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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 1  |  Page : 101-105
A histopathological study of liver and biliary remnants with clinical outcome in cases of extrahepatic biliary atresia


1 Department of Pathology, Institute of Post Graduate Medical Education and Research, 244A AJC Bose Road, Kolkata - 700 020, India
2 Park Children's Center for Treatment and Research, 4 Gorky Terrace, Kolkata - 700 017, India

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Date of Web Publication19-Jan-2010
 

   Abstract 

Context: The indicators of poor prognosis in cases of extrahepatic biliary atresia (EHBA) continue to remain controversial. Aims: To correlate the histopathological findings of wedge biopsy from liver and tissue obtained from the shaving at the porta hepatis, during hepatic portoenterostomy, with the clinical outcome. Materials and Methods: All cases of EHBA surgically treated in our hospital from 1995 to 2006 have been reviewed. Wedge biopsies of the liver and biopsies from the porta hepatis were analyzed with hemotoxylin-eosin stains and immunohistochemistry. The parameters correlated with clinical outcomes were - presence of large bile ducts ( > 150μm diameter) in the portal tissue plaque, degree of fibrosis (semi-quantitative; graded as mild, moderate and severe), presence of ductal plate malformation (DPM) and age at operation. Results: The proportions of patients with small or large ductal diameter who remained clinically controlled (serum bilirubin < 1.5mg/dl with no evidence of end stage liver failure) were 39% and 66.6% respectively (P=0.44). There was a highly significant correlation between the extent of fibrosis and clinical outcome. Mild, moderate and severe fibrosis resulted in clinical control rates of 78.5%, 34.4% and 24% respectively (P=0.001). Ductal plate malformation was seen in 15% of our cases and was uniformly associated with poor outcome. A non-significant trend towards poorer outcome was seen with increasing age at surgery. Conclusions: Histopathological correl ations with clinical outcome in EHBA have been rarely reported from the Indian subcontinent. A greater degree of fibrosis at the time of hepatic portoenterostomy and presence of ductal plate malformation is associated with a significantly poorer clinical outcome.

Keywords: Ductal plate malformation, extra-hepatic biliary atresia, prognosis

How to cite this article:
Roy P, Chatterjee U, Ganguli M, Banerjee S, Chatterjee S K, Basu A K. A histopathological study of liver and biliary remnants with clinical outcome in cases of extrahepatic biliary atresia. Indian J Pathol Microbiol 2010;53:101-5

How to cite this URL:
Roy P, Chatterjee U, Ganguli M, Banerjee S, Chatterjee S K, Basu A K. A histopathological study of liver and biliary remnants with clinical outcome in cases of extrahepatic biliary atresia. Indian J Pathol Microbiol [serial online] 2010 [cited 2019 Oct 20];53:101-5. Available from: http://www.ijpmonline.org/text.asp?2010/53/1/101/59194



   Introduction Top


Extrahepatic biliary atresia (EHBA) is a unique pediatric liver disease that presents with early aggressive biliary fibrosis. The etiology of this disease is not very well understood. Biliary atresia can be divided into two main groups. [1] The perinatal group presents around one month of age and is more common. The factors implicated in its etiology are genetic, toxic, vascular and infections. [2],[3] The rare fetal group presents much earlier and is associated with various congenital anomalies. Ductal plate malformation is implicated in its etiopathogenesis. [1],[4]

Hepatic portoenterostomy (modified Kasai operation) is the most widely accepted initial treatment modality in these patients. Many of the patients ultimately need liver transplantation. Early indicators of poor prognosis help to identify patients who could be referred for liver transplantation, increasing their chances of survival.

Prognostic factors for biliary atresia after Kasai operation have been widely studied and the results so far are contradictory. Higher age at operation has been consistently linked with worse prognosis by most authors. [5],[6],[7],[8],[9] However, the fetal type though presenting early, also has poor outcome. [5],[6] Those patients who have associated intrahepatic component, have worse prognosis than those with purely extrahepatic component. The size and number of bile ductules at the porta are important histological features studied by numerous authors to predict the outcome of portoenterostomy. [1],[4],[5],[6] These studies have so far not reached any clear consensus regarding the prognostic importance of the size of the bile ducts, though most have found that a complete absence of bile ductules at the porta hepatis, is associated with a bad prognosis. Features like increased amount of fibrosis, inflammation and ductular proliferation are thought to be poor prognostic markers.

Recently, ductal plate malformation (DPM) has been reported in cases of EHBA with an incidence varying from 21-63%. [10],[11],[12] It is a condition where there is persistence of excess embryonic bile duct structures and is a basic component of many congenital diseases of the liver, such as congenital hepatic fibrosis, extrahepatic biliary atresia, autosomal recessive polycystic kidney disease and Caroli's syndrome. [4],[13] Low et al. [10] were the first to suggest the importance of DPM as an indicator of poor prognosis in EHBA.

This study aims to correlate the clinical outcome following hepatic portoenterostomy with the age at operation, morphometry of bile ductules at the porta hepatis, degree of fibrosis, cholestasis, bile duct proliferation and the presence of ductal plate malformation.


   Materials and Methods Top


We selected 83 cases of EHBA who came to our center for hepatic portoenterostomy (Kasai operation) and with clinical follow-up for at least two years or till death. This spanned over a period of 11 years and six months from January 1995 to June 2006.

Hepatic wedge biopsy, taken at the time of portoenterostomy, was studied in all cases using conventional stains such as hematoxylin and eosin (H and E), reticulin, periodic acid-Schiff (PAS) with and without diastase and Masson's trichrome. Porta hepatis biopsy was additionally done in 37 of these cases.

The parameters studied were the degree of fibrosis, cholestasis and bile duct proliferation. The severity of fibrosis was graded in a semi-quantitative manner into mild, moderate and severe categories. In the mild category, fibrosis was localized in the portal area. Intermediate category comprised of moderate to severe fibrosis with portal-portal (P-P) bridging. In the severe category there was liver cirrhosis with reconstruction of hepatic lobules. In our study, grades II and III of Okhuma's classification were together included in the intermediate group. [14],[15] Bile ductular proliferation was semiquantitatively graded as mild, moderate and severe. Portal and periportal inflammation was also graded as mild (cells in less than one third of portal tracts), moderate (cells in one third to two thirds of portal tracts), and severe (dense packing of cells in more than two thirds of portal tracts). Cholestasis was graded as absent, mild (bile accumulation in centrolobular hepatocytes), moderate (bile accumulation in centrolobular and periportal hepatocytes or in portal tracts), and severe (with presence of bile infarcts).

DPM was recognized by the presence of biliary structures in unusual curved or concentric pattern sometimes around a fibrous or vascular core within the portal tracts. [4]

To help us recognize this unusual configuration, and also to grade the degree of bile ductular proliferation, immunohistochemical staining was done for cytokeratin. Antibody for pancytokeratin (Biogenex, USA) was employed using standard immunohistochemical protocol (avidin-biotin system with diaminobenzidine tetrahydrochloride as the chromogen). Two cases of age matched controls were used.

Porta hepatis tissues were available in 37 cases in which bile duct morphometry was done using an eye piece graticule. The presence and number of large bile ducts (> 150µm diameter), or small ductules (< 150µm diameter), or complete absence of ductules with presence of a fibrotic stump was noted. All the slides were reviewed by two pathologists and difference of opinion was solved by common consensus.

In this study, successful outcome was defined as patients alive two years after surgery, with serum bilirubin less than 1.5mg/dl and no evidence of end stage liver failure. Patients who died within two years of operation or were surviving with jaundice (>1.5mg/dl), or listed for liver transplantation, were included in the poor outcome group. Other clinical parameters were also recorded.

Chi square test and student 't' test were used for analyzing the data. Statistical significance was taken at a P value of ≤0.05.


   Results Top


The ages of the patients ranged from 23 to 180 days. There were 58 males and 25 female patients. The duration of follow-up for patients alive ranged from two to 10 years. We divided the patients into three groups on the basis of the age at operation - less than 30 days, 30 to 90 days and more than 90 days. Four patients were younger than 30 days out of which three (75%) died within two years. There were 53 patients aged between 30 to 90 days who showed better prognosis, with 30 patients (56.6%) falling in the successful outcome group. Again, in the >90days group, the outcome was poor with only 8 (30.7%) of the total 26 patients surviving after two years. No statistical significance was observed between age at operation and prognosis (P = 0.158, [Table 1]).

On dividing the patients into two further age groups, 31 to 60 days, and 61 to 90 days, there was better correlation with survival. Fourteen (63.6%) of 22 patients in the 31 to 60 days age group, had good prognosis, while in the other group only 16 (51.6%) out of 31 survived. We noted a trend towards worse prognosis with increasing age group, but again it was not statistically significant. (P= 0.101, [Table 1])

Out of the 37 cases for whom bile duct morphometry could be done, 28 patients (75.67%) had bile ductules <150µm in size. A higher percentage (60.71%) of these showed poor outcome. In comparison, in the group with larger ductules, the trend was towards better survival (66.7% alive). However, no statistical correlation was observed. (P = 0.439, [Table 1])

The degree of fibrosis was categorized semi-quantitatively into mild, moderate and severe. Mild fibrosis was seen in 28 cases, out of which 22 patients (78.5%) are doing well. Ten (34.4%) out of 29 cases of moderate fibrosis are doing well, whereas in cases with severe fibrosis, only 24% (6 out of 25 patients) are doing well. [Figure 1] A highly significant correlation was noted between increasing degrees of fibrosis and poor survival (P = 0.001, [Table 1]).

Bile ductular proliferation and inflammation were also graded semi-quantitatively into mild, moderate and severe. [Figure 2]. It was observed that a higher degree of cholestasis was associated with a poorer outcome, however there was no statistical significance.

Twelve (14.45%) of our cases showed ductal plate malformation, all of whom had uniformly poor prognosis. [Figure 3]. Nine of them were males (75%).


   Discussion Top


Biliary atresia is a relatively rare disorder. It is also a disorder in which many questions remain unanswered. A considerable amount of research is currently underway on the etiological basis of this disorder and various theories have been put forth. It has also been acknowledged that the natural history of this disease is extremely variable, raising the issue of identification of clinical and pathological factors which are indicators of prognosis. This may help us determine the best possible approach to treatment and identify the patients for an early liver transplantation.

We undertook this study to identify the histopathological features which carry a prognostic significance in the outcome of children with biliary atresia. Increased age at operation, fibrosis, ductular proliferation, inflammation, cholestasis, ductal plate malformation have all been postulated to be of possible prognostic significance in various studies. We examined each of these factors in our group of 83 children.

Higher age at operation has been consistently linked with worse prognosis by most authors. [5],[6],[7],[8],[9] There are, however, differences of opinion on the cutoff - whether it should be 60 days or 90 days. Very early presentation also has a poor prognosis. From our study we felt that age at operation of more than 90 days was related with a worse outcome, but no statistical correlation could be achieved. Two of our patients who presented early (<30 days) for operation died due to post operative sepsis. This is a compounding factor which we need to keep in mind when studying prognostic factors after operation. On dividing the patients into four groups of less than 30 days, 31 to 60 days, 61 to 90 days and more than 90 days, we found a better correlation with prognosis, though again, it was not statistically significant.

Kahn et al. [1] have shown that recent research divides biliary atresia etiologically into the early presenting fetal and later presenting perinatal groups. The fetal group is affected by the more severe form of the disease and has worse outcomes in spite of earlier intervention. This could explain why our patients who were operated on early (below age 30 days) fared worse than the later presenting groups.

Fibrosis was one morphological feature that could be linked with poor outcome after portoenterostomy in nearly all our cases. Patients with severely fibrotic and nodular livers were doomed to have a down hill course, even if they presented early for portoenterostomy, or had no other associated poor prognostic factors. Schweizer et al. [16] as well as Tan et al. [5] and Landing et al.[17] have all shown similar results in their studies. Increased fibrosis compromises the flow of bile leading to jaundice and poor outcome even after surgery. It is also thought to be a progressive, continuing process, which is not reversible. In their study, Landing et al. [17] have shown how ductal proliferation increases to peak at 205 days followed by regression by 400 days, in untreated patients, while the level of connective tissue continues to increase slowly and progressively, and later becomes unresponsive to treatment.

Bile ductular size at the porta is one of the most controversial factors studied. Different authors have shown completely contradicting results. Chandra et al.[18] as well as Raweily et al. [11] and Tan et al. [5] have shown that smaller sized ductules correlate with worse prognosis; Langenburg, [6] Matsuo, [19] Lawrence [20] and many others have shown that the size does not correlate with outcome. Matsuo has suggested that the total area of all the bile ductules rather than the individual duct size might relate better with prognosis. Though we noted that the patients with duct size more than 150µ fared better, it was not a statistically significant finding. However, it was certain that the ones with completely fibrotic porta hepatis stump, with no visible remnant ducts, definitely had poor outcome.

Increased bile ductular proliferation has been reported to be associated with poor outcome by some, [5],[21] but we did not find a clear correlation. The study by Landing et al. [17] provides an explanation, as mentioned above. Degree of cholestasis is also similarly linked, but we did not find any correlation. Absence of inflammation at the porta hepatis has been said to be indicative of a poorer outcome, [1] but we did not observe any such link.

DPM has been described in biliary atresia by other authors with an incidence varying from 21-63%. [10],[11],[12] Das et al. [4] noted DPM in 51.29% of EHBA cases. We recorded a much lower frequency of 14%. Lack of strict definition, distinguishing DPM from ductal proliferation, might be responsible for this. Patients of this group are said to have 'early severe' biliary atresia, and are associated with severe degree of fibrosis, as observed by Desmet. [13] We observed a similar increase in fibrosis in our DPM cases. Low et al. [10] were the first to link DPM with poor outcome. Our work is only the second one to study the prognostic implication of DPM in cases of EHBA.


   Conclusion Top


In patients with extrahepatic biliary atresia, a higher degree of fibrosis and presence of ductal plate malformation shows definite correlation with poorer survival.

 
   References Top

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3.Silveira TM, Salzano FM, Donaldson PT, Mieli-Vergani G, Howard ER, Movat AP. Association between HLA and extra hepatic biliary atresia. J Pediatr Gastroenterol Nutr 1993;16:1114 -7.  Back to cited text no. 3      
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5.Tan CE, Davenport M, Driver M, Howard ER. Does the morphology of the extra hepatic biliary remnants in biliary atresia influence survival? A review of 205 cases. J Pediatr Surg 2004;29:1459-64.   Back to cited text no. 5      
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10.Low Y, Vijayan V, Tan CE. The prognostic value of ductal plate malformation and other histologic parameters in biliary atresia: An immunohistochemical study. J Pediatrics 2001;139:320-2.   Back to cited text no. 10      
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12.Terraciano L, Cathomas G, Vecchione R, Tomillo L, Gudat F, Bianchi L. Extra hepatic bile duct atresia associated with hyperplasia of the intrahepatic bile ducts ("early severe" form): high incidence in a South-Italian population. Pathol Res Pract 1995;191:192.   Back to cited text no. 12      
13.Desmet VJ. Ludwig symposium on biiary atresia - Part I. Pathogenesis of ductal plate abnormalities. Mayo Clinic Proc 1998;73:80-9.   Back to cited text no. 13      
14.Ohkuma Y. Pathological reappraisal of biliary atresia and a new aspect on its etiology. J Jpn Pediatr Surg Med 1975;7:205-11.  Back to cited text no. 14      
15.Kinugasa Y, Nakashima Y, Matsuo S, Shono K, Suita S, Sueishi K. Bile ductular proliferation as a prognostic factor in biliary atresia: an immunohistochemical assessment. J Pediatr Surg 1999;34:1715-20.   Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Schweizer P, Lunzmann K. Extra hepatic bile duct atresia: how efficient is the hepatoporto-enterostomy? Eur J Pediatr Surg 1998;8:150-4.   Back to cited text no. 16      
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19.Matsuo S, Ikeda K, Yakabe S, Nakagawara A, Iwashita A. Histological study of the remnant of porta hepatis in patients with extra hepatic biliary atresia - A computed picture analysis of 30 cases. Z Kinderchir 1984;39:46-9.   Back to cited text no. 19  [PUBMED]    
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21.Altman RP, Lilly JR, Greenfeld J, Weinberg A, van Leeuwen K, Flanigan L. A multivariable risk factor analysis of the portoenterostomy (Kasai) procedure for biliary atresia: twenty-five years of experience from two centers. Ann Surg 1997;226:348-53.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  

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Paromita Roy
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DOI: 10.4103/0377-4929.59194

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    Tables

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