptor in BA patients was demonstrated. However, the expression was not associated with the early outcome and native liver survival. These results suggest that HGF involved in the liver pathology of BA but its expression cannot be used as a prognostic indicator. Small sample size of patients was a main limitation. Further studies are warranted to validate our findings.

Long-term Outcomes and Health Perceptions in Pediatric-onset Portal Hypertension Complicated by Varices

OBJECTIVES

Outcomes of pediatric-onset portal hypertension are poorly defined. We aimed to assess population-based long-term outcomes of pediatric-onset portal hypertension complicated by varices.

METHODS

All children with esophageal varices (n = 126) were identified from 14,144 single nationwide referral center endoscopy reports during 1987 to 2013, and followed up through national health care and death registers. A questionnaire was sent to survivors (n = 94) of whom 65 (69%) responded.

RESULTS

Nineteen underlying disorders included biliary atresia (35%), extrahepatic portal vein obstruction (35%), autosomal recessive polycystic kidney disease (7%), and other disorders (23%). During median follow-up of 15.2 (range 0.5-43.1) years patients underwent median 9 (1-74) upper gastrointestinal endoscopies. Esophageal varices were first observed at a median age of 4.0 (0.3-18.2) years, 112 (89%) patients underwent median 6 (1-56) sclerotherapy/banding sessions, and 61 (48%) experienced median 2 (range 1-20) variceal bleeding episodes. Forty-eight surgical shunt procedures were performed to 41 (36%) patients and 38% underwent liver transplantation. Portal hypertensive biliopathy was diagnosed in 4 patients. Hepatopulmonary syndrome necessitated liver transplantation in 2 patients, hepatic encephalopathy in 2, and hepatorenal syndrome in 1. No patient died of variceal bleeding. Patient-reported perception of health on a scale of 1 to 10 was 9 (range 4-10), and 86% reported no current symptoms attributable to esophageal varices.

CONCLUSIONS

Pediatric-onset portal hypertension is a heterogeneous disease with significant long-term morbidity, requiring multimodal approach with considerable resources and continuation of follow-up in adulthood. Although mortality to variceal bleeding was avoided, bleeding episodes recurred also in adulthood, while patient-reported health of long-term survivors was encouraging.

[Value of serum gamma-glutamyl transpeptidase combined with direct bilirubin in the diagnosis of biliary atresia in infants]

OBJECTIVE

To study the value of serum gamma-glutamyl transpeptidase (GGT) combined with direct bilirubin (DB) in the diagnosis of biliary atresia.

METHODS

A total of 667 infants with cholestasis who were hospitalized and treated from July 2010 to December 2018 were enrolled as subjects. According to the results of intraoperative cholangiography and follow-up, they were divided into biliary atresia group with 234 infants and cholestasis group with 433 infants. The two groups were compared in terms of age of onset, sex, and serum levels of total bilirubin (TB), DB, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bile acid (TBA), and GGT. A receiver operating characteristic (ROC) curve analysis was performed for indices with statistical significance, and the area under the ROC curve (AUC) and the optimal cut-off value for diagnosis were calculated.

RESULTS

The biliary atresia group had a significantly younger age of onset than the cholestasis group (P<0.001). There were no significant differences in sex, ALT, and AST between the two groups (P>0.05), while the biliary atresia group had significantly higher serum levels of TB, DB, TBA, and GGT than the cholestasis group (P<0.05). GGT combined with DB had the highest AUC of 0.892 (95% confidence interval: 0.868-0.916) in the diagnosis of biliary atresia. At the optimal cut-off values of 324.0 U/L for GGT and 115.1 μmmol/L for DB, GGT combined with DB had a sensitivity of 79.8% and a specificity of 83.2% in the diagnosis of biliary atresia.

CONCLUSIONS

GGT combined with DB has high sensitivity and specificity in the diagnosis of biliary atresia and can be used as an effective indicator for diagnosis of biliary atresia in infants.