Laparoscopic Kasai Portoenterostomy Research Articles

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

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

A Comparison of Laparoscopic-Modified Kasai Versus Conventional Open Kasai for Biliary Atresia in Infants: A Single-Center Experience.

Background: The purpose of this study was to evaluate the efficacy of our modified laparoscopic Kasai portoenterostomy for type III biliary atresia (BA) in children. Methods: A total of 56 type III BA patients underwent laparoscopic-modified Kasai procedure from January 2015 to July 2021. Conventionally control group of 45 BA patients from January 2012 to January 2016 were operated by open Kasai. The clinical data between the two groups were retrospectively compared. Results: The mean operating time was 235.5 ± 20.5 minutes (range, 210-275 minutes) in Group I, whereas 180.5 ± 25.5 minutes (range, 155-210 minutes) in Group II. The oral intake resumption was faster in Group I than that in Group II (mean 3.5 days versus 4.5 days). The follow-up time was mean 18.5 months in Group I and 24 months in Group II. The clearance of jaundice (total bilirubin <20 μmol/L) was significant different in Group I (78.6%) (44/56) versus that of Group II (74.3%) (33/45). The native liver survival rate was 71.4% (40/56) in Group I and was 66.7% (30/45) in Group II at the follow-up time, respectively. Conclusion: The laparoscopic-modified Kasai would improve the outcome of BA patients.

Laparoscopic Kasai portoenterostomy can be a standard surgical procedure for treatment of biliary atresia.

BACKGROUNDBiliary atresia (BA) is a rare pediatric disease.AIMTo compare the outcomes of laparoscopic portoenterostomy (Lap-PE) with those of laparotomy (Open-PE) at a single institution. METHODSThe surgical outcomes of PE were retrospectively analyzed for patients with a non-correctable type of BA from 2003 to 2020.RESULTSThroughout the assessment period, 119 patients received PE for BA treatment, including 66 Open-PE and 53 Lap-PE cases. Although the operation duration was longer (medians: for Open-PE, 242 min; for Lap-PE, 341 min; P < 0.001), blood loss was considerably less (medians: for Open-PE, 52 mL; for Lap-PE, 24 mL; P < 0.001) in the Lap-PE group than in the Open-PE group. The postoperative recovery of the Lap-PE group was more favorable; specifically, both times to resume oral intake and drain removal were significantly shorter in the Lap-PE group. Complete resolution of jaundice was observed in 45 Open-PE cases and 42 Lap-PE cases, with no statistically significant difference (P = 0.176). Native liver survival rates were >80% for both groups for the first half year post surgery, followed by a gradual decrease with time; there were no statistically significant differences in the native liver survival rates for any durations assessed.CONCLUSIONLap-PE could be a standard therapy for BA.

Learning Curve of Laparoscopic Kasai Portoenterostomy in a Tertiary Hospital with Low Caseload of Biliary Atresia.

Background: Laparoscopic Kasai portoenterostomy (KPE) is generally considered to be technically challenging. A scarcity of studies has particularly focused on the learning curve (LC) of this technique. The present study was aimed to objectively evaluate the LC of laparoscopic KPE in a medical center with relatively low caseload of biliary atresia (BA). Materials and Methods: Thirty-five consecutive pediatric patients treated with laparoscopic KPE for BA by the same surgeon team between 2012 and 2018 were retrospectively enrolled in the present study. Operative time (OT) was selected as the surrogate marker. Cumulative sum (CUSUM) analysis was applied to describe the LC of laparoscopic KPE. Results: The turning point of the CUSUM curve occurred at the 21st case, which divided the curve into two distinct phases, phase 1 (the initial 21 cases) and phase 2 (the remaining 14 cases). The curve was best modeled as a second-order polynomial with equation CUSUM in minutes equal to -0.9161 × case number2 + 32.097 × case number + 7.8217 (R2 = 0.981). Age at surgery, sex, weight, and preoperative liver function were well balanced between the two phases (each P > .05). The OT was significantly decreased in phase 2 compared with phase 1 (P < .0001). Furthermore, the rates of early jaundice clearance and 2-year native liver survival were higher in phase 2. The rate of postoperative cholangitis was comparable between the two phases. Conclusions: Two characteristic phases of the LC for laparoscopic KPE were identified using CUSUM analysis and represented the initial learning period and the subsequent period of technical mastery, respectively. Surgeons are possible to acquire competency of laparoscopic KPE in relatively low-case centers.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies.

Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery. Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification. A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades. Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Multiple vertical slit incisions at redo laparoscopic Kasai portoenterostomy

Pediatrics InternationalVolume 64, Issue 1 e14743 Clinical Notes Multiple vertical slit incisions at redo laparoscopic Kasai portoenterostomy Go Miyano, Corresponding Author Go Miyano go@juntendo.ac.jp orcid.org/0000-0003-0076-3748 Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan Correspondence: Go Miyano, MD, Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan. Email: go@juntendo.ac.jpSearch for more papers by this authorJoel Cazares, Joel Cazares Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this authorTakafumi Mikami, Takafumi Mikami Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this authorGeoffrey J. Lane, Geoffrey J. Lane Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this authorAtsuyuki Yamataka, Atsuyuki Yamataka Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this author Go Miyano, Corresponding Author Go Miyano go@juntendo.ac.jp orcid.org/0000-0003-0076-3748 Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan Correspondence: Go Miyano, MD, Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan. Email: go@juntendo.ac.jpSearch for more papers by this authorJoel Cazares, Joel Cazares Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this authorTakafumi Mikami, Takafumi Mikami Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this authorGeoffrey J. Lane, Geoffrey J. Lane Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this authorAtsuyuki Yamataka, Atsuyuki Yamataka Department of Pediatric General & Urogenital Surgery, Juntendo University School of Medicine, Tokyo, JapanSearch for more papers by this author First published: 27 September 2021 https://doi.org/10.1111/ped.14743Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume64, Issue1January/December 2022e14743 RelatedInformation

Comparative study of open and laparoscopic Kasai portoenterostomy in children undergoing living donor liver transplantation for biliary atresia.

The effectiveness of laparoscopic Kasai portoenterostomy (Laparoscopic-KPE) for biliary atresia (BA) has been reported but remains controversial. We reviewed our own cases and cases described in previous studies of liver transplantation (LT) for BA after Laparoscopic-KPE to investigate the efficacy of Laparoscopic-KPE. Subjects were children of ≤ 2years old with LT for BA after KPE who underwent Laparoscopic-KPE (n = 10) or Open-KPE (n = 115) between 2009 and 2020. Propensity score matching was performed to reduce the effect of treatment selection bias. The clinical data regarding the preoperative characteristics and surgical results were compared. The rates of hypoplastic portal vein and retrograde portal vein flow were lower in the Laparoscopic-KPE group than in the Open-KPE group (0 vs. 40.0%, p = 0.02 and 0 vs. 35.0%, p = 0.04). There was no marked difference in the operation time or duration of hepatectomy. For portal vein reconstruction, a vein graft was not required in the Laparoscopic-KPE group (0 vs. 35.0%, p = 0.03). No patients in the Laparoscopic-KPE group developed portal vein complications or required re-laparotomy for bowel perforation or re-bleeding, in contrast to the Open-KPE group (0 vs. 15.0% and 0 vs. 10.0%, respectively). Laparoscopic-KPE may reduce postoperative complications that necessitate re-laparotomy in LT.

Laparoscopic Kasai portoenterostomy for cystic biliary atresia: midterm follow-up results of 35 patients.

To investigate the clinical characteristics of cystic biliary atresia (CBA) and evaluate the midterm follow-up outcomes after laparoscopic treatment. We analyzed and compared data retrospectively on CBA patients (group A) and nonsyndromic type III biliary atresia (BA) patients (group B), who underwent laparoscopic Kasai portoenterostomy (LKPE) during the same period. There were no significant differences in operative time, conversion rate, or the incidence of any postoperative complications between groups A and B (P > 0.05). The mean age at surgery (P < 0.01), rates of clearance of jaundice (CJ), cholangitis (P < 0.05), and 5-year survival with a native liver (SNL) were significantly lower in group A than in group B. Among the 35 patients with CBA, the CJ and 5-year SNL rates were significantly better in those with type I (n = 27) than in those with type IIId (n = 8) (P < 0.05). LKPE is a feasible and safe procedure for CBA. The 5-year SNL after LKPE was better in patients with CBA than in those with nonsyndromic type III BA. The 5-year SNL after LKPE for type I CBA was better than that for type IIId CBA.

Medium-term outcomes after laparoscopic revision of laparoscopic Kasai portoenterostomy in patients with biliary atresia

ObjectiveTo determine whether revision laparoscopic Kasai portoenterostomy (RLKPE) is a viable treatment option for patients with biliary atresia (BA) who had undergone initially successful laparoscopic Kasai portoenterostomy (ILKPE).MethodsThe medical records of 312 patients with nonsyndromic BA who had undergone ILKPE between May 2009 and May 2017 were retrospectively reviewed. The patients were divided into three groups according to their outcomes after ILKPE: group A: 25 patients who had undergone RLKPE; group B: 203 patients who had undergone ILKPE and required no further surgical intervention; group C: 84 patients with failed ILKPE who had either died or required liver transplantation for survival. The 3-year and 5-year survival with native liver (SNL) rates were compared between groups A and B and between groups A and C. Among the 25 patients in group A, the perioperative data of RLKPE were compared with those of ILKPE.ResultsOf the 312 patients who had undergone ILKPE, 228 reached the normal bilirubin concentration range within 6 months postoperatively. Among them, 25 patients with a sudden cessation of bile flow had undergone RLKPE. Adequate biliary drainage, as evidenced by normalized conjugated bilirubin levels, was achieved in 80% of patients who had undergone RLKPE. The perioperative variables, including the operative time, blood loss, rate of conversion to open surgery and complications of RLKPE, were not significantly different between RLKPE and ILKPE. The 3-year and 5-year SNL rates in patients after RLKPE were 64.0% and 52.0%, respectively, which were not significantly different from the corresponding rates of 86.2% and 73.9%, respectively, in patients after unrevised ILKPE (P > 0.05).ConclusionOur data demonstrated that RPLKE is a viable and effective treatment option in patients with sudden cessation of bile drainage after ILKPE. RPLKE can delay the need for liver transplantation, yielding encouraging medium-term patient outcomes.

Investigation into multi-centre diagnosis and treatment strategies of biliary atresia in mainland China

Biliary atresia (BA) is an obstructive hepatobiliary disease which manifests during infancy. Kasai portoenterostomy (KPE) is the preferred operation for BA, supplemented with glucocorticoids, antibiotics, and choleretic agents. A great deal of research has been carried out regarding diagnosis, operation, and adjuvant therapies of BA, but no consensus had been reached. To understand the variation in diagnosis and treatment strategies of BA across mainland China and to help achieve a unified treatment strategy in the future, this investigation was carried out. This investigation was conducted via electronic questionnaire. The centres were divided into three groups based on their annual caseload: low (0-20)-, mid (21-40)-, and high (≥ 41)-volume group. Differences in the clinical practice among three groups were analyzed by Chi-square test and considered statistically significant at P < 0.05. 41 Centres from 26 different administrative regions were involved. The average age at KPE was mainly 51-60days (39%, 16/41) and 61-70days (32%, 13/41). The annual caseload was 0-20 patients in 17 centres, 21-40 patients in 11 centres, and > 40 patients in 13 centres. Preoperative ultrasound and intraoperative cholangiography were performed in all centres. Low-volume centres had a high proportion of MRI (P = 0.005), while the high-volume group had a high proportion of LSM (P = 0.015). Open KPE without liver mobilisation is the most common surgical procedure (71%, 29/41). Open KPE without liver mobilisation was more commonly used in low-volume group (P = 0.044), and laparoscopic KPE was mainly used in high-volume group (P = 0.011). The spur anti-reflux intestinal valve was performed in more than half of the centres (51%, 21/41). The length of the Roux-en-Y loop was ≥ 30cm in the majority of centres (78%, 32/41). Glucocorticoids and antibiotics were used in most centres (90%, 37/41; 100%, 41/41) with marked variations in type, administration, dose, and duration. Oral ursodeoxycholic acid (UDCA) was used in 38 centres, in varying doses of 10-20mg/kg/day. The duration of oral UDCA was over a year in 19 centres. Mainland China has a large number of patients with biliary atresia. Diagnostic and surgical methods vary from centre to centre and are related to its caseload. In most centres, KPE is supplemented with glucocorticoids, antibiotics, and choleretic agents without a standard regimen.

The short-term outcome of modified laparoscopic Kasai portoenterostomy for biliary atresia.

Laparoscopic Kasai portoenterostomy (LKPE) has been shown to be a safe and feasible procedure in patients with biliary atresia (BA). The purpose of this study was to investigate the efficacy of modified LKPE (MLKPE) in the treatment of BA. Data of 58 BA patients undertaken MLPKE from July 2014 to December 2015 were retrospectively analyzed (group B), and compared with that of 43 BA patients received open Kasai portoenterostomy (OKPE) during the same period (group C). In addition, 195 BA patients who had undergone LKPE during May 2009 to June 2014 were also included (group A). All 296 patients enrolled in this study were non-syndromic type III BA. Compared with group A, group B had shorter operative time (ORT) (P < 0.01) and fewer intraoperative blood transfusion (IOBT) (P < 0.05). The conversion rate and cholangitis rate were also significantly lower in group B than that in group A (P < 0.05). The postoperative oral intake resumed (POOR), any postoperative complications (APOC), clearance of jaundice (CJ), 1-year and 3-year survival rate with native liver (SNL) were not significantly different between group A and group B (P > 0.05). The ORT, IOBT, POOR, APOC, CJ, 1-year and 3-year SNL in group B were much better than that of group C (P < 0.05). The MLKPE was associated with good perioperative with ORT, IOBT, POOR, and APOC. The short-term outcomes in MLKPE were no worse than that of OKPE and LKPE. MLKPE can be regarded as a treatment option for BA.

Laparoscopic Kasai portoenterostomy is advantageous over open Kasai portoenterostomy in subsequent liver transplantation.

Native liver survival after laparoscopic Kasai portoenterostomy (Lap-PE) for biliary atresia (BA) is controversial. We examined whether a jaundice-free native liver survival rate is comparable between conventional Kasai portoenterostomy (Open-PE) and Lap-PE. Then, the impact of the two types of PE on subsequent living-donor liver transplantation (LTx) was addressed in this study. The jaundice-free rate in 1- and 2-year-old patients who underwent Open-PE and Lap-PE from January 2006 to December 2017 was investigated. Additionally, perioperative data (duration from the start of surgery to the completion of hepatectomy and others) of patients aged 2years or younger who underwent LTx after either Open-PE or Lap-PE from 2006 to 2017 were evaluated. Thirty-one (67%) out of 46 Open-PE patients and 23 (77%) out of 30 Lap-PE patients showed native liver survival with jaundice-free status at 1year of age (p = 0.384); 29 (63%) out of 46 Open-PE patients and 19 (70%) out of 27 Lap-PE patients showed native liver survival with jaundice-free status at 2years of age (p = 0.524); there were no significant differences. Additionally, there were 37 LTx cases after PE within 2years of birth, including 29 Open-PE and 8 Lap-PE cases. The patients in the Lap-PE group had fewer adhesions and significantly shorter durations of surgery up to the completion of the recipient's hepatectomy and durations of post-LTx hospital stay compared to the Open-PE group. There were no differences in blood loss or duration of stay in intensive care unit between the Lap-PE and Open-PE groups. Jaundice-free native liver survival rate has been comparable between Open-PE and Lap-PE. Lap-PE resulted in fewer adhesions, contributing to better outcomes of subsequent LTx compared to Open-PE.

Efficacy of and prognosis after steroid pulse therapy in patients with poor reduction of jaundice after laparoscopic Kasai portoenterostomy.

High-dose postoperative steroid therapy after Kasai portoenterostomy is reported to improve jaundice clearance and a strong anti-inflammatory activity might prevent fibrous tissue formation which is often observed at the porta hepatis in revision surgery. We started steroid pulse therapy for the patients with cessation of decrease in jaundice and aimed to evaluate the efficacy in this study. The demographics and outcomes of patients who underwent laparoscopic Kasai portoenterostomy and received steroid pulse therapy within 2months postoperatively between September 2014 and December 2018 were retrospectively reviewed; the therapy was determined successful when the serum total bilirubin level decreased to or below two-thirds of the pre-therapy level after 2weeks. Patient data in the successful group were compared with those in the unsuccessful group. Steroid pulse therapy was successful in seven of 16 patients (43.8%). The percentage of patients whose serum total bilirubin level decreased to normal was significantly higher in the successful group at 3months (85.7% vs. 11.1%, P = 0.0028) and after all (100% vs. 33.3%, P = 0.011). Steroid pulse therapy was effective for some patients. Unsuccessful cases may have little chances of jaundice clearance; revision Kasai portoenterostomy would be a good option.

Thirty Years of Minimally Invasive Surgery in Children: Analysis of Meta-Analyses.

In the last three decades, minimally invasive surgery (MIS) has been widely used in pediatric surgery. Meta-analyses (MAs) showed that studies comparing minimally invasive with the corresponding open operations are available only for selected procedures. We evaluated all available MAs comparing MIS with the corresponding open procedure in pediatric surgery. A literature search was performed on all MAs listed on PubMed. All analyses published in English, comparing pediatric minimally invasive with the corresponding open procedures, were included. End points were advantages and disadvantages of MIS. Results of 43 manuscripts were included. MAs evaluating the minimally invasive with the corresponding open procedures were available for 11 visceral, 4 urologic, and 3 thoracoscopic types of procedures. Studies included 34 randomized controlled trials. In 77% of MAs, at least one advantage of MIS was identified. The most common advantages of MIS were a shorter hospital stay in 20, a shorter time to feeding in 11, and a lower complication rate in 7 MAs. In 53% of MAs, at least one disadvantage of MIS was found. The most common disadvantages were longer operation duration in 16, a higher recurrence rate of diaphragmatic hernia in 4, and gastroesophageal reflux in 2 MAs. A lower native liver survival rate after laparoscopic Kasai-portoenterostomy was reported in one MA. In the available MAs, the advantages of MIS seem to outnumber the disadvantages. However, for some types of procedures, MIS may have considerable disadvantages. More randomized controlled trials are required to confirm the advantage of MIS for most procedures.

Retrospective investigation about anesthetic management of biliary atresia in children: laparoscopic versus conventional Kasai portoenterostomy

PurposeBiliary atresia can be fatal if surgery is not performed early. Laparoscopic Kasai portoenterostomy was recently introduced in our hospital. Despite laparoscopic surgery generally provides advantages, there are few studies of laparoscopic surgery performed in infants.We retrospectively compared anesthesia management of patients undergoing laparoscopic Kasai portoenterostomy and conventional Kasai portoenterostomy and investigated anesthetic complications of laparoscopic Kasai portoenterostomy.MethodsFifty-three biliary atresia patients who underwent surgery from April 2010 to September 2017 were assessed: 28 who underwent laparoscopy (L group) and 25 who underwent laparotomy (O group) were included. We compared body temperature, cases of hypothermia, the lowest mean blood pressure, bleeding volume, infusion volume and urine volume (ml/kg and ml/kg/h), age, weight, operation time, and the number of patients postoperatively admitted to the intensive care unit.ResultsIn the L group, volume of bleeding was significantly smaller, and the lowest body temperature was significantly lower in the L group than in the O group (22 ± 35.1 mL vs 70 ± 34.5 mL, respectively, P < 0.01; 35.6 ± 0.8 °C vs 36.5 ± 0.4 °C, respectively, P < 0.01). And severe hypothermia was significantly more in the L group (7 cases vs 0 cases P = 0.01). There was an inverse correlation between the lowest body temperature and anesthesia time (r = − 0.464, P < 0.01). Multiple linear regression analysis revealed that anesthesia time was a significant predictor of hypothermia.ConclusionOur study revealed that laparoscopic surgery in infants reduced bleeding, but induced hypothermia and upper airway edema may be caused by relatively excessive infusion. At laparoscopic Kasai surgery, anesthesiologist is recommended to prevent hypothermia and need to pay attention to amount of infusion.Trial registrationThis study was approved by the Ethics Committee of Nagoya University (2017-0290) and registered with the UMIN Clinical Trial Registry (UMIN000033158).

Learning curve of laparoscopic Kasai portoenterostomy for biliary atresia: report of 100 cases

BackgroundLaparoscopic Kasai portoenterostomy (LKPE) is performed for biliary atresia (BA). As LKPE is a technically demanding operation, a learning curve should be defined to guide training. The aim of this study was to identify the learning curve of LKPE for BA.MethodsMetrics of perioperative safety and efficiency for 100 cases of LKPE were evaluated. Outcomes were followed to 67.2 ± 12.1 months. Cumulative sum (CUSUM) analysis was used to identify inflexion point corresponding to the learning curve. Outcome measures included operative time (ORT), rate of clearance of jaundice (CJ) and survival with native liver (SNL).ResultsBetween May 2009 and May 2013, 100 consecutive patients with BA underwent LKPE. The rate of conversion from LKPE to open Kasai portoenterostomy (OKPE), intraoperative transfusion and any perioperative complications was 11, 26 and 16%, respectively. There was no perioperative mortality. The CUSUM analysis revealed a learning curve of 50 for LKPE. Precipitous ORT reductions from an initial mean operative time of 316.3 min that was observed in the first 50 to 232.2 min of the late 50 cases (P < 0.01). Subsequently, cases 1 to 50 were considered ‘early experience’, whereas cases 51 and higher were considered as ‘late experience’ for statistical analysis. The rate of CJ and SNL was significantly higher after the early 50 cases (P < 0.05). In contrast, the rate of intraoperative transfusion, the median time of oral feeding initiated after operation, and the length of hospital stay was not different between the both groups (P > 0.05).ConclusionsIn this experience, improved perioperative and postoperative parameters for LKPE were observed in the last 50 patients when compared with the first 50 patients. The dedicated training is likely to contribute to significantly shorter learning curves in future adopters.

Ten-Year Native Liver Survival Rate After Laparoscopic and Open Kasai Portoenterostomy for Biliary Atresia.

Laparoscopic Kasai portoenterostomy (LKP) remains controversial in the management of infants with biliary atresia (BA). There are no data reporting the 10-year native liver survival rate after LKP. The study aims to present the 10-year native liver survival rate after LKP and complications in native liver survivors after Kasai portoenterostomy (KP). A retrospective review was conducted for 31 consecutive infants with BA who underwent KP by day 75 of life in our institute from January 1993 to December 2007. The demographics and outcomes of patients after LKP and open KP (OKP) were compared. Eleven patients underwent LKP and 20 patients underwent OKP. No statistical difference was observed in the age at operation and the preoperative bilirubin level. The operative time for LKP was significantly longer than that for OKP (mean 314.5 minutes versus 271.5 minutes, P = .03). The 10-year native liver survival rate was 45% (5/11) after LKP and was 85% (17/20) after OKP (P = .03). Forty percent (2/5) of the native liver survivors in the LKP and 71% (12/17) in the OKP developed complications within 10 years after KP (P = .23). The 10-year native liver survival rate in patients who underwent LKP by 75 days of life was 45%. With superior 10-year liver survival rate and comparable complication rate after OKP, OKP is still the treatment of choice for BA in our institute.

Learning Curve Analysis of Laparoscopic Kasai Portoenterostomy.

To compare the surgical outcomes of Kasai Portoenterostomy (PE) and investigate the learning curve of laparoscopic Kasai Portoenterostomy (Lap-PE). Retrospective chart review of 80 cases of biliary atresia (type III) undergoing Lap-PE at Shenzhen Children's Hospital from January 2011 to June 2015, all of which were performed by the same surgical team. According to the operative sequences, the cases were equally divided into four phases (Phase I, II, III, and IV), which contain 20 cases in each. The age, weight, and gender, the volume of intraoperative blood loss, the postoperative clearance rate of bilirubin, the incidence of postoperative cholangitis, and the first and second year native liver survival rate were all reviewed. There was no significant difference among the four phases regarding age, weight at operation, and gender (P > .05). Statistical difference was observed with respect to operative time, the volume of intraoperative blood loss, the postoperative jaundice clearance, and the first and second year native liver survival rate among Phase III and IV compared to Phase I and II (P < .05), but showed no significant difference in neither the first two phases nor the latter two phases (P > .05). The incidence of postoperative cholangitis showed no significant variation among the four phases. A surgeon is able to become more experienced after performing approximately 40 laparoscopic Kasai Portoenterostomys.

Does the Level of Transection of the Biliary Remnant Affect Outcome After Laparoscopic Kasai Portoenterostomy for Biliary Atresia?

We assessed postoperative outcome in relation to the level of transection of the biliary remnant at the time of laparoscopic Kasai portoenterostomy (LKP) in biliary atresia (BA) patients. The subjects for this study were 12 consecutive nonsyndromic type III BA patients who had LKP at our institute between 2009 and 2014. All LKPs were video recorded. Four board-certified pediatric surgeons assessed the level of transection of the biliary remnant and suturing during the anastomosis in each video blindly. A standard protocol was used for postoperative management. The level of transection was assessed as being shallow and suturing techniques as being identical in all. Although all cases achieved jaundice disappearance, 4 required liver transplantation (NNL group) for relapse of jaundice and 8 remain anicteric with native livers after mean follow-up of 4.6 years (NL group). Demographic data (birth weight, weight and age at LKP, duration from onset of symptoms to LKP, size of microbile ducts, and preoperative biochemical markers) were similar for both groups. The level of transection of the biliary remnant and suturing techniques would appear to not directly influence the outcome of LKP.

Variability of diagnostic approach, surgical technique, and medical management for children with biliary atresia in Canada — Is it time for standardization?

BackgroundThe Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA. MethodsGastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices. ResultsOf gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20–50cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation. ConclusionIn Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes. Level of evidenceSurvey study. Level IV evidence.