Surgical and Medical Aspects of the Initial Treatment of Biliary Atresia: Position Paper

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.

Amyloid precursor protein as a fibrosis marker in infants with biliary atresia

BACKGROUND

Biliary atresia (BA) is a rare condition of unknown origin in newborns with jaundice. In BA bile ducts are non-functional, causing neonatal cholestasis and following liver fibrosis and failure.

METHODS

This retrospective study included liver biopsies of 14 infants with BA aged [mean ± SD] 63 ± 23 days. Patients were grouped according to the clinical course (jaundice-free vs recurrent jaundice vs required liver transplantation or liver fibrosis (Ishak fibrosis score)) and followed for 1.61-5.64 years (mean 4.03). Transcriptome profiles were assessed using a panel of 768 fibrosis-specific genes, reanalyzed via qRT-PCR, and confirmed via immunostaining. Plasma from an additional 30 BA infants and 10 age-matched controls were used for amyloid precursor protein (APP) quantification by ELISA.

RESULTS

Different clinical outcome groups showed a homogeneous mRNA expression. Altered amyloid-metabolism-related gene expression was found between cases with Ishak fibrosis score greater than 4. Immunostaining confirmed a distinct presence of APP in the livers of all BA subjects. APP plasma levels were higher in BA than in age-matched controls and correlated with the histological fibrosis grade.

CONCLUSIONS

These results suggest that amyloidosis may contribute to BA and liver fibrosis, indicating that APP could serve as a potential liquid biomarker for these conditions.

IMPACT

Biliary atresia patients with higher fibrosis scores according to Ishak have higher hepatic expression of amyloid-related genes while amyloid precursor protein accumulates in the liver and increases in the circulation. After a recent study revealed beta-amyloid deposition as a mechanism potentially involved in biliary atresia, we were able to correlate amyloid-metabolism-related transcript levels as well as amyloid precursor protein tissue and plasma levels with the degree of hepatic fibrosis. These findings suggest that amyloid precursor protein is a fibrosis marker in infants with biliary atresia, reinforcing the role of amyloid metabolism in the pathogenesis of this serious disease.

Bile acid profiles in adult patients with biliary atresia who achieve native liver survival after portoenterostomy

Bile acids have received increasing attention as a marker of the long-term prognosis and a potential therapeutic target in patients with biliary atresia, which is a progressive disease of the hepatobiliary system. A detailed analysis of serum and urinary bile acid compositions was conducted to assess the characteristics of bile acid profiles and the correlation between bile acid profiles and liver fibrosis markers in adult patients with biliary atresia who achieved bilirubin normalization. Serum total bile acids and glucuronide-conjugated (glyco- and tauro-) cholic acids (GCA and TCA) and chenodeoxycholic acids (GCDCA and TCDCA) were significantly higher in patients with biliary atresia than in healthy controls, whereas unconjugated CA and CDCA showed no significant difference. There were no significant differences in CA to CDCA ratios and glycine-to-taurine-conjugated ratios. Urinary glycocholic acid 3-sulfate (GCA-3S) was significantly higher in patients with biliary atresia. Serum GCDCA showed a strong positive correlation with Mac-2 binding protein glycosylation isomer (M2BPGi). These results demonstrate that bile acid congestion persists into adulthood in patients with biliary atresia, even after cholestasis has completely improved after Kasai portoenterostomy. These fundamental data on bile acid profiles also suggest the potential value of investigating bile acid profiles in patients with biliary atresia.