Classification of biliary atresia in the laparoscopic era

Abstract

According to Kasai's classification of biliary atresia (BA), type III is diagnosed when micro bile ducts (MBD) cannot be identified macroscopically on the surface of the biliary remnant transected at the porta hepatis. However, during laparoscopic Kasai (lapKasai), magnification produced by a 30° 10mm scope at a focal length of 5cm is×38 and ×100 when zooming, enabling more MBD to be identified than with the naked eye rendering Kasai's original classification questionable in the laparoscopic era. Intraoperative video recordings of 36 consecutive lapKasai cases (2009-2015) were reviewed to confirm MBD visibility. 85 consecutive open Kasai cases examined macroscopically served as controls. MBD were not visible under regular laparoscopic magnification during lapKasai in 6/36 (lapMBD-; 16.7%) cases and visible in 30/36 (83.3%). However, in open cases, MBD could not be identified macroscopically in 77/85 (macroMBD-; 90.6%), a typical result reported internationally. For our lapKasai cases, jaundice clearance was lower in lapMBD-cases (4/6 = 66.7 % versus 26/30 = 86.7 %), which was not statistically significant (p = 0.26). Conversely, survival with the native liver was significantly lower in lapMBD-cases (4/6 = 66.7 % versus 23/30 = 76.7 %) (p < 0.05). BA classification may benefit from revision to include laparoscopic findings to categorize BA more comprehensively.