The Beneficial Impact of Revision of Kasai Portoenterostomy for Biliary Atresia An Institutional Study

Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
Annals of surgery (Impact Factor: 8.33). 03/2012; 255(3):570-6. DOI: 10.1097/SLA.0b013e318243a46e
Source: PubMed


To determine whether portoenterostomy (PE) revision in patients afflicted with biliary atresia (BA) is a viable treatment option and, if so, identify which patients may benefit.
BA, the most common cause of neonatal liver disease, results in biliary tract obstruction and hepatic fibrosis. Kasai PE is the initial surgical intervention performed and, if successful, restores drainage and preserves the native liver. Portoenterostomy failure warrants liver transplantation, but because of complications related to transplantation, treatment strategies to salvage the native liver may be beneficial. Using uniformly applied criteria, we have revised PEs to delay or avoid transplantation.
A retrospective review of medical records of patients diagnosed with BA since 1983 was performed. Patient demographics, symptoms, indications for revision, laboratory values, and outcomes were recorded. A cohort of patients who underwent revision after initial PE was identified. Survival rates were assessed using the Kaplan-Meier method. For patients who required transplantation, operative data from the revised PE cohort were compared with those from the unrevised PE cohort. A Cox proportional hazards model was used to determine covariates predictive of a favorable outcome.
Of 181 children who underwent PE, 24 underwent revision. Adequate biliary drainage, as evidenced by normalized conjugated bilirubin levels, was achieved in 75% of revised patients. Overall survival in patients who underwent revision, regardless of transplantation, was 87%. Among patients who underwent PE revision, 46% have survived with their native liver.
Experience at our center suggests that with appropriate patient selection, PE revision may delay the need for liver transplanation yielding encouraging patient outcomes.

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    ABSTRACT: This study was conducted to reappraise the efficacy of redo-Kasai (or revision) in the era of liver transplantation as a treatment option in those patients with recurrent jaundice after initially successful Kasai procedure. We studied ten patients that received redo-Kasai, among a total of 102 patients diagnosed with biliary atresia after receiving Kasai operation from 1986 to 2011. Kasai operation was done at a median age of 55 days and redo-Kasai at 150 days. The bilirubin levels returned to normal in six patients after the procedure. Four of six enjoyed jaundice-free survival with native liver till the time of last follow-up. Three patients died and three received liver transplantation (LT). Only one out of seven patients with three or more episodes of cholangitis survived with native liver, while all the three patients with 1 or 0 episode survived with native liver. The difference was significant (P = 0.033). Re-do Kasai did not result in more blood loss or operative time during LT. Redo-Kasai is still valuable in the era of LT and the episodes of cholangitis are the decisive factors affecting the outcome of the procedure.
    No preview · Article · Aug 2012 · Pediatric Surgery International
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    ABSTRACT: The Kasai redo surgery is important for treating biliary atresia. In the era of liver transplantation (LTx), pediatric surgeons must accurately select patients for redo surgery and ensure that potential LTx can be performed later. Although optimal timing for redo varies among cases, appropriate timing is essential. We reviewed the significance, optimal timing, operative procedures, and indications of Kasai redo surgery. Between 1989 and 2011, 2,630 patients were registered in the Japanese Biliary Atresia Registry (JBAR), and the data collected from JBAR regarding Kasai redo surgery were analyzed. Patients were divided into two groups, Group 1 (1989-1999, n = 1,423) and Group 2 (2000-2011, n = 1,207). The redo incidence significantly reduced in Group 2. Although no significant difference was found in the native liver jaundice-free survival rates between the two groups, the overall survival rate at initial registry was significantly higher in Group 2. This may be because of the limited number of patients selected for redo and increased availability of early LTx. Patients who achieved sufficient bile drainage following the initial Kasai surgery but developed sudden bile flow cessation were the best candidates for Kasai redo surgery; it should be performed only once for this subset.
    No preview · Article · Aug 2013 · Pediatric Surgery International
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    ABSTRACT: The objective of this study was to investigate the detectability of bactDNA and associated clinical factors in patients with cholangitis after the Kasai procedure through the identification of bacterial DNA (bactDNA) in blood. A cross-sectional study of 110 patients who had undergone the Kasai procedure was collected including 77 cases of Cholangitis and 33 cases postoperative follow-up without Cholangitis patients. Samples of blood were obtained from the patients on admission or from follow-up at an outpatient visit. The bactDNA was analyzed by a PCR-based method, DNA nucleotide sequencing, for identification of bacterial species. The 16SrDNA were far more than that by culture method (58.4% vs. 14.3%, p < 0.0001); There was a relative abundance of bactDNA in patients with cholangitis than that without cholangitis (58.4% vs. 39.4%, p =0.095). The blood 16SrDNA primarily consisted of opportunistic pathogens derived from the gut, including Escherichia coli, Klebsiella pneumoniae, Shigella fexneri, and Enterobacteriaceae bacterium. Treatment with probiotics or antibiotics partially downregulated the presence of bactDNA. The Pediatric End-stage Liver Disease (PELD) score, Procalcitonin (PCT) level, C-reaction protein (CRP) level, and heart rate showed a significant relationship with the presence of bactDNA. bactDNA is frequently detected in patients with cholangitis after the Kasai procedure compared to those without cholangitis (and controls), with similar bacteria with those in the gut, suggesting that it is useful as a early diagnostic tool for cholangitis and other infections (ChiCTR-ECC-13003759). This article is protected by copyright. All rights reserved.
    No preview · Article · Jun 2015 · Pediatrics International
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