Indication for redo hepatic portoenterostomy for insufficient bile drainage in biliary atresia: reevaluation in the era of liver transplantation: T. Hasegawa, T. Kimura, T. Sasaki, et al. Pediatr Surg Int 19:256–259, (June), 2003

Abstract

In biliary atresia, hepatic portoenterostomy (HPE) is accepted as the surgical treatment of first choice even in the era of liver transplantation (LTx). If bile secretion is insufficient after HPE, a redo procedure may be useless and lead to surgical complications during later LTx. The authors evaluated and discussed their indications for redo HPE retrospectively. Of 91 patients patients, 31 were revised during a 24-year period and 25 of them evaluated. The age at initial operation ranged from 25 to 119 days. Connective tissue was resected between the bilateral first branches of the portal vein. Twenty-three of twenty-five patients received an external enterostomy. Antibiotic prophylaxis, anticholestatic therapy with different agents, and lavage of hepatic hilum was done to prevent cholangitis and cessation of the bile flow. If bile secretion failed, the redo procedure included complete removal of the jejunal loop, excision of granulation and scar tissue, and re-anastomosis to the Y loop. Five of twenty-five children achieved disappearance of jaundice, 8 died, 10 underwent LTx, and 2 were on the waiting list. There was no significant difference between the children with a successful redo operation and the unsuccessful cases concerning age at initial HPE, redo HPE or interval between them, serum levels of most laboratory values, and histopathologic examination of liver biopsy at initial HPE. Significance was found for a temporary disappearance of jaundice after initial HPE, for a lower serum hyaluronic acid level, and for a continued lack of cirrhosis during the redo procedure. The aim of a redo procedure is the resection of granulation and scar tissue at the liver hilum caused by ascending cholangitis. But this procedure often fails to reestablish sufficient bile flow. In this study, a positive result was reached only if jaundice had disappeared after initial HPE showing that sufficient flow may be possible. Constant jaundice, histopathologic signs of cirrhosis, and an elevated serum level of hyaluronic acid are sensitive markers of an unsuccessful redo operation. In this cases, LTx should be the second choice.