| ObjectiveBiliary atresia (BA) is a common reason for infantile obstructive jaundice. In China, the incidence of BA is 1/8000-1/15000. Nowadays the primary therapy is Kasai portoenterostomy, and its livability has increased from 30% up to 60-70%. However, the prognosis of BA is still poor after the Kasai procedure. It has been reported that two third of the children with BA will develop into biliary cirrhosis and portal hypertension.With no Kasai operation, the BA will lead to liver cirrhosis in a short time, and the expected life is only 11 months. After the treatment of Kasai operation, about 60-82% bile can be drained effectively. However, the 20-year survival rate with a native liver after the Kasai operation is only 23%. More than half of the patients require liver transplantation eventually. During the follow-up of BA postoperatively, not only the biochemical markers, such as serum bilirubin, liver function, but also the ultrasonography of abdomen should be examined. With these surveillance, doctors could find the complications as soon as possible, which contribute materially to management and therapeutic decisions.Since 1980s, most studies reported that Doppler ultrasonography is helpful in the diagnosis of hepertension and liver cirrhosis, whereas the objects are mostly adults. The hepatic hemodynamics of the liver cirrhosis in infants is rarely reported.This study aimed to approve the value of hepatic hemodynamics in the diagnosis of hepatic fibrosis of the infant, and to explore the valuable parameters of the Doppler ultrasound of the hepatic vessels in the infant with biliary atresia.Materials and Methods Twenty-two (16 boys,6 girls) infants with diagnosis of biliary atreia, having Kasai's operation between October 2008 and August 2009, were recruited in the study. All the infants after operation were examined with ultrasonography and hepatobiliary function (ALT, AST, DB,TB). We undertake a control test without known hepatic, cardiac, or pulmonary disease. All patients were fasted 8-12 hours and examined lying on back calmly. Each parameter was measured at least 3 times and was averaged for each patient. The parameters of the hepatic vein included hepatic vein diameter (HVD), the maximum velocity of hepatic vein (HVVmax), the minimum velocity of hepatic vein (HVVmin). The hepatic venous flow patterns were classified into three groups:Hvo (triphasic, reversed flow in at least), Hvl (biphasic, no reversed flow and with or without decreased phasic oscillation), Hv2 (monophasic, flat and with or without fluttering). The portal vein's parameters included portal vein diameter (PVD), the maximum velocity of portal vein (PVVmax), the time average velocity of portal vein (PVVtam). The hepatic artery's parameters included hepatic artery diameter (HAD), the maximum velocity of hepatic artery (HAVmax), the time average velocity of hepatic artery (HAVtam), the resistance index of hepatic artery (HARI). DI of hepatic vein was calculated by the minimum velocity/maximum velocity of downward HV flow. A/P is calculated by the HAVmax/PVVmax. There were three hepatic fibrosis grades in infants with biliary atresia, which were low (S1-S2), moderate (S3), high grades (S4). All the biochemical markers of hepatobiliary function (ALT, AST, DB, TB) were prognosticated. The Pearson correlation was used to analyse the relationship between the hepatobiliary function and the hemodynamic parameters.Statistical analysis was performed with software SPSS 16.0 and Stata 7.0.Results1) The preoperative hepatic hemodynamics of the biliary atresia:a) Comparing between the BA group and control group:Hepatic vein:the HVD was (2.37±0.56)mm in BA cases, (2.58±0.53) mm in control with no significant difference (P>0.05). The differences between the low (S1-S2), moderate (S3), high (S4) grade groups weren't significant (P>0.05). The HVDI of the BA group was significantly higher than that of the control. The HVDI in the high-grade fibrosis cases was significantly higher than that of the low-grade fibrosis cases. The difference of the hepatic vein waveform between the BA group and the control was not significant (P>0.05).Portal vein:the PVD was (3.93±0.76)mm in BA cases, (3.79±0.66) mm in control, the difference that wasn't significant(P>0.05). The PVVmax in the BA cases was (23.6±8.0) cm/s, the parameter in the control was (23.1±5.5) cm/s, their difference was not significant (P>0.05). The PVD and PVVmax between the low-, moderate-, and high-grade fibrosis groups weren't significant (P>0.05).Hepatic artery:the HAD in BA cases [(2.01±0.32)mm] was significantly larger (P<0.05) than that in control [(1.24±0.38)mm]. HAVmax in the BA group [108.3±49.7] cm/s] was significantly faster (P<0.05) than that in the control group[(47.5±18.4)cm/s]. The HAVtam in the BA cases was (51.6±24.6)cm/s and (22.9±8.3) cm/s in the control, the difference was significant (P<0.05); the RI between the BA and control groups was not significantly different (P>0.05); the RI of the high-grade fibrosis group was significantly higher (P<0.05) than low-grade fibrosis groups. The A/P of BA group(6.76±5.17)was significantly higher (P<0.05) than that of the control (2.26±0.95). b) ROC curve analysis of the parameters of HA:ROC curve analysis showed the values of HAD, HAVmax, HAVtam to predict the liver fibrosis. ROC curve analysis using a HAD value of 1.75mm showed a sensitivity of 86.4%, and a specificity of 90.5% for the presence of liver cirrhosis; the sensitivity and specificity was 86.4% and 95.2% when HAVmax was 59.8cm/s, the sensitivity and specificity was 72.7% and 95.2% when HAVtam was 35.2cm/s.2) The postoperative surveillance of hepatic hemodynamics and hepatobiliaryfunction of the biliary atresia:a) Comparing between the BA group and control group:Hepatic vein:The HVD of the follow-up 1-3 months,4-6 months and 7-12 months groups with BA were (2.13±0.13)mm, (2.01±0.56)mm, (2.24±0.68)mm, which was larger than that in the corresponding control group [(2.58±0.53)mm, (2.87 +0.57)mm, (2.98±0.85) mm]. The difference was significant (P<0.05). The HVD between each follow-up survey group wasn't significantly different (P>0.05). The HVDI of the follow-up 1-3 months,4-6 months and 7-12 months groups with BA was 0.86±0.13,0.84±0.15,0.87±0.19. There were significant difference (P<0.05) between the BA groups and corresponding control groups (0.57±0.29, 0.52±0.30,0.40±0.19). The difference between each BA follow-up survey group wasn't significant (P>0.05). There was more monophasic flow pattern in the BA follow-up groups than that in the corresponding control groups (P<0.05). Further more, there was more monophasic flow pattern in the BA follow-up groups than in the preoperative groups.Portal vein:The PVD of the follow-up 1-3 months,4-6 months and 7-12 months groups with BA was (4.00±0.46)mm, (4.46±0.68)mm, (4.76±0.89)mm, while the PVD of the corresponding control groups was (3.93±0.76) mm, (4.00±0.65) mm, (4.74±0.89) mm. Only the PVD in the follow-up 4-6 months group was significantly larger (P<0.05) than that in the control. The PVD of follow-up 7-12 months group was significantly larger than that of 1-3 months group. The PVVmax of the follow-up 1-3 months,4-6 months and 7-12 months groups with BAwere (19.7±7.5)cm/s, (18.4±4.4) cm/s, (21.8±9.0)cm/s, while it was (24.4±10.4)cm/s, (23.8±5.2) cm/s, (22.5±6.1) cm/s in the corresponding control groups. The PVVmax of follow-up 1-3 months and 4-6 months in BA cases was significantly slower than that of the corresponding control (P<0.05). The difference of PVVmax between each follow-up group was not significantly (P>0.05).Hepatic artery:The HAD of the follow-up 1-3 months,4-6 months and 7-12 months groups with BA were (2.21±0.40)mm, (2.24±0.26)mm,(2.51±0.69)mm, which was significantly larger than that of the corresponding control group ((1.27±0.30)mm, (1.28±0.40)mm, (1.41±0.54)). The HAVmax of the follow-up 1-3 months,4-6 months and 7-12 months with BA were (108.3±49.7) cm/s, (47.1±21.0)cm/s, (61.5±29.3)cm/s, the HAVmax of the follow-up 4-6 months and 7-12 months was significantly larger than the follow-up 1-3 months(P<0.05). The HARI of the follow-up 1-3 months,4-6 months and 7-12 months groups with BA were 0.82±0.09,0.85±0.05,0.87±0.19, the HARI of the corresponding control groups were 0.77±0.07,0.79±0.04,0.81±0.05. The HARI of the follow-up groups were significantly bigger than that of the control groups (P<0.05), there was not significantly difference between each follow-up group (P>0.05). The A/P of the follow-up 1-3 months,4-6 months and 7-12 months groups with BA were 7.29±3.67,5.63±4.82,4.70±3.11, which were1.96±0.88,2.02±0.85, 2.93±1.75 in the corresponding control. the A/P of the follow-up 1-3 months and 4-6 months were significantly larger(P<0.05) than the corresponding control groups. There wasn't significant difference between each follow-up group (P>0.05).b) The hepatobiliary function and the hepatic hemodynamic parameters during the follow-up survey:The follow-up survey of hepatobiliary function:There was about 81.8%(18/22) infants with BA had hepatobiliary function in the follow-up 1-3 months group,81.8%(18/22) in the 4-6 months group and 54.5%(12/22) in the 7-12 months group. There were 14 patients (77.8%,14/18) having low-grade liver damage in the follow-up 1-3 months group,3 patients (16.7%,3/18) having moderate liver damage, only one infant (5.5%,1/18) having severe liver damage; In the follow-up 1-3 months group,2 infants (9.1%,2/22) had normal TB,2 infants (9.1%,2/22) were with recessive jaundice, most of the BA babies were with low-grade jaundice (18/22,81.8%). In the follow-up 4-6 months group, the number of the babies with low-grade liver damage was 17 (94.5%,17/18), only one baby (5.5%,1/18) had moderate liver damage, there was no baby with severe liver damage; There were 18.1% (4/22) infants with the normal TB,27.3% (6/22) with recessive jaundice,54.6% (12/22) with low-grade jaundice. In the 7-12 months group,50%(6/12) patients had low-grade liver damage; 16.7% (2/12) had moderate liver damage,33.3% (4/12) had severe liver damage; The TB was normal in about 25%(3/12) patients with BA, in another part,16.7% patients had recessive jaundice,58.3%(7/12) had low-grade jaundice.The differences of HVDI, HARI between the low-grade and moderate-to-severe group were not significant (P>0.05), In the three follow-up groups, all the hepatic hemodynamic parameters had no relationship with AST and ALT (P>0.05).ConclusionsThe value of the hepatic vasculature and hemodynamics in infants with BA during the preoperative and follow-up survey period is significant on clinic:1) Before the Kasai's operation, the hepatic artery of enlarged diameter and high maximum velocity is valuable of the liver fibrosis, the RI is high in the BA cases with severe liver fibrosis. During the follow-up survey, the diameter of hepatic artery is larger, the maximum velocity is faster and RI is higher than normal, after six months follow-up survey, the maximum velocity of the hepatic artery may slower than before.2) the waveform and diameter of hepatic vein isn't valuable to the diagnosis of liver fibrosis in the infants less than 3 months; DI of hepatic vein is valuable of liver fibrosis during the preoperative and follow-up survey.3) the parameters of the portal vein have no meaning of the preoperative and follow-up survey in the infants with BA. |
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