A New Era of Laparoscopic Revision of Kasai Portoenterostomy for the Treatment of Biliary Atresia

Laparoscopic versus open portoenterostomy for treatment of biliary atresia: a meta-analysis

OBJECTIVE

Our goal was to compare laparoscopic portoenterostomy versus open portoenterostomy for the treatment of biliary atresia.

MATERIALS AND METHODS

Using the databases EMBASE, PubMed, and Cochrane, we carried out a thorough literature search up to 2022. Studies comparing laparoscopic and open surgery for the treatment of biliary atresia were included.

RESULTS

Twenty-three studies comparing laparoscopic portoenterostomy (LPE) (n = 689) and open portoenterostomy (OPE) (n = 818) were considered appropriate for meta-analysis. Age at surgery time was lower in the LPE group than OPE group (I² = 84%), (WMD - 4.70, 95% CI - 9.14 to - 0.26; P = 0.04). Significantly decreased blood loss (I² = 94%), (WMD - 17.85, 95% CI - 23.67 to - 12.02; P < 0.00001) and time to feed were found in the laparoscopic group (I² = 97%), (WMD - 2.88, 95% CI - 4.71 to - 1.04; P = 0.002). Significantly decreased operative time was found in the open group (I² = 85%), (WMD 32.52, 95% CI 15.65-49.39; P = 0.0002). Weight, transfusion rate, overall complication rate, cholangitis, time to drain removal, length of stay, jaundice clearance, and two-year transplant-free survival were not significantly different across the groups.

CONCLUSIONS

Laparoscopic portoenterostomy provides advantages regarding operative bleeding and the time to begin feeding. No differences in remain characteristics. Based on the data presented to us by this meta-analysis, LPE is not superior to OPE in terms of overall results.

Laparoscopic revision of Kasai portoenterostomy after initial laparoscopic portoenterostomy in patients with biliary atresia: a limited but positive effect on native liver survival

PURPOSE

It is important for patients with biliary atresia (BA) to retain the native liver after Kasai portoenterostomy (PE). Laparoscopic PE (Lap-PE) is standard, whereas laparoscopic revision of PE (Lap-revision) is performed as needed. We report the medium-term outcomes of Lap-revision.

METHODS

We retrospectively reviewed the demographics and outcomes of 63 patients who underwent Lap-PE between 2013 and 2021. Indications for revision included recurrent jaundice, repeat cholangitis, and persistent jaundice with temporary biliary excretion following the initial PE. We compared liver transplantation (LT) data of patients who underwent Lap-revision with those of patients who did not.

RESULTS

Lap-revision was performed in 20 patients. Of those 17 (excluding the two who were jaundice-free before the age of 1, and the one who underwent open conversion for bleeding), 11 (65%) were jaundice-free 1 year after Lap-revision. The surgical parameters of LT did not differ between patients who underwent Lap-revision and those who did not.

CONCLUSION

Lap-revision for patients with BA had a limited but positive effect on native liver survival and did not adversely affect subsequent LT. Therefore, Lap-revision could be second-line standard therapy in patients with BA who have demonstrated biliary drainage at least once after initial PE.

Learning Curve of Laparoscopic Kasai Portoenterostomy in a Tertiary Hospital with Low Caseload of Biliary Atresia

Background: Laparoscopic Kasai portoenterostomy (KPE) is generally considered to be technically challenging. A scarcity of studies has particularly focused on the learning curve (LC) of this technique. The present study was aimed to objectively evaluate the LC of laparoscopic KPE in a medical center with relatively low caseload of biliary atresia (BA). Materials and Methods: Thirty-five consecutive pediatric patients treated with laparoscopic KPE for BA by the same surgeon team between 2012 and 2018 were retrospectively enrolled in the present study. Operative time (OT) was selected as the surrogate marker. Cumulative sum (CUSUM) analysis was applied to describe the LC of laparoscopic KPE. Results: The turning point of the CUSUM curve occurred at the 21st case, which divided the curve into two distinct phases, phase 1 (the initial 21 cases) and phase 2 (the remaining 14 cases). The curve was best modeled as a second-order polynomial with equation CUSUM in minutes equal to -0.9161 × case number² + 32.097 × case number + 7.8217 (R² = 0.981). Age at surgery, sex, weight, and preoperative liver function were well balanced between the two phases (each P > .05). The OT was significantly decreased in phase 2 compared with phase 1 (P < .0001). Furthermore, the rates of early jaundice clearance and 2-year native liver survival were higher in phase 2. The rate of postoperative cholangitis was comparable between the two phases. Conclusions: Two characteristic phases of the LC for laparoscopic KPE were identified using CUSUM analysis and represented the initial learning period and the subsequent period of technical mastery, respectively. Surgeons are possible to acquire competency of laparoscopic KPE in relatively low-case centers.

Laparoscopic vs open portoenterostomy in biliary atresia: a systematic review and meta-analysis

Hepatoportoenterostomy remains the cornerstone of treatment for biliary atresia. Current employed techniques include laparoscopy and open surgery. This study aims to determine if either method provides an advantage. Following PRISMA guidelines, a systematic review was conducted. Nineteen studies were included. Mean operative time 34.98 (95% CI 20.10, 49.85; p ≤ 0.00001) was longer in laparoscopic while bleeding volumes - 16.63 (95% CI - 23.39, - 9.86; p ≤ 0.00001) as well as the time to normal diet - 2.42 (95% CI - 4.51, - 0.32; p = 0.02) were lower in the laparoscopic group. No differences were observed in mean length of stay - 0.83. Similar complication, transfusions, postoperative cholangitis 0.97, and transplant free survival rates 1.00 (0.63, 1.60; p = 0.99) were seen between groups. Laparoscopic portoenterostomy provides advantages on operative time and bleeding as well as to normal diet when compared to open procedures. Both procedures showed no differences in length of stay, complications, cholangitis, and importantly, native liver survival. Level of evidence: III.

Medium-term outcomes after laparoscopic revision of laparoscopic Kasai portoenterostomy in patients with biliary atresia

OBJECTIVE

To determine whether revision laparoscopic Kasai portoenterostomy (RLKPE) is a viable treatment option for patients with biliary atresia (BA) who had undergone initially successful laparoscopic Kasai portoenterostomy (ILKPE).

METHODS

The medical records of 312 patients with nonsyndromic BA who had undergone ILKPE between May 2009 and May 2017 were retrospectively reviewed. The patients were divided into three groups according to their outcomes after ILKPE: group A: 25 patients who had undergone RLKPE; group B: 203 patients who had undergone ILKPE and required no further surgical intervention; group C: 84 patients with failed ILKPE who had either died or required liver transplantation for survival. The 3-year and 5-year survival with native liver (SNL) rates were compared between groups A and B and between groups A and C. Among the 25 patients in group A, the perioperative data of RLKPE were compared with those of ILKPE.

RESULTS

Of the 312 patients who had undergone ILKPE, 228 reached the normal bilirubin concentration range within 6 months postoperatively. Among them, 25 patients with a sudden cessation of bile flow had undergone RLKPE. Adequate biliary drainage, as evidenced by normalized conjugated bilirubin levels, was achieved in 80% of patients who had undergone RLKPE. The perioperative variables, including the operative time, blood loss, rate of conversion to open surgery and complications of RLKPE, were not significantly different between RLKPE and ILKPE. The 3-year and 5-year SNL rates in patients after RLKPE were 64.0% and 52.0%, respectively, which were not significantly different from the corresponding rates of 86.2% and 73.9%, respectively, in patients after unrevised ILKPE (P > 0.05).

CONCLUSION

Our data demonstrated that RPLKE is a viable and effective treatment option in patients with sudden cessation of bile drainage after ILKPE. RPLKE can delay the need for liver transplantation, yielding encouraging medium-term patient outcomes.

Experience of treating biliary atresia with laparoscopic-modified Kasai and laparoscopic conventional Kasai: a cohort study

BACKGROUND

Complete mobilization of the left and right portal veins had been seldom utilized in the laparoscopic Kasai procedures. The purpose of this study was to evaluate the feasibility and efficacy of the key technique in detail.

METHODS

A total of 82 patients with type III biliary atresia were operated by laparoscopic Kasai at our hospital during January 2012 to October 2019. Forty-two patients underwent modified laparoscopic Kasai (group 1), and 40 patients of control group underwent general laparoscopic Kasai (group 2). The clinical data between the two groups were compared.

RESULTS

The early clearance of jaundice was significantly higher for group 1 (88.1%) versus group 2 (68.4%) (P < 0.05), the incidence of repeated cholangitis was significantly lower in group 1 (11.9%) versus group 2 (31.6%) (P < 0.05). The native liver survival rate was (85.7%) in group1 versus in group 2 (65.8%) (P < 0.05). In addition, there were no significant differences regarding the resumption oral intake and the post-operative hospital stay in the two groups.

CONCLUSION

The key technique of the complete mobilization of the left and right portal veins would improve the outcome of biliary atresia treated by laparoscopic Kasai.

Association of common variation in ADD3 and GPC1 with biliary atresia susceptibility

Biliary atresia (BA) is an idiopathic neonatal cholestatic disease. Recent genome-wide association study (GWAS) revealed that common variation of ADD3, GPC1, ARF6, and EFEMP1 gene was associated with BA susceptibility. We aimed to evaluate the association of these genes with BA in Chinese population. Twenty single nucleotide polymorphisms (SNPs) in these four genes were genotyped in 340 BA patients and 1,665 controls. Three SNPs in ADD3 were significantly associated with BA, and rs17095355 was the top SNP (P_Allele = 3.23×10^-6). Meta-analysis of published data and current data indicated that rs17095355 was associated with BA susceptibility in Asians and Caucasians. Three associated SNPs were expression quantitative trait loci (eQTL) for ADD3. Two GPC1 SNPs in high linkage disequilibrium (LD) showed nominal association with BA susceptibility (P_Allele = 0.03 for rs6707262 and P_Allele = 0.04 for rs6750380), and were eQTL of GPC1. Haplotype harboring these two SNPs almost reached the study-wide significance (P = 0.0035). No association for ARF6 and EFEMP1 was found with BA risk in the current population. Our study validated associations of ADD3 and GPC1 SNPs with BA risk in Chinese population and provided evidence of epistatic contributions of genetic factors to BA susceptibility.

Hepatic Subcapsular Flow as a Significant Diagnostic Marker for Biliary Atresia: A Meta-Analysis

Aim

Increasing evidence indicates that hepatic subcapsular flow (HSF) can serve as a noninvasive ultrasonographic marker for the early diagnosis of biliary atresia (BA). However, results regarding its diagnostic accuracy are inconsistent and inconclusive. We conducted this meta-analysis with an aim to systematically evaluate the diagnostic value of HSF in predicting BA.

Methods

A comprehensive literature search of four databases was conducted to identify the eligible studies. All analyses were performed using STATA 12.0.

Results

Nine studies from eight articles containing 368 patients and 469 controls were included in our meta-analysis. Briefly, the values for pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were 0.95 (95% CI 0.88-0.98), 0.92 (95% CI 0.85-0.96), 11.6 (95% CI 6.3-21.5), 0.06 (95% CI 0.02-0.14), 201 (95% CI 59-689), and 0.98 (95% CI 0.96-0.99), respectively. Additionally, metaregression along with subgroup analysis based on various covariates revealed the potential sources of heterogeneity and the detailed diagnostic value in each subgroup.

Conclusion

Our meta-analysis showed that HSF assay could provide high accuracy in predicting BA patients and non-BA individuals. However, further studies with better design and larger sample size are required to support the results of the present study.

Efficacy of and prognosis after steroid pulse therapy in patients with poor reduction of jaundice after laparoscopic Kasai portoenterostomy

PURPOSE

High-dose postoperative steroid therapy after Kasai portoenterostomy is reported to improve jaundice clearance and a strong anti-inflammatory activity might prevent fibrous tissue formation which is often observed at the porta hepatis in revision surgery. We started steroid pulse therapy for the patients with cessation of decrease in jaundice and aimed to evaluate the efficacy in this study.

METHODS

The demographics and outcomes of patients who underwent laparoscopic Kasai portoenterostomy and received steroid pulse therapy within 2 months postoperatively between September 2014 and December 2018 were retrospectively reviewed; the therapy was determined successful when the serum total bilirubin level decreased to or below two-thirds of the pre-therapy level after 2 weeks. Patient data in the successful group were compared with those in the unsuccessful group.

RESULTS

Steroid pulse therapy was successful in seven of 16 patients (43.8%). The percentage of patients whose serum total bilirubin level decreased to normal was significantly higher in the successful group at 3 months (85.7% vs. 11.1%, P = 0.0028) and after all (100% vs. 33.3%, P = 0.011).

CONCLUSIONS

Steroid pulse therapy was effective for some patients. Unsuccessful cases may have little chances of jaundice clearance; revision Kasai portoenterostomy would be a good option.

Laparoscopic Kasai portoenterostomy is advantageous over open Kasai portoenterostomy in subsequent liver transplantation

BACKGROUND

Native liver survival after laparoscopic Kasai portoenterostomy (Lap-PE) for biliary atresia (BA) is controversial. We examined whether a jaundice-free native liver survival rate is comparable between conventional Kasai portoenterostomy (Open-PE) and Lap-PE. Then, the impact of the two types of PE on subsequent living-donor liver transplantation (LTx) was addressed in this study.

METHODS

The jaundice-free rate in 1- and 2-year-old patients who underwent Open-PE and Lap-PE from January 2006 to December 2017 was investigated. Additionally, perioperative data (duration from the start of surgery to the completion of hepatectomy and others) of patients aged 2 years or younger who underwent LTx after either Open-PE or Lap-PE from 2006 to 2017 were evaluated.

RESULTS

Thirty-one (67%) out of 46 Open-PE patients and 23 (77%) out of 30 Lap-PE patients showed native liver survival with jaundice-free status at 1 year of age (p = 0.384); 29 (63%) out of 46 Open-PE patients and 19 (70%) out of 27 Lap-PE patients showed native liver survival with jaundice-free status at 2 years of age (p = 0.524); there were no significant differences. Additionally, there were 37 LTx cases after PE within 2 years of birth, including 29 Open-PE and 8 Lap-PE cases. The patients in the Lap-PE group had fewer adhesions and significantly shorter durations of surgery up to the completion of the recipient's hepatectomy and durations of post-LTx hospital stay compared to the Open-PE group. There were no differences in blood loss or duration of stay in intensive care unit between the Lap-PE and Open-PE groups.

CONCLUSIONS

Jaundice-free native liver survival rate has been comparable between Open-PE and Lap-PE. Lap-PE resulted in fewer adhesions, contributing to better outcomes of subsequent LTx compared to Open-PE.

Comparison of laparoscopic portoenterostomy and open portoenterostomy for the treatment of biliary atresia

BACKGROUND

Although open portoenterostomy (OPE) is considered the standard treatment for biliary atresia (BA), laparoscopic portoenterostomy (LPE) is conducted and reported by many investigators. Data on the safety and efficacy of LPE remain controversial. The aim of this meta-analysis is to compare the safety and efficacy of LPE and OPE for the treatment of BA.

METHODS

Three electronic databases were searched: PubMed, Embase, and the Cochrane Library. The eligible studies were limited to those published in English. The following keywords were used: "biliary atresia," "laparoscopic portoenterostomy," "Kasai portoenterostomy," "open portoenterostomy," "surgery," and "treatment."

RESULTS

Nine studies, including 434 patients, were analyzed. The operative time of LPE was significantly longer than that of OPE (MD = 40.55 min, 95% CI 4.83-76.27 min, P = 0.03). There was no significant difference between the two groups in terms of the time of hospital stay, the volume of intraoperative blood loss, or the rates of cholangitis, early clearance of jaundice or two-year survival with the native liver. The subgroup analyses revealed that the rate of early clearance of jaundice in the LPE group was significantly higher than that in the OPE group in studies published after 2016 (95% CI 1.04-1.75; P = 0.02).

CONCLUSIONS

The present meta-analysis provides evidence that LPE is a feasible option for patients with BA. LPE should be revaluated by further studies and longer follow-up.

Retrospective investigation about anesthetic management of biliary atresia in children: laparoscopic versus conventional Kasai portoenterostomy

PURPOSE

Biliary atresia can be fatal if surgery is not performed early. Laparoscopic Kasai portoenterostomy was recently introduced in our hospital. Despite laparoscopic surgery generally provides advantages, there are few studies of laparoscopic surgery performed in infants. We retrospectively compared anesthesia management of patients undergoing laparoscopic Kasai portoenterostomy and conventional Kasai portoenterostomy and investigated anesthetic complications of laparoscopic Kasai portoenterostomy.

METHODS

Fifty-three biliary atresia patients who underwent surgery from April 2010 to September 2017 were assessed: 28 who underwent laparoscopy (L group) and 25 who underwent laparotomy (O group) were included. We compared body temperature, cases of hypothermia, the lowest mean blood pressure, bleeding volume, infusion volume and urine volume (ml/kg and ml/kg/h), age, weight, operation time, and the number of patients postoperatively admitted to the intensive care unit.

RESULTS

In the L group, volume of bleeding was significantly smaller, and the lowest body temperature was significantly lower in the L group than in the O group (22 ± 35.1 mL vs 70 ± 34.5 mL, respectively, P < 0.01; 35.6 ± 0.8 °C vs 36.5 ± 0.4 °C, respectively, P < 0.01). And severe hypothermia was significantly more in the L group (7 cases vs 0 cases P = 0.01). There was an inverse correlation between the lowest body temperature and anesthesia time (r = - 0.464, P < 0.01). Multiple linear regression analysis revealed that anesthesia time was a significant predictor of hypothermia.

CONCLUSION

Our study revealed that laparoscopic surgery in infants reduced bleeding, but induced hypothermia and upper airway edema may be caused by relatively excessive infusion. At laparoscopic Kasai surgery, anesthesiologist is recommended to prevent hypothermia and need to pay attention to amount of infusion.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Nagoya University ( 2017-0290 ) and registered with the UMIN Clinical Trial Registry ( UMIN000033158 ).

Clinical Assessment of Differential Diagnostic Methods in Infants with Cholestasis due to Biliary Atresia or Non-Biliary Atresia

The different methods in differentiating biliary atresia (BA) from non-BA-related cholestasis were evaluated in order to provide a practical basis for a rapid, early and accurate differential diagnosis of the diseases. 396 infants with cholestatic jaundice were studied prospectively during the period of May 2007 to June 2011. The liver function in all subjects was tested. All cases underwent abdominal ultrasonography and duodenal fluid examination. Most cases were subjected to hepatobiliary scintigraphy, magnetic resonance cholangiopancreatography (MRCP) and a percutaneous liver biopsy. The diagnosis of BA was finally made by cholangiography or histopathologic examination. The accuracy, sensitivity, specificity and predictive values of these various methods were compared. 178 patients (108 males and 70 females with a mean age of 58±30 days) were diagnosed as having BA. 218 patients (136 males and 82 females with a mean age of 61 ±24 days) were diagnosed as having non-BA etiologies of cholestasis jaundice during the follow-up period in which jaundice faded after treatment with medical therapy. For diagnosis of BA, clinical evaluation, hepatomegaly, stool color, serum gamma-glutamyltranspeptidase (GGT), duodenal juice color, bile acid in duodenal juice, ultrasonography (gallbladder), ultrasonography (griangular cord or strip-apparent hyperechoic foci), hepatobiliary scintigraphy, MRCP, liver biopsy had an accuracy of 76.0%, 51.8%, 84.3%, 70.0%, 92.4%, 98.0%, 90.4%, 67.2%, 85.3%, 83.2% and 96.6%, a sensitivity of 83.1%, 87.6%, 96.1%, 73.7%, 90.4%, 100%, 92.7%, 27.5%, 100%, 89.0% and 97.4%, a specificity of 70.2%, 77.5%, 74.8%, 67.0%, 94.0%, 96.3%, 88.5%, 99.5%, 73.3%, 75.4% and 94.3%, a positive predictive value of 69.0%, 72.6%, 75.7%, 64.6%, 92.5%, 95.7%, 86.8%, 98.0%, 75.4%, 82.6% and 98.0%, and a negative predictive value of 83.6%, 8.5%, 95.9%, 75.7%, 92.3%, 100%, 84.2%, 93.7%, 100%, 84.0% and 92.6%, respectively. It was concluded that all the differential diagnosis methods are useful. The test for duodenal drainage and elements is fast and accurate. It is helpful in the differential diagnosis of BA and non-BA etiologies of cholestasis. It shows good practical value clinically.

Minimally Invasive Hepatobiliary Surgery

Comparative studies and large-scale case series that confirm the advantages of laparoscopy in children with hepatobiliary diseases are scarce, and the use of laparoscopy remains a matter of debate. This article reviews the current literature on the role of laparoscopic and robotic surgery in pediatric patients with choledochal cyst, biliary atresia, gallbladder diseases, and hepatobiliary malignancies. Studies were identified through a search of the MEDLINE database. Laparoscopy may be beneficial for resection of choledochal cyst and cholecystectomy. However, more data are required before recommendations on the use of minimally invasive techniques for other hepatobiliary conditions can be published.

Laparoscopic portoenterostomy for biliary atresia: single-center experience and review of literatures

AIM

The aim of this report was to present the laparoscopic portoenterostomy (LapPE) procedure developed by the Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine (JLapPE). We also attempted to obtain an understanding of the current status of laparoscopic portoenterostomy in the world as reported in the English literature to compare with our experience.

METHODS

There were 22 BA patients who had JLapPE between 2009 and 2016. BA classification was type III (n = 19) and type II (n = 3). There was 1 case of syndromic BA and 1 case was positive for cytomegalovirus. A systematic search in PubMed of all BA patients treated by LapPE in the English literature was conducted. Jaundice clearance (JC) and survival with the native liver (SNL) were compared.

RESULTS

Mean age at JLapPE was 67.1 days (range 29-119). Mean postoperative follow-up was 4.6 years (1.3-8.3). Mean operative time was 514 min (240-662) and mean blood loss was 13.4 g (3-21). Postoperative JC (Total bilirubin ≤ 1.5 mg/dL) was 77.3% (17/22) at 3 months and 90.9% (20/22) at 6 months. SNL at 6 months of age was 90.9% (20/22); at 1 year of age was 77.3% (17/22), at 2 years of age was 73.7% (14/19); and at 3 years of age was 81.3% (13/16).

CONCLUSIONS

Despite recent reports that outcome of LapPE for BA may be unfavorable compared with the conventional open portoenterostomy, our results would suggest that JLapPE can be performed successfully, because it is performed exactingly according to a standard protocol. JLapPE will continue to be our procedure of choice for treating BA.

A Novel Laparoscopic Surgery Model with a Device to Expand the Abdominal Working Space in Rats: The Influence of Pneumoperitoneum and Skin Incision Length on Postoperative Inflammatory Cytokines

PURPOSE

Experimental models of laparoscopic surgery generally use large animals owing to a sufficient abdominal working space. We developed a novel laparoscopic surgery model in rats. We performed intestinal anastomosis to demonstrate the feasibility and reliability of this model.

MATERIALS AND METHODS

We designed a device for rats that expanded the abdominal working space and allowed us to manipulate the intraperitoneal organs by hand under direct vision with pneumoperitoneum. We performed small bowel resection and intestinal anastomosis in rats using this model. To elucidate the effects of pneumoperitoneum and skin incision length, rats were randomly divided into four groups with differing surgical techniques: small incision group, large incision group, small incision + pneumoperitoneum group, and large incision + pneumoperitoneum group. Intraoperative abdominal pressure and postoperative cytokines were measured.

RESULTS

One experimenter completed small bowel resection and hand-sewn anastomosis under direct vision without any difficulties or assistance. Carbon dioxide pneumoperitoneum was maintained at 8-10 mmHg during surgery in both pneumoperitoneum groups. Necropsies revealed no evidence of anastomotic leakage at 24 h after surgery. The interleukin-6 and C-reactive protein concentrations were significantly greater in large incision group than in small incision group, but were not significantly different between small incision + pneumoperitoneum group and small incision group. These cytokines concentrations were the greatest in large incision + pneumoperitoneum group.

CONCLUSIONS

Our laparoscopic surgery model in rats is a simple and reliable experimental model. The length of skin incision might be a more influential determinant of surgical invasiveness than pneumoperitoneum.

Review of redo-Kasai portoenterostomy for biliary atresia in the transition to the liver transplantation era

Portoenterostomy (PE) is the standard therapy for biliary atresia (BA). PE offers the chance of survival to children with BA. PE was the ultimate therapeutic modality for BA before liver transplantation (LT) was available. Failure of biliary drainage with PE was almost invariably fatal in children with BA. In such cases, redo-PE was performed to salvage patients following PE failure. PE remains the standard first treatment for BA despite the availability of LT. Further, redo-PE is also performed in a limited number of cases despite the development of LT as an alternative means of PE. However, there is concern that redo-PE increases morbidity at the time of subsequent LT. Laparoscopic redo-PE has recently been described. Laparoscopic redo-PE is expected to reduce complications of LT by preventing abdominal adhesion associated with repetitive surgery. In the present article, the future utility of redo-PE and the history of its changing roles are reviewed.

Learning Curve Analysis of Laparoscopic Kasai Portoenterostomy

OBJECTIVE

To compare the surgical outcomes of Kasai Portoenterostomy (PE) and investigate the learning curve of laparoscopic Kasai Portoenterostomy (Lap-PE).

MATERIALS AND METHODS

Retrospective chart review of 80 cases of biliary atresia (type III) undergoing Lap-PE at Shenzhen Children's Hospital from January 2011 to June 2015, all of which were performed by the same surgical team. According to the operative sequences, the cases were equally divided into four phases (Phase I, II, III, and IV), which contain 20 cases in each. The age, weight, and gender, the volume of intraoperative blood loss, the postoperative clearance rate of bilirubin, the incidence of postoperative cholangitis, and the first and second year native liver survival rate were all reviewed.

RESULTS

There was no significant difference among the four phases regarding age, weight at operation, and gender (P > .05). Statistical difference was observed with respect to operative time, the volume of intraoperative blood loss, the postoperative jaundice clearance, and the first and second year native liver survival rate among Phase III and IV compared to Phase I and II (P < .05), but showed no significant difference in neither the first two phases nor the latter two phases (P > .05). The incidence of postoperative cholangitis showed no significant variation among the four phases.

CONCLUSION

A surgeon is able to become more experienced after performing approximately 40 laparoscopic Kasai Portoenterostomys.

Complications in pediatric hepatobiliary surgery

This review highlights the complications and their risk factors encountered in pediatric hepatobiliary surgery, specifically in the context of pediatric hepatic resection, excision of choledochal cyst, and the Kasai hepatoportoenterostomy procedure for biliary atresia as well as other procedures potentially affecting the biliary tree. With the understanding that these are relatively rare procedures, case reports and small case series are included in addition to larger series when available. The review focuses on publications in English over the past 15 years. Complications included both surgery-specific pathology, such as biliary stricture after excision of choledochal cyst, and disease-specific entities, such as malnutrition in biliary atresia. This review may be useful when considering a particular procedure or in the discussion thereof with a patient and family. Additionally, it illuminates the need for additional work with larger patient databases to refine and expand our knowledge of these complications and precipitating risk factors.

Long-term follow-up for anicteric survival with native liver after redo Kasai: a first report

PURPOSE

We present a first report of the long-term follow-up of biliary atresia (BA) patients who became anicteric with the native liver (ANL; total bilirubin <1.5mg/dL) after redo-Kasai.

METHODS

Forty-six redo-Kasai cases (1984-2015) were the subjects for this study. ANL ratios were determined using the Kaplan-Meier estimate.

RESULTS

BA type was I (n=3), II (n=1), and III (n=42). Mean ages (initial/redo) at Kasai were 60.3/231.9days, respectively. Jaundice persisted after the initial Kasai in 24/46 cases while 22 had recurrence of jaundice after initially becoming anicteric. After redo, 5/24 of the persistent jaundice cases and 14/22 of the initially anicteric cases became anicteric (p<.05). Of these 19, 7 (one type I, six type III) are currently ANL while the remaining 12 had LTx or died. Morbidity/Complications documented in the 7 post-redo ANL cases after a mean follow-up of 16.7years (range: 10.0-31.1) included 4 episodes of cholangitis, 3 episodes of portal hypertension, 4 episodes of esophageal varices, 3 episodes of splenomegaly, one splenectomy, and 4 episodes of thrombocytopenia.

CONCLUSIONS

Ours is the first long-term follow-up study of redo-Kasai cases. We found that the ANL ratio after redo-Kasai was low at 7/46 (15.2%) and that ANL were prone to multiple morbidity.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.