Inguinal Hernias Associated with Biliary Atresia

Abstract

Introduction Infants with biliary atresia (BA) develop a degree of hepatic fibrosis as a consequence of their cholangiopathy. Some of them present clinically evident ascites that might predispose to inguinal hernias. We aimed to investigate whether infants with BA have a higher incidence of inguinal hernias.

Methods Single-center retrospective review of all BA infants diagnosed between January 2006 and December 2010. Infants with a clinical diagnosis of inguinal hernia were identified and compared with those without. Data were expressed as median (range) and compared with nonparametric statistical tests. p ≤ 0.05 was regarded as significant.

Results A total of 123 infants underwent Kasai portoenterostomy (KP) during the period. Of these, 10 (8.1%) infants (7 boys) developed inguinal hernias (bilateral n = 4, right n = 5, left n = 1); 9 were repaired (at KP [n = 3] and post-KP [n = 6] at 15 [7 to 30] days) using nonabsorbable sutures, and 1 died before repair. There was no difference in median age at KP (66 vs. 58 days, p = 0.31); cytomegalovirus (IgM positive) status (p = 1.0); use of postoperative corticosteroids (p = 0.49); or ultimate need for liver transplant (p = 1.0). However, aspartate aminotransferase-to-platelet ratio (surrogate marker of liver fibrosis) was higher in hernia infants (2.0 vs. 1.0; p = 0.02). Recurrence has not been identified at a follow-up of 27 months (4 to 55).

Conclusions This is the first report to suggest that BA infants have a high incidence of inguinal hernias, which seems related to degree of liver fibrosis at presentation and presumably degree of ascites and increased intra-abdominal pressure.

Keywords

biliary atresia - inguinal hernia - Kasai - ascites

• References

• 1 Hartley JL, Davenport M, Kelly DA. Biliary atresia. Lancet 2009; 374 (9702) 1704-1713
• 2 Lykavieris P, Chardot C, Sokhn M, Gauthier F, Valayer J, Bernard O. Outcome in adulthood of biliary atresia: a study of 63 patients who survived for over 20 years with their native liver. Hepatology 2005; 41 (2) 366-371
• 3 Coran AG, Eraklis AJ. Inguinal hernia in the Hurler-Hunter syndrome. Surgery 1967; 61 (2) 302-304
• 4 Holsclaw DS, Shwachman H. Increased incidence of inguinal hernia, hydrocele, and undescended testicle in males with cystic fibrosis. Pediatrics 1971; 48 (3) 442-445
• 5 Grosfeld JL, Cooney DR. Inguinal hernia after ventriculoperitoneal shunt for hydrocephalus. J Pediatr Surg 1974; 9 (3) 311-315
• 6 McEntyre RL, Raffensperger JG. Surgical complications of Ehlers-Danlos syndrome in children. J Pediatr Surg 1977; 12 (4) 531-535
• 7 Mehregan AH, Lee SC, Nabai H. Cutis laxa (generalized elastolysis). A report of four cases with autopsy findings. J Cutan Pathol 1978; 5 (3) 116-126
• 8 Udén A, Lindhagen T. Inguinal hernia in patients with congenital dislocation of the hip. A sign of general connective tissue disorder. Acta Orthop Scand 1988; 59 (6) 667-668
• 9 Matthews DE, West KW, Rescorla FJ , et al. Peritoneal dialysis in the first 60 days of life. J Pediatr Surg 1990; 25 (1) 110-115 , discussion 116
• 10 Stringer MD, Duffy PG, Ransley PG. Inguinal hernias associated with bladder exstrophy. Br J Urol 1994; 73 (3) 308-309
• 11 Powell TG, Hallows JA, Cooke RW, Pharoah PO. Why do so many small infants develop an inguinal hernia?. Arch Dis Child 1986; 61 (10) 991-995
• 12 Davenport M, Savage M, Mowat AP, Howard ER. Biliary atresia splenic malformation syndrome: an etiologic and prognostic subgroup. Surgery 1993; 113 (6) 662-668
• 13 Caponcelli E, Knisely AS, Davenport M. Cystic biliary atresia: an etiologic and prognostic subgroup. J Pediatr Surg 2008; 43 (9) 1619-1624
• 14 Zani A, Quaglia A, Hadzic N , et al. Cytomegalovirus-associated biliary atresia—an aetiological and prognostic subgroup. Oral presentation at the LVII Congress of the British Association of Paediatric Surgeons (BAPS); July 21–24, 2010; Aberdeen, Scotland
• 15 Kim SY, Seok JY, Han SJ, Koh H. Assessment of liver fibrosis and cirrhosis by aspartate aminotransferase-to-platelet ratio index in children with biliary atresia. J Pediatr Gastroenterol Nutr 2010; 51 (2) 198-202
• 16 Cox JA. Inguinal hernia of childhood. Surg Clin North Am 1985; 65 (5) 1331-1342
• 17 Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J Surg 1989; 13 (5) 506-515
• 18 Knox G. The incidence of inguinal hernia in Newcastle children. Arch Dis Child 1959; 34: 482-486
• 19 Boocock GR, Todd PJ. Inguinal hernias are common in preterm infants. Arch Dis Child 1985; 60 (7) 669-670
• 20 Ron O, Eaton S, Bartington S , et al. Population based study of hernia and hydrocele repair in children. Oral presentation at the LIV Congress of the British Association of Paediatric Surgeons (BAPS); July 17–20, 2007; Edinburgh, Scotland
• 21 Harper RG, Garcia A, Sia C. Inguinal hernia: a common problem of premature infants weighing 1,000 grams or less at birth. Pediatrics 1975; 56 (1) 112-115
• 22 Rescorla FJ, Grosfeld JL. Inguinal hernia repair in the perinatal period and early infancy: clinical considerations. J Pediatr Surg 1984; 19 (6) 832-837
• 23 Baird R, Gholoum S, Laberge JM, Puligandla P. Prematurity, not age at operation or incarceration, impacts complication rates of inguinal hernia repair. J Pediatr Surg 2011; 46 (5) 908-911
• 24 Shaheen AA, Myers RP. Diagnostic accuracy of the aspartate aminotransferase-to-platelet ratio index for the prediction of hepatitis C-related fibrosis: a systematic review. Hepatology 2007; 46 (3) 912-921
• 25 Park JK, Lee SH, Yoon WJ , et al. Evaluation of hernia repair operation in Child-Turcotte-Pugh class C cirrhosis and refractory ascites. J Gastroenterol Hepatol 2007; 22 (3) 377-382
• 26 Oh HK, Kim H, Ryoo S, Choe EK, Park KJ. Inguinal hernia repair in patients with cirrhosis is not associated with increased risk of complications and recurrence. World J Surg 2011; 35 (6) 1229-1233 , discussion 1234
• 27 Celik A, Ergün O, Arda MS, Yurtseven T, Erşahin Y, Balik E. The incidence of inguinal complications after ventriculoperitoneal shunt for hydrocephalus. Childs Nerv Syst 2005; 21 (1) 44-47