Experience of treating biliary atresia with three types of portoenterostomy at a single institution: extended, modified Kasai, and laparoscopic modified Kasai.

Abstract

Generally, open portoenterostomy (PE) involves a wide extended anastomosis and all sutures are deep [extended PE (EP)]. In contrast, the anastomosis in Kasai's PE (KP), our modified open Kasai PE (MK), and our laparoscopic modified Kasai PE (lapMK) involve shallow suturing, especially at the 2 and 10 o'clock positions where the right and left bile ducts would be normally. We compared outcomes of 36 consecutive biliary atresia (BA) patients treated by three types of PE at a single institution during the period 2005-2014; EP (n = 13), MK (n = 11), and lapMK (n = 12). We compared age at PE, time taken to become jaundice-free (total bilirubin ≤1.2 mg/dL; JF time), proportion of JF subjects [JF ratio (JFR)], steroid dosage, incidence of cholangitis, postoperative liver function and CRP, presence of hypersplenism, requirement for liver transplantation (LTx), and JF survival with the native liver (JF+NL) as indicators of outcome. Patient demographics, steroid dosage, JF time, incidence of cholangitis, presence of hypersplenism, operating time, blood loss and postoperative biochemistry were similar for all groups. However, JFR was significantly higher for lapMK (100 %) versus EP (46.2 %) (p < 0.05), but not for MK (81.8%) versus EP. Kaplan-Meier analysis showed survival with NL was significantly higher for lapMK (10/12: 83.3%: JF in 9; not JF in 1) and MK (9/11: 81.8 %: JF in all) versus EP (3/13: 23.1%: JF in all) (p < 0.05, respectively), but not for lapMK versus MK. JF+NL in both lapMK (9/12: 75.0%) and MK (9/11: 81.8%) were significantly higher compared with EP (3/13: 23.1%) (p < 0.05, respectively). Intraperitoneal adhesions were less pronounced at LTx in lapMK compared with MK or EP. This study would suggest that depth of suturing during PE would appear to influence post-PE outcome. LapMK should be reconsidered as a valid treatment option for BA.