Congenital extrahepatic biliary atresia

A long-term follow-up of five patients with atresia of the common bile duct

BACKGROUND/PURPOSE

Description of the long-term follow-up of 5 patients operated on for atresia of the common bile duct.

METHODS

During a 25-year period (1960 to 1985) 45 infants underwent surgical exploration for biliary atresia (BA), of which, 5 (11.1%) were found to have atresia of the common bile duct. The children were followed up into adult life by pediatric surgeons, pediatricians, and later, adult hepatologists with the range of 19 to 36 years. Liver function tests, histology, complications, and somatic development (including sexual maturation and mental development) were obtained continuously.

RESULTS

Liver function test results were normal in all but 1 patient. Repeated ultrasound scan and postoperative liver biopsies were normal in 2 patients and moderately and mildly abnormal in 3 patients, respectively, suggesting hepatic fibrosis. HIDA hepatic scans in all but 1 patient showed prompt uptake by the liver with passage into the bowel within 30 minutes. Endoscopic retrograde cholangiography (ERCP; 1 patient) and duodenography (4 patients) showed, at most, mild reflux of contrast material into the extra- or intrahepatic bile ducts. One patient with cholecysto-duodenostomy had 3 episodes of clinically proven ascending cholangitis. All 5 patients had normal physical growth and mental development, they are all age-appropriate schooled, and they are working and living a normal life.

CONCLUSIONS

Long-term favorable outcome has been suggested to be more influenced by anatomic and biological features rather than the surgical correction. The hypothesis is supported that BA is not a static congenital malformation but a progressive inflammatory panductular obliterative disease of the bile ducts starting in the antenatal period, which might cease, either early at birth or any time in infancy. The destructive inflammatory process might involve only the distal part of the extrahepatic bile duct causing obstruction and leaving the proximal ducts patent.

The surgery of "correctable" biliary atresia

Seven of 114 (6%) patients treated in Denver for biliary atresia had a variant of the disease in which only microscopic bile ducts or ductules were identified at the porta hepatis, hepatic lesions were present, even in the neonatal example, and intrahepatic biliary hypoplasia was uniformly present. The excised bile duct cysts consisted of fibrosis or scar tissue and with little or no epithelial lining. Six patients had corrective surgery. The first patient was treated by choledochoenterostomy and became totally obstructed. Definitive operation in this patient and all subsequent patients consisted of excision of all extrahepatic duct structures and Roux-en-Y portoenterostomy. Two patients died, the one who did not have surgical correction and a second who had correction at age 35 weeks. The other five patients have been followed for 18 to 158 months and are anicteric but have some degree of residual liver damage. We conclude that so-called correctable biliary atresia occurs in less than 10% of cases, that because of coincident biliary hypoplasia, "cure" is not a possible outcome, and that the treatment of choice is complete surgical excision of the extrahepatic bile ducts and Roux-en-Y portoenterostomy.

Contemporary surgery of biliary atresia

The etiology of biliary atresia is not due to a congenital malformation but rather to a continuing process beginning in utero that affects not only the extrahepatic biliary ducts but also the intrahepatic parenchyma. Over the last decade, the outlook for patients who were previously felt to be uncorrectable has been significantly improved by Kasai's operation. Successful biliary reconstruction depends on early diagnosis and treatment (before three months of age). The essentials of hepatic portoenterostomy consist of excision of the entire extrahepatic duct structure with anastomosis of an intestinal conduit to the area of the transected duct at the liver hilus. After operation, many patients experience complications, including cholangitis, portal hypotension, and vitamin deficiencies. Despite these difficulties, growth and development continue on a relatively normal course, and long-term survival has been accomplished in many children. For those in whom biliary drainage is not achieved or with significant parenchymal damage, liver transplantation should be considered as part of ongoing care.