Current concept about postoperative cholangitis in biliary atresia

"Post-Kasai Portoenterostomy Cholangitis: What Have We Learnt So Far?"

Post-Kasai portoenterostomy (KPE) cholangitis is one of the most common complications that has a negative impact on liver function and native liver survival. Early diagnosis and judicious empiric antimicrobial management are, therefore, important to prevent further liver damage and decompensation. However, there is no consensus regarding the standard definition of post-KPE cholangitis, and established guidelines on evaluation and management are also lacking. Metagenomic next-generation sequencing, a new molecular diagnostic technique, has the potential for detecting broader spectrum of pathogens, especially in blood culture-negative patients. Antibiotic prophylaxis to prevent cholangitis has been widely used, but questions over the choice of antibiotics, route of administration, and optimal duration remain unsettled. The available evidence on the efficacy of antibiotic prophylaxis in preventing cholangitis has shown conflicting results. This review offers a summary of the current research on advances in diagnostic approaches, including molecular techniques, and therapeutic challenges in managing intractable cholangitis.

A comprehensive clinical and microbiological study on the diagnosis and management of cholangitis in patients with biliary atresia undergoing kasai portoenterostomy

BACKGROUND AND OBJECTIVES

Kasai-portoenterostomy (KPE) is the initial attempt to restore the bile flow and salvage the native liver in biliary atresia (BA) patients. Cholangitis is a frequent complication after KPE and adequate treatment impacts the long-term outcome. The aim of our study is to assess the severity of cholangitis episodes in a cohort of BA patients post KPE, identify the causative agents, using several diagnostic methods, as well as to assess the tolerability and efficacy of our antimicrobial protocol.

METHODS

This analytical retrospective observational study, conducted at Pediatric Hepatology Unit, Cairo University Pediatric Hospital, included infants and children with cholangitis post-KPE enrolled over 30 months. Clinical data collection, basic laboratory investigations inflammatory markers, B-D glucan, blood culture, 16SrDNA, 18SrDNA were performed in all enrolled patients. Cholangitis episodes were treated with intravenous antibiotics according to our antimicrobial protocol that has been implemented in conjunction with the antimicrobial stewardship committee.

RESULTS

This study included 30 post-KPE patients, who experienced 47 episodes of cholangitis. Twenty-five episodes of cholangitis were culture positive cholangitis (positive blood culture and/or PCR results and/or liver biopsy). Klebsiella Variicola and Klebsiella pneumoniae were the most prevalent pathogens in 13 and seven cultures, respectively. Meropenem was the most successful antibiotic in the eradication of infection in 11(23.4%) episodes. Culture positive cholangitis showed increased incidence of sepsis and worse outcome in comparison to culture negative cholangitis. The severity of cholangitis was classified into 16 patients (34%) with infection, 28 (60%) sepsis, one (2%) severe sepsis and two (4%) septic shock.

CONCLUSION

Almost half of cholangitis episodes were culture-positive; the commonest pathogen was Klebsiella, showing more severe sepsis and worse outcome.

Comparison of surgical results and technical performance between robotic and laparoscopic approaches for Kasai portoenterostomy in biliary atresia: a multicenter retrospective study

BACKGROUND

Many variables, including age at surgery, disease type, surgical approaches and perioperative management factors have been demonstrated to influence efficacy in BA infants, however, the effect of surgical performance remains unclear. The objective of this retrospective study was to compare the postoperative efficacy and surgical performance of robotic (RKPE) versus laparoscopic Kasai portoenterostomy (LKPE) for BA.

METHODS

Between October 2018 and June 2023, 158 type III BA patients undergoing minimally invasive surgery (RKPE = 66, LKPE = 92) were included in this multicenter retrospective study. All procedures were performed by surgical teams experienced in Kasai portoenterostomy techniques. Technical performance was quantified and analyzed using the Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments (GERT). Postoperative outcomes and surgical performance were compared.

RESULTS

Compared with LKPE group, RKPE group had shorter fibrous cone transection time (48.92 ± 6.98 vs. 61.45 ± 8.98 min; p < 0.001), shorter hepaticojejunostomy time (47.55 ± 6.57 vs. 59.93 ± 7.88 min; p < 0.001) and less estimated intraoperative bleeding [7.00 (5.00-10.00) vs. 13.50 (10.50-16.50) mL; p < 0.001]. More importantly, RKPE group showed a superior OSATS score [30.50 (29.00-31.00) vs. 28.00 (28.00-29.00); p < 0.001], number of errors (46.62 ± 6.32 vs. 56.40 ± 6.82 times/case; p < 0.001), and number of events [9.40 (8.40-10.40) vs. 16.00 (14.00-17.80) times/case; p < 0.001]. On postoperative days 1 and 3, RKPE group had lower C-reactive protein levels (19.87 ± 12.28 vs. 27.05 ± 11.16 mg/L, p < 0.001; 14.88 ± 7.11 vs. 20.73 ± 9.09 mg/L, p < 0.001). During follow-up, RKPE group had higher jaundice clearance rate at 3 (68.18% vs. 51.09%; p = 0.032) and 6 months (78.79% vs. 64.13%; p = 0.047) postoperatively. However, the cholangitis rate within 1 year postoperatively (46.97% vs. 50.00%; p = 0.707), as well as one-year (75.76% vs. 72.83%; p = 0.678) and two-year survival with native liver rates (68.42% vs. 66.67%; p = 0.857), were comparable between two groups.

CONCLUSIONS

RKPE provided superior technical skill performance and a higher jaundice clearance rate than LKPE, indicating that it may be a better minimally invasive option for BA. In addition, the survival with native liver rate showed no significant difference between the two cohorts, which needs to be confirmed by further study.

Post-Kasai cholangitis evaluation and management strategies: Review of the literature with insights from the Swiss Biliary Atresia Registry

Cholangitis, defined as the inflammation of the bile ducts, is the most frequent complication after Kasai hepatoportoenterostomy in patients with biliary atresia (BA). This review seeks to provide a comprehensive synthesis of current knowledge on diagnosing and managing BA-associated cholangitis while identifying gaps in the existing literature. A scoping literature review was conducted to gather global insights into the definition, evaluation, and management of post-Kasai cholangitis, illustrated through data from the Swiss Biliary Atresia Registry (SBAR). In the literature many different decision algorithms exist for BA-associated cholangitis underlining the clear need for standardizing diagnostic criteria. As an illustration, in 2015 the Swiss center introduced structured guidelines to diagnose BA-associated cholangitis. Upon retrospective analysis of SBAR data (2010-2022) we noted significant differences in disease management before and after implementation: The number of multiple diagnosed cholangitis episodes was reduced and we observed a reduced transplantation rate. Building on this, the Biliary Atresia and Related Diseases consensus has developed key diagnostic and management guidelines with objective criteria that have yet to undergo prospective validation. Indeed, prospective multicenter assessment is clearly needed to enhance acceptance and improve outcomes. Further, rigorous evaluation of prophylactic and therapeutic interventions, including antibiotics and immunomodulatory treatments, seems essential, with randomized trials required to establish their effectiveness and explore microbiota modulation in cholangitis management. The BA-community should strive to establish and adopt a widely accepted protocol for the diagnosis, management and prevention of BA-associated cholangitis. The implementation of such protocols is expected to significantly improve clinical outcomes for these patients.

Comparison of different Kasai portoenterostomy techniques in the outcomes of biliary atresia: a systematic review and network meta-analysis

BACKGROUND

Biliary atresia (BA) is a progressive disease affecting the bile duct structure and function, leading to poor outcomes without timely surgical intervention. Kasai portoenterostomy (KPE) is a commonly used treatment to restore bile flow. However, the success rate and postoperative outcomes of KPE vary with different surgical techniques, including laparoscopic, robot-assisted, and open approaches.

METHODS

Following the PRISMA guidelines, this study systematically searched PubMed, EMBASE, and Cochrane databases for literature on BA surgical techniques of KPE. Studies comparing two or all three techniques-laparoscopic, robot-assisted, and open-in terms of postoperative outcomes of KPE in BA patients were included. Utilizing the "gemtc" package in R version 4.3.3, NMA was conducted to compare postoperative clearance of jaundice (COJ) among different surgical techniques. We also performed traditional paired meta-analysis in which multiple surgical outcomes were compared.

RESULTS

According to the traditional definition of a successful KPE surgery, in terms of successful postoperative COJ, robotic-assisted Kasai portoenterostomy (RAKPE) shows advantage over open Kasai portoenterostomy (OKPE) and laparoscopic Kasai portoenterostomy (LKPE), while the outcomes between OKPE and LKPE are equivalent. However, statistically speaking, there is no significant difference among the three techniques. LKPE has a longer operation time and less intraoperative bleeding compared to OKPE. There are no statistically significant differences in hospital stay, cholangitis incidence, or liver survival rates at 6 months, 1 year, 2 years, or 5 years.

CONCLUSION

The surgical success rates of KPE with various technical aids are similar, highlighting the need to consider individual patient conditions and cost when choosing a surgical technique. Effective postoperative management is vital for preventing complications and slowing liver fibrosis. Future research should focus on improving surgical techniques and postoperative care to enhance long-term outcomes for BA patients. For those who cannot maintain liver function with KPE, timely LT consideration is crucial.

Association of gut microbiota and gut metabolites and adverse outcomes in biliary atresia: A longitudinal prospective study

BACKGROUND

The Kasai portoenterostomy (KPE) aims to re-establish bile flow in biliary atresia (BA); however, BA remains the commonest indication for liver transplantation in pediatrics. Gut microbiota-host interplay is increasingly associated with outcomes in chronic liver disease. This study characterized fecal microbiota and fatty acid metabolites in BA.

METHODS

Fecal samples were prospectively collected in newly diagnosed BA infants (n = 55) before and after KPE. Age-matched healthy control (n = 19) and cholestatic control (n = 21) fecal samples were collected. Fecal 16S rRNA gene amplicon sequencing for gut microbiota and gas chromatography for fecal fatty acids was performed.

RESULTS

Increased abundance of Enterococcus in pre-KPE BA and cholestatic control infants, compared to healthy infants, was demonstrated. At the early post-KPE time points, increased alpha diversity was revealed in BA versus healthy cohorts. A lower relative abundance of Bifidobacterium and increased Enterococcus, Clostridium, Fusobacterium, and Pseudomonas was seen in infants with BA. Fecal acetate was reduced, and fecal butyrate and propionate were elevated in early post-KPE BA infants. Higher post-KPE alpha diversity was associated with nonfavorable clinical outcomes (6-month jaundice and liver transplantation). A higher relative abundance of post-KPE Streptococcus and Fusobacterium and a lower relative abundance of Dorea, Blautia, and Oscillospira were associated with nonfavorable clinical outcomes. Blautia inversely correlated to liver disease severity, and Bifidobacterium inversely correlated to fibrosis biomarkers. Bifidobacterium abundance was significantly lower in infants experiencing cholangitis within 6 months after KPE.

CONCLUSIONS

Increased diversity, enrichment of pathogenic, and depletion of beneficial microbiota early post-KPE are all factors associated with nonfavorable BA outcomes. Manipulation of gut microbiota in the early postsurgical period could provide therapeutic potential.

Inflammation patterns in early post-operative cholangitis predict long-term outcomes in biliary atresia: a potential role of non-suppurative cholangitis

PURPOSE

Frequent post-operative cholangitis in biliary atresia (BA) affects the long-term native liver survival. This study assessed the characteristics of early cholangitis and their influence on the prognosis.

METHODS

Forty-three patients with BA who underwent surgery between 2000 and 2020 were analyzed for routine inflammatory markers. Early cholangitis characteristics were compared between native liver survivor (NLS) and living donor liver transplant (LDLT) patients.

RESULTS

Among the 43 patients, 30 (69.8%) experienced 130 episodes of cholangitis. In the area under the receiver operating characteristics curve (AUROC) analysis, the cutoff value of the total cholangitis episodes was 3, with an area under the AUROC curve of 0.695 (95% confidence interval 0.522-0.868). Before 3 years old, 113 episodes (86.9%) of cholangitis were observed. The white blood cell, C-reactive protein, and alanine aminotransferase values at cholangitis onset did not markedly differ between the LDLT and NLS groups. Conversely, the neutrophil-to-lymphocyte ratio in the NLS group was significantly lower than in the LDLT group (0.85 vs. 1.63, p < 0.001).

CONCLUSIONS

Cholangitis in the NLS group was lymphocyte-dominant and atypical in its pathogenesis. Lymphocyte-dominant cholangitis is non-suppurative, and future research should clarify its pathogenesis to improve the treatment and prognosis of BA.

"Where Did This Come From?": Antibiotic Prophylaxis in Biliary Atresia After Kasai Procedure

For patients with Biliary atresia, antibiotic prophylaxis after Kasai portoenterostomy is a common practice. Societal guidelines often cite one reference as supportive evidence for this practice. In this paper, we go back to review the quality of this evidence and suggest more research is required to demonstrate the efficacy of antibiotic prophylaxis in this population.

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.

Prophylactic Antibiotics to Prevent Cholangitis in Children with Biliary Atresia After Kasai Portoenterostomy: A Meta-Analysis

OBJECTIVES

A connection between the bowel and bile ducts after the Kasai hepatoportoenterostomy (HPE) procedure poses a risk of ascending cholangitis. There were only a few evidence-based consensuses on the benefits of prophylactic antibiotics. This study aims to assess the value of prophylactic antibiotics in reducing the risk of cholangitis following the Kasai HPE procedure.

METHODS

Meta-analysis is performed using random-effects model from the search result of 5 online databases (PubMed, Google Scholar, EBSCO MEDLINE, ClinicalTrials.gov , and EuropePMC) from inception to October 27, 2021. The keywords used were "antibiotic," "antimicrobial," "Kasai," "portoenterostomy," "biliary atresia," and "bile duct atresia." Cochrane Risk of Bias tool and Newcastle-Ottawa Scale is used to assess the risk of bias. The outcomes are incidence of cholangitis and native liver survival.

RESULTS

Six studies consisting of 4 cohorts and 2 cross-sectional studies were extracted. A total of 714 patients reported different cholangitis incidence after prophylactic antibiotics administration post-Kasai HPE. The incidence of cholangitis following Kasai HPE was not statistically significant among participants. There is conflicting evidence on the efficacy of antibiotics in prolonging native liver survival.

CONCLUSIONS

The existing evidence does not support the administration of prophylactic antibiotics in preventing cholangitis after Kasai HPE among biliary atresia patients. Additionally, their roles in native liver survival are still inconclusive. The fact that there were heterogeneous method and antibiotic usage between existing studies must also be highlighted for better design in future studies.

Systematic review: The quality of life of patients with biliary atresia

BACKGROUND

The quality of life of patients with Biliary Atresia (BA) have not been systematically examined. The goal of this meta-analysis is to determine patients' postoperative health-related Quality of life (HrQoL) with native or transplanted livers.

METHODS

From 2000 to August 2021, a literature-based search for relevant cohorts was conducted using Pubmed/Medline, the Cochrane Library, and Embase. Original research on BA, Hepatoportoenterostomy (HPE), portoenterostomy, Kasai, Liver transplantation and HrQoL was included. Using RevMan, a forest plot analysis of HrQoL after surgical treatment after BA was calculated (version 5.4). Using MetaXL, a pooled prevalence for cholangitis, secondary liver transplantation, or related malformations was computed (version 5.3).

RESULTS

Nine studies compared individuals with BA to an age-matched healthy control group. 4/9 (n = 352) of these studies found poorer scores for BA patients, while 5/9 (n = 81) found equivalent health status. Factors associated with HrQoL: older age at the time of the survey was linked to greater HrQoL; whereas females, higher total bilirubin and the amount of immunosuppressive medicines were associated with lower HrQoL in BA patients.

CONCLUSION

The current study emphasises the critical need to improve the many parameters influencing HrQoL in BA patients, as well as the methods utilized to assess those factors. This includes immunosuppression, withdrawal from polydrug regimes and recognizing the differences in disease burden between males and females.

TYPE OF STUDY

Systematic review.

LEVEL OF EVIDENCE

Level III.

Native liver survivors of portoenterostomy for biliary atresia with excellent outcome: redefining "successful" portoenterostomy

PURPOSE

Native liver survivors (NLS) after portoenterostomy (PE) for biliary atresia (BA) with normal biomarkers defined as total bilirubin (T-Bil), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) for liver function (LF), cholinesterase (ChE), platelet count (PC), and absence of portal hypertension (PHT) were reviewed to redefine "successful" PE.

METHODS

92 post-PE BA patients were classified as NLS-1: normal biomarkers, PHT (-); NLS-2: at least one abnormal biomarker, PHT (-); NLS-3: normal biomarkers, PHT ( +); NLS-4: abnormal biomarkers, PHT ( +) and reviewed for a maximum 32 years.

RESULTS

As of June 2022, 55/92 (59.8%) had received liver transplants and 37/92 (40.2%) were NLS. NLS patients were classified as excellent outcome (EO): NLS-1 (n = 10; 27.0%) or non-EO: NLS-2: (n = 8; 21.6%), NLS-3: (n = 6; 16.2%), and NLS-4: (n = 13; 35.1%). Compared with non-EO, EO had PE earlier (50.5 versus 65 days; not significant; p = 0.08), significantly earlier onset of symptoms (13 days versus 32 days; p = 0.01) and significantly shorter jaundice-clearance (JC; 34.5 days versus 56.0 days; p < 0.001). Durations of follow-up were similar: 13 years in EO, 18.5 years in NLS-2, 20 years in NLS-3, and 15 years in NLS-4.

CONCLUSION

Incidence of "successful" PE or EO is low and correlated with early onset of symptoms and quicker JC.

Adding a spur valve to laparoscopic portoenterostomy for patients with biliary atresia can achieve a high jaundice clearance rate and lower the number of episodes of cholangitis

PURPOSE

This study aimed to evaluate the efficacy of adding a spur valve to laparoscopic portoenterostomy for patients with biliary atresia.

METHODS

We retrospectively reviewed the records of all patients diagnosed with biliary atresia (BA) who underwent laparoscopic portoenterostomy (Lap-PE) between 2013 and 2021. The patients were divided into two groups: Lap-PE with a spur valve (spur group) and without it (control group). Perioperative management was the same in both groups. We compared patient backgrounds and clinical outcomes, including jaundice clearance and the number of postoperative cholangitis episodes.

RESULTS

Of 63 patients reviewed, 16 received a spur valve. There were no statistically significant differences in the patient backgrounds between the groups. All patients in the spur group achieved jaundice clearance. The number of postoperative cholangitis episodes one year after surgery was significantly lower in the spur group than in the control group (1 [0-3] vs. 3 [0-9], p = 0.04). The jaundice-free survival rate with the native liver at one year after surgery was significantly higher in the spur group (100% vs. 53%, p = 0.01).

CONCLUSIONS

Adding a spur valve during Lap-PE significantly lowered the number of cholangitis episodes 1 year after surgery.

Autologous bone marrow mononuclear cell infusion for liver cirrhosis after the Kasai operation in children with biliary atresia

Aim

To evaluate the safety and early outcomes of autologous bone marrow mononuclear cell (BMMNC) infusion for liver cirrhosis due to biliary atresia (BA) after Kasai operation.

Methods

An open-label clinical trial was performed from January 2017 to December 2019. Nineteen children with liver cirrhosis due to BA after Kasai operation were included. Bone marrow was harvested through anterior iliac crest puncture under general anesthesia. Mononuclear cells (MNCs) were isolated by Ficoll gradient centrifugation and then infused into the hepatic artery. The same procedure was repeated 6 months later. Serum bilirubin, albumin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and prothrombin time were monitored at baseline, 3 months, 6 months, and 12 months after the first transplantation. Esophagoscopies and liver biopsies were performed in patients whose parents provided consent. Mixed-effect analysis was used to evaluate the changes in Pediatric End-Stage Liver Disease (PELD) scores.

Results

The average MNC and CD34+ cell counts per kg body weight were 50.1 ± 58.5 × 10⁶/kg and 3.5 ± 2.8 × 10⁶ for the first transplantation and 57.1 ± 42.0 × 10⁶/kg and 3.7 ± 2.7 × 10⁶ for the second transplantation. No severe adverse events associated with the cell therapy were observed in the patients. One patient died 5 months after the first infusion at a provincial hospital due to the rupture of esophageal varices, while 18 patients survived. Liver function was maintained or improved after infusion, as assessed by biochemical tests. The severity of the disease reduced markedly, with a significant reduction in PELD scores.

Conclusion

Autologous BMMNC administration for liver cirrhosis due to BA is safe and may maintain or improve liver function.

Trial registration

ClinicalTrials.gov identifier: NCT03468699. Name of the registry: Vinmec Research Institute of Stem Cell and Gene Technology.

https://clinicaltrials.gov/ct2/show/NCT03468699?cond=biliary+atresia&cntry=VN&draw=2&rank=2. Registered on March 16, 2018. The trial results will also be published according to the CONSORT statement at conferences and reported in peer-reviewed journals.

Cholangitis Definition and Treatment after Kasai Hepatoportoenterostomy for Biliary Atresia: A Delphi Process and International Expert Panel

(1) Background: Acute cholangitis during the first year after Kasai hepatoportoenterostomy (HPE) has a negative impact on patient and native liver survival. There are no consistent guidelines for the definition, treatment, and prophylaxis of cholangitis after HPE. The aim of this study was to develop definition, treatment, and prophylaxis guidelines to allow for expeditious management and for standardization in reporting. (2) Methods: the Delphi method, an extensive literature review, iterative rounds of surveys, and expert panel discussions were used to establish definition, treatment, and prophylaxis guidelines for cholangitis in the first year after HPE. (3) Results: Eight elements (pooled into two groups: clinical and laboratory/imaging) were identified to define cholangitis after HPE. The final proposed definitions for suspected and confirmed cholangitis are a combination of one element, respectively, two elements from each group; furthermore, the finding of a positive blood culture was added to the definition of confirmed cholangitis. The durations for prophylaxis and treatment of suspected and confirmed cholangitis were uniformly agreed upon by the experts. (4) Conclusions: for the first time, an international consensus was found for guidelines for definition, treatment, and prophylaxis for cholangitis during the first year after Kasai HPE. Applicability will need further prospective multicentered studies.

Analysis of Cholangitis Rates with Extended Perioperative Antibiotics and Adjuvant Corticosteroids in Biliary Atresia

PURPOSE

There is no consensus regarding adjuvant therapies following Kasai portoenterostomy (KP) for biliary atresia (BA). This study aimed to analyze the effect of extended perioperative intravenous antibiotics (PI-Abx) and adjuvant corticosteroid on cholangitis and jaundice clearance rates in the 3 years post-KP in children with BA.

METHODS

Data of patients who underwent KP between 1999-2018 at a single center were retrospectively analyzed. Group A (1999-2010) received PI-Abx for 5 days, Group B (2010-2012) received PI-Abx for 5 days plus low-dose prednisolone (2 mg/kg), and Group C (2012-2017) received PI-Abx for 14 days plus high-dose prednisolone (5 mg/kg).

RESULTS

Fifty-four patients were included with groups A, B, and C comprising 25, 9, and 20 patients, respectively. The number of episodes of cholangitis was 1.0, 1.6, and 1.3 per patient (p=NS) within the first year and 1.8, 2.3, and 1.7 (p=NS) over 3 years in Groups A, B, and C, respectively. The jaundice clearance rate at 6 months was 52%, 78%, and 50% (p=NS), and the 3-year native liver survival (NLS) rate was 76%, 100%, and 80% (p=NS) in Groups A, B, and C, respectively. A near-significant association was observed between the incidence of cholangitis within the first year and decompensated liver cirrhosis/death at 3 years post KP (p=0.09). Persistence of jaundice at 6 months was significantly associated with decompensated cirrhosis/death at 3 years (p<0.001).

CONCLUSION

The extended duration of PI-Abx and adjuvant corticosteroids was not associated with improved rates of cholangitis, jaundice clearance, or NLS in patients with BA.

The Intestinal Flora at Kasai Procedure in Children with Biliary Atresia Appears Not to Affect Postoperative Cholangitis

INTRODUCTION

 Evidence supports long-term oral antibiotic prophylaxis to prevent cholangitis after Kasai procedure. Data regarding perioperative intravenous prophylaxis are lacking. Ascending pathogens from the intestine are made responsible for recurrent cholangitis. Therefore, we analyzed the flora in the upper jejunum during the Kasai procedure and their potential impact on postoperative cholangitis.

MATERIALS AND METHODS

 In 26 patients, swabs were taken at the bowel prepared for the Roux-en-Y-loop. Our postoperative protocol includes intravenous third-generation cephalosporins for 2 weeks and rectal steroids starting at day 4. Cholangitis was defined as the postoperative reappearance of acholic stools or increase of serum bilirubin in combination with fevers or increase of inflammatory parameters. In this scenario, Tazocin was administered for another 2 weeks.

RESULTS

 Swabs remained sterile in nine patients (34.6%). In 17 patients (65.4%), gram-positive and gram-negative pathogens were identified; all belonging to physiological intestinal flora. A total of 96.2% pathogens were covered by the antibiotic prophylaxis. The cholangitis incidence was 55.6% in the sterile cohort, and 23.5% in the gram-positive and gram-negative cohort (p = 0.06). In the cholangitis cohort, no significant differences were detected for the age at Kasai and the pre- and postoperative total bilirubin.

CONCLUSION

 We found that our antibiotic regiment covered bacteria in the upper gastrointestinal (GI) tract in the majority of our patients at the time of Kasai. Nonetheless, a significant proportion of patients developed signs of cholangitis. There was no higher rate of cholangitis in patients with resistant bacteria. Thus, our data do not support the hypothesis of extended postoperative intravenous antibiotics to prevent ascending cholangitis.

Characteristics of the Gut Microbiome and IL-13/TGF-β1 Mediated Fibrosis in Post-Kasai Cholangitis of Biliary Atresia

Aims: Cholangitis in biliary atresia (BA), which accelerates liver fibrosis progression, is among the most common serious complications after Kasai surgery; however, its etiology remains elusive. Gut microbiome migration may contribute to post-Kasai cholangitis. Further, there is no appropriate model of BA post-Kasai cholangitis for use in investigation of its pathogenesis. Methods: We explored the characteristics of gut microbiome in patients with BA before and after Kasai procedure based on 16S rDNA sequencing. We isolated the dominant strain from patient stool samples and established an in vitro model by infecting patient-derived liver organoids. Bulk RNA-seq was performed, and we conducted qPCR, ELISA, and western blot to explore the mechanism of fibrosis. Results: Gut microbiome diversity was lower in patients after, relative to before, Kasai procedure, while the relative abundance of Klebsiella was higher. Patients who developed cholangitis within 1 month after discharge tended to have simpler gut microbiome composition, dominated by Klebsiella. Klebsiella pneumoniae (KPN) was isolated and used for modeling. RNA-seq showed that BA liver organoids expressed markers of hepatic progenitor cells (KRT19, KRT7, EPCAM, etc.) and that organoids were more stable and less heterogeneous among individuals than liver tissues. After infection with KPN, gene expression patterns in BA liver organoids were enriched in pathways related to infection, apoptosis, and fibrosis. Preliminary experiments indicated the presence of IL-13/TGF-β1-mediated fibrosis in post-Kasai cholangitis. Conclusions: Our findings using a newly-developed model, demonstrate a key role for Klebsiella, and a potential mechanism underlying fibrosis in post-Kasai cholangitis, mediated by the IL-13/TGF-β1 pathway.

Does the Treatment After Kasai Procedure Influence Biliary Atresia Outcome and Native Liver Survival?

OBJECTIVES

Biliary atresia (BA) is a rare and progressive idiopathic disease affecting the biliary tract that can lead to end-stage liver disease. The main treatment is Kasai portoenterostomy (KP). The use of adjuvant therapy (AT; prophylactic antibiotics and steroids) after KP aims to prevent cholangitis and reduce the need for liver transplantation (LT), but there is a lack of evidence on their effectiveness. We investigated the impact of significant changes in the post-KP protocol on the overall outcomes of BA.

METHODS

We enrolled 43 consecutive infants undergoing KP at Bambino Gesù Children's Hospital between July 2012 and October 2018. We compared AT (AT group; n=25) against no treatment (AT-free group; n = 18).

RESULTS

No significant differences in anthropometric and laboratory parameters were shown between the 2 groups at baseline and every study evaluation (1, 3, and 6 months). The incidences of clinical complications of liver disease were similar. Six months post-KP, the achievement of serum total bilirubin ≤1.5 mg/dL and satisfactory Pediatric End-Stage Liver Disease scores were not significantly different between the 2 groups. Cholangitis was observed in 30% of patients in the first 6 months postoperatively: 33% and 28% in the AT-free and AT groups, respectively (P = 0.18). Survival to LT listing at 12 months and without LT at 24 months were not significantly different between the 2 groups (P > 0.05).

CONCLUSIONS

AT after KP confirmed conflicting results; therefore, multicentered, prospective, randomized control studies are needed to better understand its utility after KP, especially in the multidrug resistance spread era.

Long-Term Effects of Kasai Portoenterostomy for Biliary Atresia Treatment in Russia

This prospective study enrolled 144 patients after surgical treatment of biliary atresia in early infancy. We analyzed the immediate effectiveness of the surgery and the age-related structure of complications in the up to 16-year follow-up. The immediate 2-year survival rate after the surgery constituted 49.5%. At the time of this writing, 17 of the patients had celebrated their 10th birthdays with good quality of life and no indications for transplantation of the liver. The obtained results underscore the critical importance of surgical correction of biliary atresia by Kasai surgery in the first 60 days of life and subsequent dynamic follow-up of patients for the purpose of the early detection and timely correction of possible complications.

Adjuvant treatments for biliary atresia

The treatment of biliary atresia (BA) is predominantly surgical with firstly an attempt at restoration of bile flow from the native liver by wide excision of the obstructed, obliterated extrahepatic biliary tree to the level of the porta hepatis and a portoenterostomy using a long Roux loop-Kasai portoenterostomy (KPE). Liver transplantation is reserved for those that fail this and for those where surgery is considered futile for reasons of age or stage of disease. As the aetiology of BA remains ill-defined, so adjuvant treatment has been largely based on pragmatism, trial and error. Systematic analysis of the few randomized placebo-controlled trial data and less well-controlled cohort studies have suggested benefit from post-operative high-dose steroids and ursodeoxycholic acid (UDCA) while the benefit of long-term prophylactic antibiotics, bile acid sequestrants (e.g., colestyramine) or probiotics remains unproven. Newer modalities such as antiviral therapy (AVT), immunoglobulin, FXR agonists (e.g., obeticholic acid), ileal bile acid transporter (IBAT) antagonists (e.g., maralixibat) remain unproven. This article reviews the current evidence for the efficacy of adjuvant medical therapy in BA.

The Epidemiology and Etiology of Cholangitis After Kasai Portoenterostomy in Patients With Biliary Atresia

OBJECTIVES

We investigated the incidence and characteristics of cholangitis after Kasai portoenterostomy (KPE) in patients with biliary atresia. We also examined the distribution and antimicrobial susceptibility patterns of the causative pathogens, which were isolated in sterile specimens, such as blood and ascites.

METHODS

A retrospective chart review was performed in patients with biliary atresia who underwent KPE at Severance Children's Hospital in Korea from 2006 to 2015. The Kaplan-Meier method was used to assess the cumulative incidence of cholangitis.

RESULTS

Among the 160 included patients, there were 494 episodes of cholangitis in 126 patients (78.8%) during the study period. The cumulative incidence of cholangitis at 1 and 5 years after KPE was 75.5% and 84.2%, respectively, and cholangitis recurred in most cases (76.2%). The cumulative incidence of culture-proven cholangitis at 1 and 5 years after KPE was 22.1% and 23.9%, respectively. Enterococcus faecium (27.7%) was the most prevalent pathogen, followed by Escherichia coli (14.9%), Enterobacter cloacae (10.6%), and Klebsiella pneumoniae (8.5%). Gram-positive isolates (n = 19) showed low susceptibility to ampicillin (42.1%) and gentamicin (66.7%), and only 38.1% of Gram-negative isolates (n = 21) were susceptible to cefotaxime.

CONCLUSIONS

The present study is the largest to show the high incidence and characteristics of cholangitis after KPE in patients with biliary atresia. Enterococcus is a common pathogen of cholangitis after KPE and should be considered when choosing empiric antimicrobial therapy.

Evaluation of Perioperative Complications in the Management of Biliary Atresia

Purpose: To analyze the influence of perioperative complications in the management of biliary atresia (BA). Methods: A retrospective study was performed using a total of 422 BA patients who underwent Kasai portoenterostomy (KPE) in a single institution between February 2016 and May 2017. Data on patients' clinical characteristics, laboratory examinations, perioperative complications, and outcomes were collected. Unpaired two-tailed t-test and χ² test were employed for the comparison between BA patients with and without perioperative complications. Cox regression analysis was used to screen the risk factors for 2-years NLS in BA, and their influence on the 2-years NLS was analyzed using Kaplan-Meier survival analysis as well as the log-rank test. Results: The incidence of perioperative complications, 6-months jaundice clearance (JC) and 2-years native liver survival (NLS) rate were 60.4, 59.5, and 56.6%, respectively. Patients with perioperative complications had lower serum albumin (ALB) level, but higher aspartate aminotransferase-to-platelet ratio index (APRI) and international normalized ratio (INR) levels when compared with those without perioperative complications (ALB, P < 0.05; APRI, P < 0.01; INR, P < 0.05). Moreover, perioperative complications were correlated with glucocorticoid administration (P = 0.002). Univariate Cox regression analysis showed no relationship between perioperative complications and 2-years NLS (P > 0.05). However, multivariate Cox regression analysis indicated 6-months JC was an independent protective factor for 2-years NLS [P < 0.0001, hazard ratio (HR) = 0.074, 95% confidence interval = 0.05-0.11], and concordance index of this prediction model including age, weight, APRI, glucocorticoid, and 6-months JC was 0.811. Conclusion: Although perioperative complication is common during and after KPE, it had no influence on the prognosis of BA. However, assessment of the serum level of total bilirubin after KPE may serve as an important predictor for the outcome in BA.

Risk factors and prognostic effects of cholangitis after Kasai procedure in biliary atresia patients: A retrospective clinical study

PURPOSE

Cholangitis after Kasai procedure has been previously shown to be related to poor prognosis in Biliary Atresia (BA). To investigate the risk factors and clinical outcomes of cholangitis, we did a retrospective study in post-Kasai BA patients.

METHODS

Two-year follow-up data of 180 type-III BA patients after Kasai procedure in 2016 in our hospital were analyzed, including 119 cholangitis patients (66.11%). Among the cholangitis group, patients were further divided into early vs late cholangitis and single vs recurrent cholangitis groups. Liver pathology, liver function, cholangitis occurrence and frequency, jaundice clearance, and survival rates were examined.

RESULTS

Higher gamma-glutamyl transferase level before Kasai is a risk factor for cholangitis (p = 0.0393). Older age and higher liver fibrosis score at Kasai are risk factors for recurrent cholangitis (p < 0.05). Shorter prophylactic intravenous antibiotics usage may contribute to early cholangitis, which may lead to higher cholangitis frequency (p < 0.0001). Recurrent cholangitis is associated with earlier cholangitis onsets (p < 0.0001). Cholangitis patients have a relatively delayed jaundice clearance, while early and recurrent cholangitis may contribute to lower overall survival.

CONCLUSIONS

Personalized treatment considering risk factors in individual BA patients is needed to prevent cholangitis, especially early onsets, and to improve postoperative outcomes.

LEVEL OF EVIDENCE

III.

Biliary Atresia-associated Cholangitis: The Central Role and Effective Management of Bile Lakes

OBJECTIVES

Cholangitis and bile lakes are incompletely understood complications after portoenterostomy (PE). We investigated relationships between recurrent cholangitis, bile lakes, and clinical outcomes as well as surgical management of bile lakes.

METHODS

In this retrospective observational single institution study medical records and imaging studies of all patients who had undergone PE for biliary atresia during 1987 to 2016 (N = 61) were reviewed. We related occurrence of cholangitis episodes with the presence of intrahepatic bile lakes, patient characteristics, and PE outcomes. Risk factors for recurrent cholangitis and bile lakes, and management of bile lakes were analyzed.

RESULTS

Despite routine antibiotic prophylaxis median of 3.0 cholangitis episodes (0.75 episodes/year) occurred in 48 (79%) patients. Intrahepatic bile lakes were discovered in 8 (13%) patients by 16 months after PE. Overall, 54% had survived with their native liver at median age of 7.3 years and 28 (46%) patients had ≥1 cholangitis episodes/year. Number and frequency of cholangitis episodes were >5 times higher among patients with bile lakes (P < 0.001). Six patients underwent Roux-en-Y bile lake-jejunostomy, resulting in regression/disappearance of bile lakes and normalization of serum bilirubin in 5 with reduction of median yearly cholangitis rate from 8.8 to 1.1 (P = 0.028) and native liver survival of 6.3 (range, 1.3-17) years after the operation.

CONCLUSIONS

Bile lakes are a significant risk factor for recurrent cholangitis after PE and efficiently treated by operative intestinal drainage providing prolonged jaundice-free native liver survival. Bile lakes should be actively screened among patients presenting with recurrent cholangitis after PE.

Ten-Year Experience in the Prevention of Post-Kasai Cholangitis

BACKGROUND

Cholangitis is the most common complication after the Kasai procedure. It can be life-threatening and may affect long- and short-term outcomes of children with biliary atresia. We summarize our experiences in the prevention of early-onset cholangitis.

PATIENTS AND METHODS

From January 2002 to March 2013, children with biliary atresia (BA) who underwent the Kasai procedure in the General Surgical Department were included in a retrospective cohort study. These patients were divided into group A (therapy 1) and group B (therapy 2) depending on the infection prevention protocol and occurrences of cholangitis within the six months after surgery were recorded. Two hundred eighteen children were included in this cohort study. Seventy-six children (35 females and 41 males) were included in group A. One hundred forty-two children (65 females and 77 males) were included in group B. Therapy 1 was our primary protocol and included a third-generation cephalosporin, metronidazole, and human immunoglobulin. Therapy 2 was a modification of therapy 1 that involved imipenem-cilastatin and human immunoglobulin. Statistical analyses were performed. A p value below 0.05 was regarded as significant.

RESULTS

In group A, 45 children developed cholangitis within the six months after the Kasai procedure. In group B, 14 of these children experienced post-operative cholangitis. A χ² analysis was used to examine the difference in the incidence of cholangitis between groups A and B. There was a substantial difference in the morbidity of post-operative cholangitis between groups A and B (59.2% vs. 9.9%, p = 0.000).

CONCLUSION

Cholangitis in the early period after a Kasai procedure can be prevented effectively with an advanced prophylactic protocol.

Early Cholangitis after Portoenterostomy in Children with Biliary Atresia

Aims and Objectives

Biliary atresia (BA) is a cholangiodestructive disease of the biliary tree. The first line of treatment is a Kasai portoenterostomy (PE) following which patients may develop cholangitis. We studied the effect of early cholangitis on the outcome of PE, namely jaundice clearance and early native liver survival (NLS).

Methods

We reviewed the data of all children who developed cholangitis after PE from our prospectively maintained database of children with BA. The standardized treatment of all children in the database is described. The frequency and nature of these episodes were characterized, and the outcome of PE and NLS 1 year after PE was calculated.

Results

Of 62 children who underwent PE in our institutions, 27 developed cholangitis. All episodes of cholangitis occurred within 14 months of PE. Of 25 children who cleared jaundice in the overall series, 19 had cholangitis. The incidence of cholangitis was significantly higher in children who cleared jaundice. Nine children who had cholangitis are alive with native livers for more than 1 year after PE. Twelve children had intractable cholangitis. Three of these children are alive with native liver 1 year after PE.

Conclusion

In our series, cholangitis occurred in most children who cleared jaundice. Furthermore, the 1-year NLS of children who developed cholangitis was 33%.

The Prognostic Value of CD8+ and CD45RO+ T Cells Infiltration and Beclin1 Expression Levels for Early Postoperative Cholangitis of Biliary Atresia Patients after Kasai Operation

BACKGROUND

Postoperative cholangitis is a common but severe complication after Kasai portoenterostomy for biliary atresia (BA). This study aimed to identify its prognostic factors.

METHODS

Two sets of liver paraffin-embedded tissue samples were collected from BA patients who received Kasai portoenterostomy (n = 25 and n = 31, respectively). Patients were divided into non-cholangitis and cholangitis groups. The infiltration of CD4⁺, CD8⁺, CD45RO⁺, CD68⁺ cells and expression of Beclin1 were quantitatively evaluated in immunohistochemical analysis.

RESULTS

Cholangitis group had a significantly lower CD8⁺ T cell infiltration but a higher CD45RO⁺ cell infiltration, and a lower Beclin1 level than non-cholangitis group (all P < 0.01). Multivariate logistic regression analysis indicated that infiltration of CD8⁺ cells (odds ratio [OR], 0.112; 95% confidence interval [CI], 0.022-0.577) and CD45RO⁺ cells (OR, 3.88; 95% CI, 1.37-11.03), and Beclin1 level (OR, 0.088; 95% CI, 0.018-0.452) were independent influence factors for early postoperative cholangitis. Receiver operating characteristic (ROC) analysis showed that area under ROC curve (AUROC) values for CD8⁺ cells, CD45RO⁺ cells and Beclin1 were 0.857, 0.738 and 0.900, respectively.

CONCLUSION

Our findings demonstrated the CD8⁺ cells, CD45RO⁺ cells and Beclin1 level possessed the prognostic value for early postoperative cholangitis following Kasai operation, which may be helpful to develop new prevention and treatment strategies for postoperative cholangitis.

Endoscopic retrograde cholangiopancreatography in adult patients with biliary atresia: PROCESS-compliant case series

INTRODUCTION

Biliary atresia is a progressive inflammatory disease of the bile duct that eventually results in biliary cirrhosis. It is a rare neonatal disease that mandates treatment within the first 2 years of life in order for the infant to survive. Patients usually undergo palliative Kasai portoenterostomy. Even when Kasai portoenterostomy has been performed in a timely manner, progression is still inevitable. In fact, the majority of patients require curative liver transplantation at a later stage before reaching adulthood.

METHODS

Two jaundiced biliary atresia patients who have lived well beyond 20 years with their native liver after undergoing Kasai portoenterostomy and underwent endoscopic retrograde cholangiopancreatography (ERCP) were identified. The data on patients' clinical information, procedures performed, and outcomes were retrospectively collected by chart review.

RESULTS

Presence of a long Roux limb and acute angulation from external adhesions along with ductal anomaly from disease itself rendered ERCP challenging, and intraoperative ERCP had to be performed in 1 patient. As enteroscopes had to be used, availability of accessory devices was limited.

CONCLUSION

Management of adult biliary atresia patients with biliary obstruction with ERCP is feasible, at times, through multidisciplinary means.

A review of long-term outcome and quality of life of patients after Kasai operation surviving with native livers

Biliary atresia (BA) is a rare neonatal cholestatic disease which leads to progressive obliterative cholangiopathy, resulting in biliary obstruction and jaundice. The standard surgical treatment is hepatoportoenterostomy (Kasai operation). Although approximately 50% of the affected infants would require liver transplantation within the first 2 years of life, the other 50% of the patients can live for years with their native liver, despite the progression of cirrhosis and chronic liver disease. Many of these patients will be affected by long-term complications such as repeated cholangitis, portal hypertension, variceal bleeding, growth problems, biochemical abnormalities, and hepatic osteodystrophy. These morbidities impose a huge impact on the quality of life of the patients and their families. Herein, we performed a comprehensive review on the clinical status and quality of life of long-term survivors of biliary atresia with their native livers, to facilitate meticulous longitudinal follow-up of these patients, and alert caregivers the probable complications to be aware of.

Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries

BACKGROUND/PURPOSE

The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients.

METHODS

We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure.

RESULTS

We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers.

CONCLUSIONS

AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.

The extended Kasai portoenterostomy for biliary atresia: A preliminary report

AIMS

In 1955, Professor Morio Kasai first performed a hepatic portoenterostomy. Since then, the procedure has changed the lives of children with biliary atresia (BA). We report our initial experience in performing "extended" Kasai portoenterostomy (KPE), a modification of the original procedure.

MATERIALS AND METHODS

Since 2013, we have used the technique of "extended KPE" and prospectively recorded data on all children undergoing this operation. Data on demographics, clinical features, liver function tests, and perioperative cholangiogram findings were collected. Outcome of KPE was measured by Jaundice Disappearance Rate (JDR) and Native Liver Survival Rate (NLSR). We present our preliminary results from a 30-month period (February 2013 to May 2015).

RESULTS

Thirty-one children underwent KPE during this period (19 males) and only 1 child had biliary atresia splenic malformation (BASM). The mean age at KPE was 73 ± 24 days. Five (16.1%) children were more than 90 days old at the time of KPE. Fourteen children cleared jaundice (JDR 45.2%). Eleven (35.5%) children developed episodes of cholangitis, of whom 8 had early cholangitis (within 3 months of the operation). The proportion of children who survived with their own liver 6 months after KPE (NLSR) was 84.2%. Of those children older than 90 days, 2 cleared jaundice and have survived with their native livers for more than 16 months.

CONCLUSION

In our preliminary report of 31 children, we conclude that the extended KPE leads to increased jaundice clearance and improved NLSR in children with BA.

Prophylactic Antibiotics for Prevention of Cholangitis in Patients With Biliary Atresia Status Post-Kasai Portoenterostomy: A Systematic Review

PURPOSE

To determine effectiveness of prophylactic antibiotics in preventing cholangitis, we conducted a systematic review comparing cholangitis occurrence in biliary atresia patients after Kasai portoenterostomy (KP) with and without antibiotics.

METHODS

We searched online bibliographic databases from April 1, 2013, using search terms "biliary atresia" OR "cholangitis" AND "antibiotics," selecting studies with control group data.

RESULTS

Four of 509 titles met inclusion criteria, yielding a total of 319 patients from 3 countries. Three studies were retrospective cohorts and one was a randomized clinical trial. Two cohort studies concluded that prophylactic antibiotics reduced incidence of cholangitis and one did not. The randomized clinical trial supported prophylaxis after comparing the prospective randomized groups to a historical control group.

CONCLUSION

Few published studies measure the effect of prophylactic antibiotics after Kasai portoenterostomy. We identified 4 studies and they presented contradictory results. Prospective research is needed.

Serum bacterial DNA detection in patients with cholangitis after Kasai procedure

BACKGROUND

The aim of this study was to investigate the detectability of bacterial DNA (bactDNA) and associated clinical factors in patients with cholangitis after the Kasai procedure through the identification of bactDNA in blood.

METHODS

A cross-sectional study of 110 patients who had undergone the Kasai procedure was carried out. A total of 77 patients had cholangitis and 33 did not. Blood samples were obtained on admission or on follow up at the outpatient visit. bactDNA was analyzed using a polymerase chain reaction-based method, DNA nucleotide sequencing, for identification of bacterial species.

RESULTS

Rate of bactDNA positivity was higher using the 16SrDNA method than the culture method (58.4% vs 14.3%, P < 0.0001), and more patients with cholangitis were positive for bactDNA compared with the patients without cholangitis (58.4% vs 39.4%, P = 0.095). Bacteria identified on blood 16SrDNA primarily consisted of opportunistic pathogens derived from the gut, including Escherichia coli, Klebsiella pneumoniae, Shigella fexneri, and Enterobacteriaceae bacterium. Treatment with probiotics or antibiotics showed a trend toward reduced prevalence of bactDNA. Pediatric end-stage liver disease score, procalcitonin, C-reactive protein, and heart rate were all significantly associated with the presence of bactDNA.

CONCLUSION

bactDNA is frequently detected in patients with cholangitis after the Kasai procedure compared with those without cholangitis (and controls), and the bacteria are similar to those in the gut, suggesting that it is useful as an early diagnostic tool for cholangitis and other infections (registration number in Chinese Clinical Trial Registry ChiCTR-ECC-13003759).

Predictors for failure after Kasai operation

AIM OF THE STUDY

The outcome of Kasai operation is not uniformly successful. This objective of this study is to identify risk factors that predict early failure of this operation.

METHODS

A retrospective study was carried out for all patients who received Kasai operation between 1980 and 2012. Patients referred from other centers for liver transplantation because of failed Kasai operation were also recruited.

MAIN RESULTS

A total of 185 patients were reviewed. A total of 119 (64.3%) patients failed Kasai operation, whereas 86 (46.5%) were considered as cases of early failure (<3 years post-Kasai). With univariate analysis, the presence of associated anomaly (RR: 1.90, 95%CI 1:45-2:36), operation with laparoscopic surgery (RR: 3.14, 95% CI: 2.39-5.42), delayed clearance of jaundice (RR: 1.89, 95% CI: 1.56-2.67), and repeated cholangitis (RR: 2.56, 95% CI: 1.39-3.42) were associated with adverse outcome, whereas the use of adjuvant steroid at post-operative period appeared to be protective (RR: 0.64, 95% CI: 0.29-0.93). With multivariate analysis, repeated cholangitis was an independent risk factor for early failure after Kasai operation (RR: 3.16, 95% CI: 1.83-4.62). Furthermore, it was also considered as a risk factor for failure after 3 year post-Kasai (RR: 2.07, 95% CI: 1.43-3.42).

CONCLUSION

Patients with above risk factors are prone to fail Kasai operation in an early stage and require more frequent monitoring. Prevention and aggressive management of cholangitis should be considered as measures to avoid disease progression in the early stage. Lastly, performing open Kasai operation and the use of adjuvant steroid are potentially beneficial.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification of HSP90 as potential biomarker of biliary atresia using two-dimensional electrophoresis and mass spectrometry

Biliary atresia (BA) is a devastating cholestatic liver disease targeting infants. Current diagnosis depends on surgical exploration of the biliary tree. The aim of the present study was to identify potential biomarkers for the diagnosis of biliary atresia (BA). Two-dimensional electrophoresis was utilized for the identification of proteins that were differentially expressed in liver biopsies of 20 BA patients and 12 infants with non-BA neonatal cholestasis (NC) as controls. Using mass spectrometry, we identified 15 proteins with expressions significantly altered. Out of the 15 proteins identified, heat shock protein (HSP) 90 was the most significantly altered and was down-regulated in BA samples compared to NC samples using immunoblotting analysis. Our findings suggest that HSP90 might be a potential biomarker for the diagnosis of BA and may be used for monitoring further development and therapy for BA. This study demonstrated that a comprehensive strategy of proteomic identification combined with further validation should be adopted in biomarker discovery.

Biliary atresia: 50 years after the first kasai

Biliary atresia is a rare neonatal disease of unknown etiology, where obstruction of the biliary tree causes severe cholestasis, leading to biliary cirrhosis and death in the first years of life, if the condition is left untreated. Biliary atresia is the most frequent surgical cause of cholestatic jaundice in neonates and should be evoked whenever this clinical sign is associated with pale stools and hepatomegaly. The treatment of biliary atresia is surgical and currently recommended as a sequence of, eventually, two interventions. During the first months of life a hepatoportoenterostomy (a "Kasai," modifications of which are discussed in this paper) should be performed, in order to restore the biliary flow to the intestine and lessen further damage to the liver. If this fails and/or the disease progresses towards biliary cirrhosis and life-threatening complications, then liver transplantation is indicated, for which biliary atresia represents the most frequent pediatric indication. Of importance, the earlier the Kasai is performed, the later a liver transplantation is usually needed. This warrants a great degree of awareness of biliary atresia, and the implementation of systematic screening for this life-threatening pathology.

+276 G/T single nucleotide polymorphism of the adiponectin gene is associated with the susceptibility to biliary atresia

BACKGROUND

Biliary atresia (BA) is an intractable neonatal inflammatory and obliterative cholangiopathy, leading to progressive fibrosis and cirrhosis. Adiponectin, an anti-inflammatory adipokine, is known to play a possible role in liver diseases. The objective of our study was to determine the relationship between adiponectin gene polymorphisms and BA susceptibility.

METHODS

A total of 106 BA patients and 107 healthy controls were included in this study. Two single nucleotide polymorphisms (SNPs) of the adiponectin gene, +45T/G (rs2241766) and +276G/T (rs1501299), were genotyped by polymerase chain reaction-restriction fragment length polymorphism analysis.

RESULTS

Genotype distributions of +45 T/G and +276 G/T SNPs were seen in the Hardy-Weinberg equilibrium for both BA patients and controls. The frequency of the G/G genotype at +276G/T was significantly higher in BA patients than in the controls (P=0.009). Regarding +45T/ G in BA patients, the frequency of the T/T genotype tended to be lower than in the controls, but the difference was not significant. Moreover, the G allele at +276G/T in BA patients was more common than in the controls (P=0.0043). In contrast, the frequency of the T allele at +45T/G was not significantly different between BA patients and the controls. None of the haplotypes studied was found to significantly influence the risk of BA.

CONCLUSIONS

+276G/T SNP is strongly associated with BA, particularly with the G allele. We postulate that the +276G/T adiponectin gene polymorphism confers increased susceptibility to BA.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography for treatment of cholangitis in a patient with a Kasai portoenterostomy

Primary therapy for biliary atresia is a surgical hepatoportoenterostomy (Kasai procedure), which has been shown to reduce mortality, but is frequently complicated by ascending cholangitis and the development of biliary cirrhosis. Previously reported therapy for recurrent cholangitis caused by biliary obstruction has included surgical revision and percutaneous biliary drainage, but endoscopic retrograde cholangiopancreatography has not been previously described. Here, we report a patient with recurrent cholangitis after a Kasai procedure and an anastomotic stricture successfully treated with single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography. This novel technique could be considered in patients with this common complication of the Kasai procedure and may impact long-term outcomes in this patient population.

Home intravenous antibiotic treatment for intractable cholangitis in patients with biliary atresia following Kasai portoenterostomies

Purpose

Patients with biliary atresia (BA) treated with Kasai portoenterostomy may later develop intractable cholangitis (IC) that is unresponsive to routine conservative treatment. It may cause biliary cirrhosis and eventually hepatic failure with portal hypertension. Control of IC requires prolonged hospitalization for the administration of intravenous antibiotics. To reduce the hospitalization period, we designed a home intravenous antibiotic treatment (HIVA) which can be administered after initial inpatient treatment. In this study, we reviewed the effects of this treatment.

Methods

We reviewed medical records of 10 patients treated with HIVA for IC after successful Kasai portoenterostomies performed for BA between July 1997 and June 2009.

Results

The duration of HIVA ranged from 8 to 39 months (median, 13.5 months). The median length of hospital stay was 5.7 days per month for conventional treatments to manage IC before HIVA and, 1.5 days per month (P = 0.012) after HIVA. The median amount of medical expenses per month was reduced by about one tenth with HIVA. One patient underwent liver transplantation due to uncontrolled esophageal variceal bleeding, but the other nine patients had acceptable hepatic function with native livers.

Conclusion

HIVA may be an effective primary treatment for IC after Kasai portoenterostomies for BA, and reduce length of hospital stay and medical expense.

Biliary atresia: how medical complications and therapies impact outcome

Biliary atresia (BA) is a progressive fibro-obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction in the neonatal period. Untreated, BA is a uniformly fatal disease and, yet, even with our existing therapies, at least 50% of children with BA will undergo liver transplantation by the age of 2 years. Current treatment strategies are, at best, palliative; they focus on prompt diagnosis, supportive nutritional care and interventions for sequelae. The purpose of this article is to discuss the current treatment paradigm for BA and to assess the impact these strategies have on outcomes. As more children with BA survive into adulthood with their native liver, it is important to understand which factors predict good and poor outcomes.

Recent advances in biliary atresia: prospects for novel therapies

BACKGROUND

Biliary atresia (BA) is a progressive fibro-obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction before 2 months of age. Untreated BA is a uniformly fatal disease and even with our current therapies only 50% of children with BA will be transplant-free by 2 years of age. Despite descriptions of this disorder dating back to the 1800s our current therapies are palliative. They focus on prompt diagnosis, supportive nutritional care and interventions for sequelae.

OBJECTIVE

To present the literature supporting current treatment strategies and potential future therapies.

METHOD

Each of the aspects of care is described and the literature about nuances of care is provided.

CONCLUSION

Therapies will not improve outcomes until novel treatments are introduced, such as those suggested, which may intervene in the inflammatory or fibrotic steps of the disease process.