Laparoscopic vs open portoenterostomy in biliary atresia: a systematic review and meta-analysis

Comparison of surgical results and technical performance between robotic and laparoscopic approaches for Kasai portoenterostomy in biliary atresia: a multicenter retrospective study

BACKGROUND

Many variables, including age at surgery, disease type, surgical approaches and perioperative management factors have been demonstrated to influence efficacy in BA infants, however, the effect of surgical performance remains unclear. The objective of this retrospective study was to compare the postoperative efficacy and surgical performance of robotic (RKPE) versus laparoscopic Kasai portoenterostomy (LKPE) for BA.

METHODS

Between October 2018 and June 2023, 158 type III BA patients undergoing minimally invasive surgery (RKPE = 66, LKPE = 92) were included in this multicenter retrospective study. All procedures were performed by surgical teams experienced in Kasai portoenterostomy techniques. Technical performance was quantified and analyzed using the Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments (GERT). Postoperative outcomes and surgical performance were compared.

RESULTS

Compared with LKPE group, RKPE group had shorter fibrous cone transection time (48.92 ± 6.98 vs. 61.45 ± 8.98 min; p < 0.001), shorter hepaticojejunostomy time (47.55 ± 6.57 vs. 59.93 ± 7.88 min; p < 0.001) and less estimated intraoperative bleeding [7.00 (5.00-10.00) vs. 13.50 (10.50-16.50) mL; p < 0.001]. More importantly, RKPE group showed a superior OSATS score [30.50 (29.00-31.00) vs. 28.00 (28.00-29.00); p < 0.001], number of errors (46.62 ± 6.32 vs. 56.40 ± 6.82 times/case; p < 0.001), and number of events [9.40 (8.40-10.40) vs. 16.00 (14.00-17.80) times/case; p < 0.001]. On postoperative days 1 and 3, RKPE group had lower C-reactive protein levels (19.87 ± 12.28 vs. 27.05 ± 11.16 mg/L, p < 0.001; 14.88 ± 7.11 vs. 20.73 ± 9.09 mg/L, p < 0.001). During follow-up, RKPE group had higher jaundice clearance rate at 3 (68.18% vs. 51.09%; p = 0.032) and 6 months (78.79% vs. 64.13%; p = 0.047) postoperatively. However, the cholangitis rate within 1 year postoperatively (46.97% vs. 50.00%; p = 0.707), as well as one-year (75.76% vs. 72.83%; p = 0.678) and two-year survival with native liver rates (68.42% vs. 66.67%; p = 0.857), were comparable between two groups.

CONCLUSIONS

RKPE provided superior technical skill performance and a higher jaundice clearance rate than LKPE, indicating that it may be a better minimally invasive option for BA. In addition, the survival with native liver rate showed no significant difference between the two cohorts, which needs to be confirmed by further study.

Comparison between robotic-assisted Kasai portoenterostomy and open Kasai portoenterostomy in patients with biliary atresia

BACKGROUND

Robotic-assisted Kasai portoenterostomy (RAKPE) is regarded as a treatment option for patients with biliary atresia (BA). We aimed to compare the clinical outcomes of RAKPE to the open Kasai portoenterostomy (OKPE).

METHODS

A retrospective review was conducted on a total of 74 type III BA patients who underwent RAKPE (RA group, n = 36) or OKPE (OP group, n = 38) from January 2018 to December 2022. The study analyzed demographic characteristics, intraoperative findings, and postoperative outcomes.

RESULTS

The operative time in the RA group was significantly longer than that in the OP group (218.61 ± 31.70 min vs 178.50 ± 27.90 min, P < 0.05). The estimated blood loss in RA group was significantly lower than that in the OP group (8.65 ± 2.30 mL vs 17.55 ± 3.60 mL, P < 0.05). The recovery time of bowel sounds was significantly shorter in RA group than in the OP group (0.96 ± 0.12 days vs 2.84 ± 0.37 days, P < 0.05). All patients had bile-stained stools within 1-3 days after surgery. The clearance rate of jaundice at 3 and 6 months were significantly higher in RA group than in OP group (69.44% vs 60.53%, 75.00% vs 68.42%, P < 0.05). The rate of cholangitis in RA group was similar to that in OP group (50.00% vs 52.63%, P > 0.05). The native liver survival rate during the follow-up period was comparable between two groups (66.67% vs 63.16%, P > 0.05).

CONCLUSION

Robotic-assisted Kasai surgery offers advantages in short-term outcomes and the clearance of jaundice in patients with type III BA.

Comparison of Da Vinci Robotic-Assisted with Open Kasai Portoenterostomy for Biliary Atresia

BACKGROUND

Robotic-assisted Kasai portoenterostomy (RAKPE) has been used to treat biliary atresia (BA). This study aimed to compare the efficacy of RAKPE and open Kasai portoenterostomy (OKPE) for BA.

METHODS

Thirty-one children with type III BA who underwent surgical treatment in two centers from January 2022 to December 2023 were retrospectively collected. According to the operative techniques, the participants were divided into the RAKPE group (13 cases) and the OKPE group (18 cases). The operative time, jaundice clearance (JC) rate, and incidence of cholangitis were analyzed.

RESULTS

The operative time in the RAKPE group (204.3 ± 19.9 min) was significantly longer than that in the OKPE group (186.2 ± 22.2 min), P < 0.05. However, the blood loss (8.1 ± 2.5 ml) in the RAKPE group was significantly decreased compared with the OKPE group (13.6 ± 4.8 ml), and 15.4% patient need blood transfusion in RAKEP group was litter than that 55.6% in the OKPE group, P < 0.05. The time to oral feeding (2.8 ± 0.4 days vs. 4.3 ± 0.7 days) and the time to pass ICG-positive stools (3.6 ± 0.6 days vs. 4.7 ± 0.9 days) in the RAKPE group were significantly shorter than those in the OKPE group, P < 0.05. No significant differences were observed in the bile excretion rate, hospital stay time, and JC rate. The incidence of cholangitis in the RAKPE group was significantly lower than that in the OKPE group during short follow-up.

CONCLUSION

RAKPE may be associated with lower intraoperative blood loss, decrease need for postoperative transfusions and decreased rate of postoperative cholangitis compared to OKPE.

LEVEL OF EVIDENCE

III.

Comparison of different Kasai portoenterostomy techniques in the outcomes of biliary atresia: a systematic review and network meta-analysis

BACKGROUND

Biliary atresia (BA) is a progressive disease affecting the bile duct structure and function, leading to poor outcomes without timely surgical intervention. Kasai portoenterostomy (KPE) is a commonly used treatment to restore bile flow. However, the success rate and postoperative outcomes of KPE vary with different surgical techniques, including laparoscopic, robot-assisted, and open approaches.

METHODS

Following the PRISMA guidelines, this study systematically searched PubMed, EMBASE, and Cochrane databases for literature on BA surgical techniques of KPE. Studies comparing two or all three techniques-laparoscopic, robot-assisted, and open-in terms of postoperative outcomes of KPE in BA patients were included. Utilizing the "gemtc" package in R version 4.3.3, NMA was conducted to compare postoperative clearance of jaundice (COJ) among different surgical techniques. We also performed traditional paired meta-analysis in which multiple surgical outcomes were compared.

RESULTS

According to the traditional definition of a successful KPE surgery, in terms of successful postoperative COJ, robotic-assisted Kasai portoenterostomy (RAKPE) shows advantage over open Kasai portoenterostomy (OKPE) and laparoscopic Kasai portoenterostomy (LKPE), while the outcomes between OKPE and LKPE are equivalent. However, statistically speaking, there is no significant difference among the three techniques. LKPE has a longer operation time and less intraoperative bleeding compared to OKPE. There are no statistically significant differences in hospital stay, cholangitis incidence, or liver survival rates at 6 months, 1 year, 2 years, or 5 years.

CONCLUSION

The surgical success rates of KPE with various technical aids are similar, highlighting the need to consider individual patient conditions and cost when choosing a surgical technique. Effective postoperative management is vital for preventing complications and slowing liver fibrosis. Future research should focus on improving surgical techniques and postoperative care to enhance long-term outcomes for BA patients. For those who cannot maintain liver function with KPE, timely LT consideration is crucial.

Cholestasis after Kasai operation predicts portal hypertension in native liver survivors of biliary atresia: a multicenter study

PURPOSE

This study evaluated portal hypertension (PHT) and its predictors among native liver survivors (NLS) of biliary atresia (BA) after Kasai portoenterostomy (KPE).

METHODS

This was a multicenter study using prospectively collected data. The subjects were patients who remained transplant-free for 5 years after KPE. Their status of PHT was evaluated and variables that predicted PHT were determined by regression analysis and receiver operating characteristic (ROC) curve.

RESULTS

Six centers from East Asia participated in this study and 320 subjects with KPE between 1980 to 2018 were analyzed. The mean follow-up period was 10.6 ± 6.2 years. At the 5th year after KPE, PHT was found in 37.8% of the subjects (n = 121). Patients with KPE done before day 41 of life had the lowest percentage of PHT compared to operation at older age. At 12 months after KPE, PHT + ve subjects had a higher bilirubin level (27.1 ± 11.7 vs 12.3 ± 7.9 µmol/L, p = 0.000) and persistent jaundice conferred a higher risk for PHT (OR = 12.9 [9.2-15.4], p = 0.000). ROC analysis demonstrated that a bilirubin level above 38 µmol/L at 12 months after KPE predicted PHT development (sensitivity: 78%, specificity: 60%, AUROC: 0.75).

CONCLUSIONS

In BA, early KPE protects against the development of PHT among NLSs. Patients with persistent cholestasis at one year after KPE are at a higher risk of this complication. They should receive a more vigilant follow-up.

LEVEL OF EVIDENCE

Level III.

Laparoscopic versus open Kasai procedure for biliary atresia: long-term results of a randomized clinical trial

PURPOSE

The role of the laparoscopic approach for the Kasai procedure in the management of biliary atresia is still controversial. The aim of this study is to compare the long-term results of the laparoscopic Kasai procedure (LKP) to the open Kasai procedure (OKP).

METHODS

A randomized clinical trial was carried out from October 2009 to March 2017. Patients diagnosed with biliary atresia type III were randomized into 2 groups: one group underwent LKP and the other group-OKP. All the surgical procedures were performed by the same surgeon with the same technical principles. The long-term outcomes were compared between the two groups.

RESULTS

61 patients underwent LKP and 61 patients-OKP, with a median age at the surgery of 79.7 days. The two groups had no significant differences regarding the patients' baseline characteristics. At follow-up up to 142 months, the jaundice-free rate at the 6th postoperative month for LKP and OKP was 52.5% and 60.7%, respectively (p = 0.23). The 10-year cumulative survival after LKP tended to be inferior to OKP, respectively 44.3% vs. 58.9% (p = 0.09).

CONCLUSIONS

In this study, the long-term results of LKP tended to be inferior compared to OKP although the differences were not significant.

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.

Robotic-assisted Kasai portoenterostomy for biliary atresia

BACKGROUND

Robotic-assisted Kasai portoenterostomy (RAKPE) has been utilized to treat biliary atresia (BA). However, RAKPE is not widely performed and its efficacy remains unknown. We summarized the experience of RAKPE for BA and determined its efficacy.

MATERIALS AND METHODS

We retrospectively analyzed 25 consecutive infants with non-syndromic type III BA who received RAKPE in our center from January 2020 to July 2021. RAKPE is a three-arm setup and four-trocar operation. Bipolar coagulation was used to dissect the small blood vessels at the hepatic portal. The fibrous cone was shallowly transected with bending electric scissors, followed by gelatin sponge compression to staunch the hemorrhage. Finally, a wide anastomosis was accurately constructed. Demographics and outcomes were recorded.

RESULTS

The mean operative time was 211.64 ± 18.93 min. No conversion to laparotomy or intraoperative complications occurred. The mean estimated blood loss was 7.64 ± 2.43 mL. Enteral feeding was resumed after 3.44 ± 1.23 days. All patients achieved bile excretion postoperatively, and dark green bile-stained stools were passed 1.50 days (range 1.00-3.00 days) after surgery. The average postoperative length of hospital stay was 10.32 ± 2.59 days. The jaundice clearance (JC) rate was 76.00% within 6 months after surgery and the incidence of cholangitis was 48.00% within 1 year following surgery. The survival with native liver (SNL) rate was 80.00% at 1 year and 66.67% at 2 years.

CONCLUSION

RAKPE can be regarded as a treatment option for patients with BA due to the good outcomes reported. However, long-term studies comparing open or laparoscopic approaches are needed.

Advances in the Treatment of Neonatal Biliary Disease

This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.

Peri-Operative Liver Fibrosis and Native Liver Survival in Pediatric Patients with Biliary Atresia: A Systematic Review and Meta-Analysis

No systematic review to date has examined histopathological parameters in relation to native liver survival in children who undergo the Kasai operation for biliary atresia (BA). A systematic review and meta-analysis is presented, comparing the frequency of native liver survival in peri-operative severe vs. non-severe liver fibrosis cases, in addition to other reported histopathology parameters. Records were sourced from MEDLINE, Embase, and CENTRAL databases. Studies followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and compared native liver survival frequencies in pediatric patients with evidence of severe vs. non-severe liver fibrosis, bile duct proliferation, cholestasis, lobular inflammation, portal inflammation, and giant cell transformation on peri-operative biopsies. The primary outcome was the frequency of native liver survival. A random effects meta-analysis was used. Twenty-eight observational studies were included, 1,171 pediatric patients with BA of whom 631 survived with their native liver. Lower odds of native liver survival in the severe liver fibrosis vs. non-severe liver fibrosis groups were reported (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.08-0.33; I2 =46%). No difference in the odds of native liver survival in the severe bile duct destruction vs. non-severe bile duct destruction groups were reported (OR, 0.17; 95% CI, 0.00-63.63; I2 =96%). Lower odds of native liver survival were documented in the severe cholestasis vs. non-severe cholestasis (OR, 0.10; 95% CI, 0.01-0.73; I2 =80%) and severe lobular inflammation vs. non-severe lobular inflammation groups (OR, 0.02; 95% CI, 0.00-0.62; I2 =69%). There was no difference in the odds of native liver survival in the severe portal inflammation vs. non-severe portal inflammation groups (OR, 0.03; 95% CI, 0.00-3.22; I2 =86%) or between the severe giant cell transformation vs. non-severe giant cell transformation groups (OR, 0.15; 95% CI, 0.00-175.21; I2 =94%). The meta-analysis loosely suggests that the presence of severe liver fibrosis, cholestasis, and lobular inflammation are associated with lower odds of native liver survival in pediatric patients after Kasai.

Extended Adhesion-Sparing Liver Eversion during Kasai Portoenterostomy for Infants with Biliary Atresia

Background: Despite the fact that Kasai portoenterostomy (KPE) is the primary treatment for biliary atresia (BA), liver transplantation (LT) remains the ultimate surgery for two-thirds of these patients. Their true survival rate with the native liver reflects the original KPE and the burden of post-operative complications. We report an original modification of the adhesion-sparing liver eversion (ASLE) technique during KPE that facilitates the total native hepatectomy at time of transplantation. Methods: All consecutive patients with BA who underwent KPE at our department and subsequent LT at Paediatric Liver Transplant Centre at Papa Giovanni XXIII Hospital between 2010–2018 were retrospectively enrolled. All patients underwent ASLE during KPE. Patients’ demographic data, type of KPE, total transplant time (TTT), hepatectomy time (HT), intra-operative packed red blood cells and plasma transfusions, intra- and post-operative complications were noted. Results: 44 patients were enrolled. Median TTT and HT were 337 and 57 min, respectively. The median volume of packed red blood cell transfusion was 95 mL. No patients presented bowel perforation during the procedure or in the short post-operative course. No mortality after LT was recorded. Conclusions: In addition to the well-known advantages of the standard liver eversion technique, ASLE reduces the formation of intra-abdominal adhesions, lowering significantly the risk of bowel perforation and bleeding when liver transplantation is performed for failure of KPE.