C. Buonpane1,2, G. Ares1, G. Englert3, I. Helenowski3, F. Hebal1, C. Hunter1,3 1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Geisinger Medical Center,General Surgery,Danville, PA, USA 3Northwestern University,Chicago, IL, USA
Introduction:
Cholestasis is a common and serious complication of total parenteral nutrition (TPN) in neonates, however the pathogenesis is poorly understood. Approximately 50% of infants requiring long-term TPN develop hepatic dysfunction. The diagnosis is made when there is development of cholestasis and an absence of other causes such as biliary obstruction, viral hepatitis, drug toxicity, and other metabolic disorders. Liver biopsies may be requested to assess the severity of cholestasis and fibrosis; however, the impact on treatment strategies and patient outcomes has not been defined. We hypothesize that liver biopsies in the evaluation of TPN cholestasis do not lead to changes in management or improved patient outcomes.
Methods:
This study is a single institution retrospective review of infants diagnosed with TPN cholestasis from January 2008 to January 2016. Primary outcomes were length of stay (LOS), 30-day readmission, complication after biopsy, change in management after biopsy (Omegavan and Ursodiol) and mortality. Univariate analysis was performed using Fisher’s exact test.
Results:
Ninety-five patients with TPN cholestasis were identified, of which 27 (28%) underwent a liver biopsy. Nineteen (73%) patients had concurrent abdominal surgery for other indications at the time of liver biopsy. Sixty percent of patients with TPN cholestasis had short bowel syndrome and 78% of patients that had a liver biopsy had short bowel syndrome (P=0.036). There was a significant difference in race (P=0.047) between neonates that had liver biopsies versus those that did not. Forty eight percent of patients who underwent liver biopsy were African American.
Liver biopsy was associated with a significant change in medical management, including the initiation of Omegavan or Ursodiol. Eleven (41%) patients were started on medical therapy as a result of liver biopsy, thirteen (48%) patients were on medical therapy prior to biopsy and three patients (11%) were unchanged.
Patient total bilirubin levels normalized within 6 months of stopping TPN in 92% of cases, with or without liver biopsy. There was no difference in LOS or mortality in patients with liver biopsy versus without; however, patients with liver biopsy had a higher rate of 30-day re-admission (40% vs 19%, P=0.04). Five (19%) patients had complications after liver biopsy including bleeding requiring transfusion, need for additional procedures and apnea after anesthesia.
Conclusion:
Liver biopsy in patients with TPN cholestasis was associated with an increase in utilization of medical therapy but did not result in improved patient outcomes.