Drivers of Hospital Readmission and Early Liver Transplant after Kasai Portoenterostomy

Outcomes of Liver Transplantation in Patients With Congenital Heart Disease and Biliary Atresia. A Multicenter Analysis

INTRODUCTION

Congenital heart disease (CHD) frequently coexists with noncardiac malformations. Among which, biliary atresia (BA) occurs in approximately 5%-15% of patients Despite this, outcomes of liver transplantation (LT) in patients with CHD and BA remain unknown.

METHODS

A retrospective review of the Pediatric Health Information System (PHIS) database from January 1, 2004 to October 30, 2023. All patients who underwent LT and had a diagnosis of BA were included. Multiorgan transplants were excluded. International Classification of Diseases 9th and 10th editions were utilized to identify patients with a diagnosis consistent with CHD.

RESULTS

A total of 1677 patients were identified with 983 (59%) female, 811 (5%) white non-Hispanic, and a median age at transplant of 11.6 (interquartile range [IQR]: 7.7-26.6) months. A CHD diagnosis was present in 83 (5%). Overall, the majority of transplants were performed in the CHD population in the modern era (2016-2023) (42/83.51%). CHD had a longer median preoperative length of stay (LOS) compared to non-CHD (1 [1.0-15.0] vs. 1 [0-6.0], p = 0.031). No increased risk of in-hospital mortality was evident (OR: 1.61, 95% CI: 0.37-6.95, p = 0.519). On multivariable analysis, CHD was associated with a 29% (95% CI: 11.04-50.34) increase in LOS (p < 0.001), 25% (95% CI: 6.98-46.47, p = 0.005) increase in postoperative LOS, and was not associated with increased risk for 30-day readmission (OR: 1.14; CI: 0.53-2.45, p = 0.736). Over a median follow-up of 3.5 years (IQR: 0.86-7.78) years, no difference in retransplantation rate was evident.

CONCLUSIONS

LT in patients with CHD and BA is safe. Although patients with CHD display heightened utilization of in-hospital resources, no discernible variance in long-term outcomes was observed. However, additional research is imperative to comprehensively elucidate the influence of CHD on management decisions and outcomes throughout the liver transplant process.

Outcomes of Kasai Portoenterostomy in Patients With Congenital Heart Disease: A Silent Comorbidity

INTRODUCTION

Biliary atresia (BA) is the most common cause of end-stage liver disease in children. Around 5 %-15 % of patients with BA have a congenital heart disease (CHD) diagnosis. Despite high prevalence of a CHD diagnosis in patients with BA, outcomes of Kasai portoenterostomy (KPE) in the CHD population remain unexplored.

METHODS

This is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2022. All patients undergoing KPE were included. Patients with CHD were identified using previously validated ICD9/10 codes.

RESULTS

A total of 854 patients underwent a KPE during the study period. Of this cohort, 502 (59 %) were female, 342 (40 %) White Non-Hispanic, median age of 57.0[IQR: 40.0-72.0] days, and a median weight of 9.4 [IQR: 8.1-10.7] kilograms. A total of 89 (10 %) patients had a diagnosis of CHD. Of those, 63 (7 %) had a simple-CHD diagnosis and 26 (3 %) a complex-CHD diagnosis. A single-ventricle (SV-CHD) diagnosis was present in 7 (1 %) patients. Notably, no in-hospital mortalities were found. When compared to non-CHD, simple-CHD (OR: 2.51; 95 % CI: 1.45-4.36, p = 0.001) and complex-CHD (OR: 3.20; 95 % CI: 1.30-7.87, p = 0.011) had increased risk for any complication. Furthermore, when compared to non-CHD complex-CHD patients had higher odds of undergoing a Kasai related reintervention (OR: 5.01; 95 % CI: 1.76-14.22, p = 0.002. After propensity score matching, when compared to non-CHD a CHD diagnosis was only associated with an increased risk for any complication (OR: 2.50; 95 % CI: 1.30-4.81, p = 0.005).

CONCLUSION

A CHD diagnosis is present in 10 % of children undergoing KPE. KPE appears to be safe in patients with CHD, but associated with increased in-hospital resource utilization. Further studies are needed to understand the impact of a CHD diagnosis on the long-term outcomes after KPE.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

Level 3.

Early Hospital Readmission After Pediatric Liver Transplant: A Retrospective Analysis of the Society of Pediatric Liver Transplantation (SPLIT) Database

INTRODUCTION

Incidence of and risk factors for early hospital readmission (EHR) are poorly defined in pediatric liver transplant recipients. Therefore, we evaluated EHR incidence and risk factors for pediatric liver recipients in a nationally representative sample.

METHODS

Using the Society of Pediatric Liver Transplantation database, we retrospectively analyzed 2808 pediatric liver-only recipients transplanted 2011-2022. Recipient-, donor-, and center-level characteristics were evaluated as possible risk factors for EHR within 30 days of hospital discharge using multivariable modified Poisson regression.

RESULTS

Overall, 23% (N = 642) of pediatric recipients experienced EHR. Independent risk factors for EHR include diabetes (adjusted relative risk [aRR] 2.33, 95% CI: 1.41-3.86, p = 0.001), history of malignancy (aRR 1.59, 95% CI: 1.19-2.11, p = 0.002), and shorter length of transplant hospitalization. Recipients in the shortest length of stay quartile (median [IQR] 8 [7-9] days) had a ninefold increased risk for EHR compared with recipients in the longest length of stay quartile (34 [28-48] days) (aRR 8.86, 95% CI: 5.68-13.81, p < 0.001). Incidence of EHR did not vary by transplant center and was not associated with other characteristics of the donor (DCD vs. not DCD), recipient (age, race, sex, and diagnosis), procedure (whole vs. split liver, ischemic time), or transplant center.

CONCLUSION

We found the 30-day readmission rate for pediatric liver transplant recipients was 23%. Shorter hospital stays were a major risk factor for EHR, highlighting that longer initial transplant hospital stays may be beneficial for predischarge optimization and coordination of their complex care.

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.

Retrospective analysis of the standardized BARD criteria for acute cholangitis in biliary atresia patients

Objectives

In 2022, the Biliary Atresia and Related Diseases (BARD) community reached a consensus for the definition of suspected and confirmed cholangitis for biliary atresia (BA) patients after hepatoportoenterostomy (HPE). This study assessed the new standardized BARD definition in a retrospective, multicenter cohort study.

Methods

We included BA cases managed between 2010 and 2020 at the Hannover Medical School and Geneva University Hospitals' Swiss Pediatric Liver Center. The standardized BARD cholangitis definition assesses four clinical items and four imaging/laboratory items to define cholangitis. The definition was retrospectively applied to all BA cases having presented, according to their physician, cholangitis within the first year after the HPE. The diagnosis defined by the standardized BARD definition was compared with the final clinical diagnosis made by physicians. The Spearman's correlation coefficient was used to test for correlation between diagnoses made by standardized and clinical appreciation.

Results

Of 185 consecutive BA patients, 59 (32%) had at least one episode of cholangitis within the first year after HPE. The correlation between the clinician's impression and the standardized BARD definition was very strong (r = 0.8). Confirmed cholangitis definition coincided with the clinician's impression (2.5 [±0.7]/4 clinical items, 2.6 [±0.5]/4 imaging/laboratory items). For suspected cholangitis, the threshold for diagnosis was lower within the standardized BARD definition (1.1 [±0.3]/4 clinical items, 2.2 [±0.8]/4 laboratory/imaging items).

Conclusions

This first retrospective application of the standardized BARD cholangitis definition reveals a very strong correlation with the physician's assessment before standardization. A prospective study is needed to further refine the standardized definition for cholangitis in BA patients.

Combined Predictors of Long-Term Outcomes of Kasai Surgery in Infants with Biliary Atresia

Purpose

Biliary atresia (BA) is the leading cause of neonatal cholestasis (25-45%). The primary treatment is hepatic portoenterostomy (Kasai procedure), but only 20-40% provide long-term benefits. This study aimed to develop a predictive model for surgical efficacy by comparing preoperative and early postoperative indicators in infants with different outcomes.

Methods

We enrolled 166 infants with BA (93 girls, 73 boys) who underwent the Kasai procedure between September 2002 and December 2021, dividing them into favorable or adverse outcome groups. Over 40 parameters were measured, and the diagnostic significance of the prognostic model was evaluated.

Results

Kasai surgery was efficacious in 69 patients (42%) and non-efficacious in 97 (58%). Our model assesses efficacy by day 14 after surgery, improving on the <34 µmol/L direct bilirubin threshold established for 3-6 months after the procedure. Including the Desmet fibrosis score refined the model.

Conclusion

Blood cholesterol below 5.41 mmol/L, direct bilirubin below 56.3 µmol/L on postoperative days 14±3, and a low Desmet score indicate a high probability of efficacious Kasai surgery in infants with BA.

Alterations of gut microbiota in infants with biliary atresia identified by 16S rRNA-sequencing

BACKGROUND

Biliary atresia (BA) is a severe neonatal disease with progressive intra- and extra-hepatic bile ducts inflammation and hepatic fibrosis. Characterization of gut microbiome profiles in infants with biliary atresia can provide valuable information and potential disease biomarkers. Our study aims to explore the relationship between gut microbiota and biliary atresia.

METHODS

16 S ribosomal RNA (rRNA) gene sequencing was carried out to identify the differences in composition and diversity of gut microbiota between infants with BA and healthy subjects. A total of 31 infants with biliary atresia and 20 healthy subjects were recruited.

RESULTS

The composition of gut microbiota in BA group was significantly different with the normal control group (P < 0.05) and the abundance ratio of Klebsiella/Bifidobacterium showed great potential for identification of BA (P < 0.01). In addition, the differential bacterial taxa were involved in lipid and vitamins metabolism.

CONCLUSION

Our results could provide potential non-invasive biomarker for identification of biliary atresia and contribute to the treatment in terms of ameliorating microbiota dysbiosis.

Early bile drainage improves native liver survival in biliary atresia without cholangitis

Objectives

To explore the outcomes and related factors in children without cholangitis after Kasai portoenterostomy (KPE).

Methods

We retrospectively analyzed the data of infants with type III BA who underwent KPE from June 2016 to December 2021. We compared and analyzed the difference in native liver survival (NLS) rates in different types of cholangitis. We also investigated the relationship between the absence of cholangitis and the effect of early bile drainage (EBD) as well as the related factors affecting EBD efficacy.

Results

A total of 145 children were included in this study. Among these children, 82 (56.6%, 82/145) had cholangitis, including 40 (48.8%, 40/82) with early cholangitis and 33 (40.2%, 33/82) with recurrent cholangitis. The median follow-up period was 29 months (range, 2-75 months). The NLS rates were 67.6%, 51.7%, 45.5% and 43.4% at 6 months, 1 year, 2 years and 5 years following KPE, while the NLS rates for infants without cholangitis after KPE were 68.3%, 50.8%, 46.0% and 46.0%, respectively. Higher gamma-glutamyl transferase (γ- GT) and total bile acid (TBA) before KPE were risk factors for cholangitis (P < 0.05). The NLS rate in recurrent cholangitis was significantly lower than that in occasional cholangitis (P < 0.01). Compared with the EBD-poor group, the NLS rate in the EBD-good group of infants was significantly increased (P < 0.001). EBD was significantly correlated with the occurrence and frequency of cholangitis (P < 0.05).

Conclusions

Recurrent cholangitis was an important factor affecting NLS. For children without cholangitis after KPE, early bile drainage was better, and the NLS was longer.

Laparoscopic versus open pyloromyotomies: Outcomes and disparities in pyloric stenosis

PURPOSE

Pyloromyotomy for hypertrophic pyloric stenosis (HPS) is one of the most common non-elective operations performed in the neonatal period. This project aims to explore outcomes of pyloromyotomy and compare differences between laparoscopic versus open pyloromyotomies in newborns diagnosed with HPS.

METHODS

The Nationwide Readmissions Database (NRD) from 2010 to 2014 was queried to identify patients diagnosed with HPS that underwent repair.

RESULTS

In total, 30,915 children (18% female) underwent pyloromyotomy for HPS. Median length of stay for index admission was 2 days. A total of 212 (0.7%) patients required a redo pyloromyotomy. 127 (60%) were performed during index admission. Readmission rate at 30 days was 3% and 5% at one year, and 22% presented to a different hospital. The most common indications for readmission were feeding intolerance (24%), dehydration (10%), and malnutrition (10%). Patients from low-income households were more likely to present with malnutrition and weight loss (9% vs 4%, p<0.001) and had higher readmission rates (8% vs 4%, p<0.001). Laparoscopic pyloromyotomies accounted for 10% (n = 2951) of cases. Those undergoing laparoscopy were less likely to have electrolyte disturbances (41% vs 54%, p<0.001) or weight loss (2% vs 11%, p<0.001) on admission. The rate of open conversion was 1%. Intraoperative perforation was not more common in laparoscopic than open cases. Open pyloromyotomies had higher 30-day readmission rates and more surgical site infections.

CONCLUSION

Complications from pyloromyotomies are rare. Although infrequent, the incidence of incomplete pyloromyotomy is higher than previously reported and more common with open approaches. Newborns from low-income households are more likely to present with advanced symptoms and have disproportionately higher rates of readmission.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Treatment Study, retrospective.

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.

Long-term outcomes of biliary atresia patients surviving with their native livers

Portoenterostomy (PE) has remained as the generally accepted first line surgical treatment for biliary atresia (BA) for over 50 years. Currently, close to half of BA patients survive beyond 10 years with their native livers, and most of them reach adulthood without liver transplantation (LT). Despite normalization of serum bilirubin by PE, ductular reaction and portal fibrosis persist in the native liver. The chronic cholangiopathy progresses to cirrhosis, complications of portal hypertension, recurrent cholangitis or hepatobiliary tumors necessitating LT later in life. Other common related health problems include impaired bone health, neuromotor development and quality of life. Only few high-quality trials are available for evidence-based guidance of post-PE adjuvant medical therapy or management of the disease complications. Better understanding of the pathophysiological mechanisms connecting native liver injury to clinical outcomes is critical for development of accurate follow-up tools and novel therapies designed to improve native liver function and survival.