Re-evaluation of Laparoscopic Hepatic Subcapsular Spider-Like Telangiectasis Sign: A Highly Accurate Method to Diagnose Biliary Atresia in Infants

Comparison between robotic-assisted Kasai portoenterostomy and open Kasai portoenterostomy in patients with biliary atresia

BACKGROUND

Robotic-assisted Kasai portoenterostomy (RAKPE) is regarded as a treatment option for patients with biliary atresia (BA). We aimed to compare the clinical outcomes of RAKPE to the open Kasai portoenterostomy (OKPE).

METHODS

A retrospective review was conducted on a total of 74 type III BA patients who underwent RAKPE (RA group, n = 36) or OKPE (OP group, n = 38) from January 2018 to December 2022. The study analyzed demographic characteristics, intraoperative findings, and postoperative outcomes.

RESULTS

The operative time in the RA group was significantly longer than that in the OP group (218.61 ± 31.70 min vs 178.50 ± 27.90 min, P < 0.05). The estimated blood loss in RA group was significantly lower than that in the OP group (8.65 ± 2.30 mL vs 17.55 ± 3.60 mL, P < 0.05). The recovery time of bowel sounds was significantly shorter in RA group than in the OP group (0.96 ± 0.12 days vs 2.84 ± 0.37 days, P < 0.05). All patients had bile-stained stools within 1-3 days after surgery. The clearance rate of jaundice at 3 and 6 months were significantly higher in RA group than in OP group (69.44% vs 60.53%, 75.00% vs 68.42%, P < 0.05). The rate of cholangitis in RA group was similar to that in OP group (50.00% vs 52.63%, P > 0.05). The native liver survival rate during the follow-up period was comparable between two groups (66.67% vs 63.16%, P > 0.05).

CONCLUSION

Robotic-assisted Kasai surgery offers advantages in short-term outcomes and the clearance of jaundice in patients with type III BA.

Comparison of surgical results and technical performance between robotic and laparoscopic approaches for Kasai portoenterostomy in biliary atresia: a multicenter retrospective study

BACKGROUND

Many variables, including age at surgery, disease type, surgical approaches and perioperative management factors have been demonstrated to influence efficacy in BA infants, however, the effect of surgical performance remains unclear. The objective of this retrospective study was to compare the postoperative efficacy and surgical performance of robotic (RKPE) versus laparoscopic Kasai portoenterostomy (LKPE) for BA.

METHODS

Between October 2018 and June 2023, 158 type III BA patients undergoing minimally invasive surgery (RKPE = 66, LKPE = 92) were included in this multicenter retrospective study. All procedures were performed by surgical teams experienced in Kasai portoenterostomy techniques. Technical performance was quantified and analyzed using the Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments (GERT). Postoperative outcomes and surgical performance were compared.

RESULTS

Compared with LKPE group, RKPE group had shorter fibrous cone transection time (48.92 ± 6.98 vs. 61.45 ± 8.98 min; p < 0.001), shorter hepaticojejunostomy time (47.55 ± 6.57 vs. 59.93 ± 7.88 min; p < 0.001) and less estimated intraoperative bleeding [7.00 (5.00-10.00) vs. 13.50 (10.50-16.50) mL; p < 0.001]. More importantly, RKPE group showed a superior OSATS score [30.50 (29.00-31.00) vs. 28.00 (28.00-29.00); p < 0.001], number of errors (46.62 ± 6.32 vs. 56.40 ± 6.82 times/case; p < 0.001), and number of events [9.40 (8.40-10.40) vs. 16.00 (14.00-17.80) times/case; p < 0.001]. On postoperative days 1 and 3, RKPE group had lower C-reactive protein levels (19.87 ± 12.28 vs. 27.05 ± 11.16 mg/L, p < 0.001; 14.88 ± 7.11 vs. 20.73 ± 9.09 mg/L, p < 0.001). During follow-up, RKPE group had higher jaundice clearance rate at 3 (68.18% vs. 51.09%; p = 0.032) and 6 months (78.79% vs. 64.13%; p = 0.047) postoperatively. However, the cholangitis rate within 1 year postoperatively (46.97% vs. 50.00%; p = 0.707), as well as one-year (75.76% vs. 72.83%; p = 0.678) and two-year survival with native liver rates (68.42% vs. 66.67%; p = 0.857), were comparable between two groups.

CONCLUSIONS

RKPE provided superior technical skill performance and a higher jaundice clearance rate than LKPE, indicating that it may be a better minimally invasive option for BA. In addition, the survival with native liver rate showed no significant difference between the two cohorts, which needs to be confirmed by further study.

Inhibition of Notch3/Hey1 ameliorates peribiliary hypoxia by preventing hypertrophic hepatic arteriopathy in biliary atresia progression

Emerging evidence indicates the presence of vascular abnormalities and ischemia in biliary atresia (BA), although specific mechanisms remain undefined. This study examined both human and experimental BA. Structural and hemodynamic features of hepatic arteries were investigated by Doppler ultrasound, indocyanine green angiography, microscopic histology, and invasive arterial pressure measurement. Opal multiplex immunohistochemistry, western blot, and RT-PCR were applied to assess Notch3 expression and the phenotype of hepatic arterial smooth muscle cells (HASMCs). We established animal models of Notch3 inhibition, overexpression, and knockout to evaluate the differences in overall survival, hepatic artery morphology, peribiliary hypoxia, and HASMC phenotype. Hypertrophic hepatic arteriopathy was evidenced by an increased wall-to-lumen ratio and clinically manifested as hepatic arterial hypertension, decreased hepatic artery perfusion, and formation of hepatic subcapsular vascular plexuses (HSVPs). We observed a correlation between overactivation of Notch3 and phenotypic disruption of HASMCs with the exacerbation of peribiliary hypoxia. Notch3 signaling mediated the phenotype alteration of HASMCs, resulting in arterial wall thickening and impaired oxygen supply in the portal microenvironment. Inhibition of Notch3/Hey1 ameliorates portal hypoxia by restoring the balance of contractile/synthetic HASMCs, thereby preventing hypertrophic arteriopathy in BA.

Intraoperative hepatic subcapsular spider-like telangiectasia sign for the definitive diagnosis of biliary atresia

OBJECTIVE

To evaluate the accuracy of intraoperative hepatic subcapsular spider-like telangiectasia (HSST) sign for differentiating biliary atresia (BA) from other causes of hepatic cholestasis.

METHODS

The data of 69 patients with jaundice treated from January 2019 to December 2021 were retrospectively analyzed. Based on intraoperative cholangiography (IOC), the patients were divided into two groups: the BA group (n = 49) and the non-BA group (n = 20). The biochemistry tests, liver ultrasound, liver stiffness value and HSST sign of the two groups were compared.

RESULTS

The incidence of abnormal gallbladder, elevated γ-glutamyl transpeptidase (γ-GGT) > 182.0U/L and abnormal liver stiffness (> 6.4 kPa) in BA group were significantly higher than those in non-BA group (P < 0.001). The HSST sign was present in all BA patients and not found in non-BA group. The area under receiver operating curve of direct bilirubin(DBIL), γ-GGT, abnormal gallbladder, liver stiffness value and HSST sign were 0.53, 0.84, 0.78, 0.96, and 1.00, respectively. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value(NPV) of HSST sign in the diagnosis of BA were all 100%.

CONCLUSION

Presence of HSST sign on diagnostic laparoscopy is highly suggestive of BA.It can be used in the differential diagnosis of BA and non-BA.

LEVEL OF EVIDENCE

Level III.

Robotic-assisted Kasai portoenterostomy for biliary atresia

BACKGROUND

Robotic-assisted Kasai portoenterostomy (RAKPE) has been utilized to treat biliary atresia (BA). However, RAKPE is not widely performed and its efficacy remains unknown. We summarized the experience of RAKPE for BA and determined its efficacy.

MATERIALS AND METHODS

We retrospectively analyzed 25 consecutive infants with non-syndromic type III BA who received RAKPE in our center from January 2020 to July 2021. RAKPE is a three-arm setup and four-trocar operation. Bipolar coagulation was used to dissect the small blood vessels at the hepatic portal. The fibrous cone was shallowly transected with bending electric scissors, followed by gelatin sponge compression to staunch the hemorrhage. Finally, a wide anastomosis was accurately constructed. Demographics and outcomes were recorded.

RESULTS

The mean operative time was 211.64 ± 18.93 min. No conversion to laparotomy or intraoperative complications occurred. The mean estimated blood loss was 7.64 ± 2.43 mL. Enteral feeding was resumed after 3.44 ± 1.23 days. All patients achieved bile excretion postoperatively, and dark green bile-stained stools were passed 1.50 days (range 1.00-3.00 days) after surgery. The average postoperative length of hospital stay was 10.32 ± 2.59 days. The jaundice clearance (JC) rate was 76.00% within 6 months after surgery and the incidence of cholangitis was 48.00% within 1 year following surgery. The survival with native liver (SNL) rate was 80.00% at 1 year and 66.67% at 2 years.

CONCLUSION

RAKPE can be regarded as a treatment option for patients with BA due to the good outcomes reported. However, long-term studies comparing open or laparoscopic approaches are needed.

Protocols of Investigation of Neonatal Cholestasis-A Critical Appraisal

Neonatal cholestasis (NC) starts during the first three months of life and comprises extrahepatic and intrahepatic groups of diseases, some of which have high morbimortality rates if not timely identified and treated. Prolonged jaundice, clay-colored or acholic stools, and choluria in an infant indicate the urgent need to investigate the presence of NC, and thenceforth the differential diagnosis of extra- and intrahepatic causes of NC. The differential diagnosis of NC is a laborious process demanding the accurate exclusion of a wide range of diseases, through the skillful use and interpretation of several diagnostic tests. A wise integration of clinical-laboratory, histopathological, molecular, and genetic evaluations is imperative, employing extensive knowledge about each evaluated disease as well as the pitfalls of each diagnostic test. Here, we review the difficulties involved in correctly diagnosing the cause of cholestasis in an affected infant.

Intraoperative indocyanine green fluorescence cholangiography can rule out biliary atresia: A preliminary report

BACKGROUND

The prognosis of BA is known to be poor if definitive surgery is performed too late. Therefore, excluding BA as a diagnosis at an early stage is crucial. Conventional cholangiography requiring cannulation through the gallbladder may be unnecessarily invasive for patients, especially when ruling out BA. Therefore, a less invasive alternative such as indocyanine green (ICG) cholangiography, which does not require cannulation, should be established. In this study, we focused on excluding BA and confirmed the usefulness of intravenous ICG fluorescence cholangiography. To the best of our knowledge, this is the first preliminary study to report the use of intravenous ICG cholangiography for BA exclusion.

METHODS

The study participants were patients who underwent liver biopsy and intraoperative cholangiography after they were suspected to have BA, between 2013 and 2022. ICG fluorescence cholangiography was performed on all patients who provided informed consent.

RESULTS

During the study period, 88 patients underwent a laparoscopic liver biopsy and cholangiography. Among them, 65 (74%) were diagnosed with BA and underwent a subsequent laparoscopic Kasai portoenterostomy. BA was ruled out intraoperatively in 23 patients. Of the 23 patients in whom BA was ruled out, 14 underwent ICG cholangiography, 11 had gallbladder (GB) fluorescence, and 9 had both GB and common bile duct (CBD) fluorescence. Conventional cholangiography was very difficult in 2 of 23 cases: in 1 case, cannulation of the atrophic gallbladder was impossible, and cholecystectomy was indicated after multiple attempts; in 1 case, upstream cholangiography was not possible. In both cases, ICG fluorescence cholangiography successfully imaged the CBD and the GB.

CONCLUSIONS

In conclusion, intravenous ICG fluorescence cholangiography might be a useful and less invasive diagnostic procedure that can rule out BA in infants.