Abstract
Abstract
Purpose:
The benefit of laparoscopic Kasai portoenterostomy remains controversial. With the progression of the disease, significant numbers of patients require liver transplantation. It has been reported that reduced internal scarring and fewer adhesions could facilitate the subsequent liver transplantation and thus represent a potential advantage of the laparoscopic technique.
Subjects and Methods:
All patients undergoing liver transplantation in our hospital between 2006 to 2008 after a laparoscopic or conventional Kasai procedure were included in this retrospective analysis. Primary outcome measure was duration of liver explantation. Secondary outcome measures were total duration of transplantation, amount of blood transfusion, and need for reoperation within the first year.
Results:
In total, 19 patients were included: 11 patients after open Kasai and 8 patients after laparoscopic Kasai. There was no significant difference in patient characteristics. The mean duration of liver explantation was comparable in laparoscopic (125±8 minutes) and conventional (116±6 minutes) (P>.05) patients. Moreover, we did not identify any significant difference in the need for blood transfusions, total liver transplantation duration, and need for reoperation.
Conclusions:
We did not detect any measurable benefit of laparoscopic compared with conventional portoenterostomy for subsequent liver transplantation. Thus, prevention of adhesion formation and facilitating subsequent liver transplantation are not rationales for laparoscopic Kasai portoenterostomy.
Introduction
Since its introduction by Kasai et al., 1 portoenterostomy remains the initial treatment of choice, but despite early diagnosis and prompt surgical intervention to improve biliary drainage, liver transplantation is required in about 60–80% of all white patients with BA.2–8
In this era of rapid development of pediatric minimally invasive surgery, a wide range of surgical procedures is now routinely performed laparoscopically, and few centers have reported the feasibility of laparoscopic Kasai portoenterostomy.9–11 Nonetheless, the rationale for laparoscopic portoenterostomy is controversial. We had to stop a prospective study early because of a significantly increased rate of liver failure in patients after laparoscopic Kasai procedures. 12 Nonetheless, laparoscopic portoenterostomy continues to be practiced and is recommended as the gold standard in some centers.10,13
One potential benefit of the minimal invasive approach that has been postulated is a reduction of postoperative adhesions, facilitating subsequent liver transplantation.10,14 Nonetheless, the data on this topic are limited. Therefore, the aim of our study was to determine the effect of laparoscopic or conventional Kasai operation on the feasibility of a subsequent liver transplantation.
Subjects and Methods
All infants with BA and portoenterostomy undergoing liver transplantation by the second author between October 2006 and September 2008 were included in this retrospective analysis. Institutional review board approval and written informed consent were obtained from all guardians for this retrospective report. Approval was received from the Local Research Ethical Committee (No. 41/206). Kasai portoenterostomies were performed by two experienced senior surgeons using the same operative techniques as previously reported. 12
Outcome parameters
The primary end point was the duration of liver explantation (i.e., time between incision and clamping of the vessels). Secondary outcome measures were total duration of the liver transplantation, the amount of intraoperative transfusion of erythrocyte and platelet concentrates, and the need for reoperation within the first year.
Patients' characteristics included indication for liver transplantation, sex, age, and weight at the time of surgery, concomitant diseases, previous abdominal surgical interventions, and any previous episodes of ileus and length of postoperative hospital stay.
Statistical methods
The comparisons of patient characteristics between both groups were performed by Mann–Whitney rank sum test or Fisher's exact test. Data are expressed as mean±standard error of the mean. Significance was assumed at a P value of<.05. The SigmaStat statistical software package (Jandel Scientific, San Rafael, CA) was used.
Results
Patients' characteristics
A total of 19 patients with non-syndromic biliary atresia underwent liver transplantation: 8 with previous laparoscopic and 11 after conventional Kasai portoenterostomy. Preoperative patient characteristics immediately prior to liver transplantation are shown in Table 1. Both groups were similar in terms of the distribution of sex, and there was no significant difference regarding weight and age. Nonetheless, the average age and the interval between Kasai and liver transplantation were lower in patients after laparoscopic versus conventional portoenterostomy (244±41.6 days versus 398±118.9 days and 188.13±37.45 days versus 327.18±127.89 days [difference not significant]). No relevant difference was found with respect to the proportion of patients who developed typical symptoms of liver failure (Table 2). There was 1 patient with a hemodynamically stable cardiac malformation and 1 patient with medically treated hypothyroidism, both in the laparoscopic group.
None of the patients underwent a major abdominal surgical procedure other than Kasai portoenterostomy before liver transplantation, and there were no episodes of ileus noted in the medical history of all included patients.
End points
There was no difference in duration of total liver transplantation in patients after laparoscopic versus conventional Kasai portoenterostomy (Table 3), with slightly longer times after laparoscopy (125±8.1 minutes versus 116±6.1 minutes [difference not significant]). Similar results were found for the duration of liver implantation and the total time of liver transplantation, with slightly but not significantly longer times in patients after laparoscopic Kasai (146±9.8 minutes versus 135±6.1 minutes [difference not significant] and 270±17.6 minutes versus 251±12.7 minutes [difference not significant], respectively).
Number of patients (%).
LTx, liver transplantation.
There was no significant difference between patients after laparoscopic or conventional portoenterostomy regarding the intraoperative application of platelet concentrates (27±4.1 mL/kg versus 20±7.6 mL/kg [difference not significant]) and erythrocyte concentrates (139±37.0 mL/kg versus 123±30.4 mL/kg [difference not significant]) with slightly higher values in the laparoscopy group. There was no difference in the duration of the hospital stay in patients undergoing liver transplantation after laparoscopic or conventional Kasai (68±11.2 days versus 58±6.4 days [difference not significant]) with slightly but not significantly higher values in the conventional group. Two patients in the laparoscopic group and 4 patients in the conventional group underwent relaparatomy due to anastomosis insufficiency (2 of 8 versus 4 of 11 [difference not significant]). Retransplantation became necessary in 1 patient (12.5%) in the laparoscopic group and 3 patients (1 of 8 versus 3 of 11 [difference not significant]) in the conventional group. One patient (9%) died within the first year after liver transplantation from graft failure in the conventional Kasai group.
Discussion
The benefit of laparoscopic Kasai portoenterostomy is still under debate. Postulated advantages of the minimal invasive approach are faster recovery, a lower rate of complications, better cosmesis, and fewer adhesions compared with open surgery. 12 It remains controversial to what degree these general advantages apply to the laparoscopic Kasai portoenterostomy. However, because of the high rate of subsequent liver transplantation, a reduction of internal scarring could represent a relevant advantage of the laparoscopic technique, facilitating transplant surgery.
It is well known that postoperative adhesions can increase the technical difficulty of subsequent intraabdominal surgical procedures,15,16 and laparoscopic techniques have been shown to reduce adhesion formation in several studies.17,18
Indeed, several publications have suggested that laparoscopic Kasai would be associated with very few intraperitoneal adhesions and therefore would be beneficial for BA patients, as reviewed in Table 4. However, the data available are mostly uncontrolled and with a very limited number of patients. Besides the non-controlled reports of Dutta et al. 14 and Koga et al., 13 Martinez-Ferro et al. 10 described their extensive experience in 2005. Within this article the authors compared liver transplantation in 6 of their patients with patients who had undergone Kasai portoenterostomy elsewhere and found a higher rate of adhesions in the conventionally operated group. There was no significant difference in operative time or blood loss between both groups. 10
LTx, liver transplantation.
In contrast, we did not detect any relevant benefit of laparoscopic Kasai on subsequent liver transplantation. The assessment of adhesions is difficult and in the clinical setting mostly based on subjective description, thus lacking any rigorous evaluating system. Besides the difficulties in assessing the degree of intraabdominal adhesions, their localization is an important aspect in evaluating their impact on the feasibility of a liver transplantation. In his subjective assessment, the transplant surgeon observed generally reduced adhesions after laparoscopic Kasai, but similar scarring in the portal area, defining the difficulty of the transplantation.
We decided against using the subjective assessment as an end point in our study, but instead focused on the quantitative parameters of operative time and blood loss during transplantation as indirect markers of relevant adhesion formation. In these objective markers there was no benefit of laparoscopic surgery for the subsequent liver transplantation detectable: the average time for liver explantation and the time of total liver transplantation were even slightly, although not significantly, higher in the laparoscopy group. Furthermore, there was no significant difference in the application of blood transfusion regimens, in the events of relaparatomy, or the duration of hospitalization comparing the laparoscopic versus the conventional group.
Our outcome appears to differ from those of previous reports, especially the study of Martinez-Ferro et al. 10 However, whereas these previous authors assessed the subjective presence of intraperitoneal adhesions, we defined operative time, blood loss, and complications as end points in our study. In these parameters, both studies did not find a significant difference. Moreover, the lack of clear data on the follow-up and jaundice-free survival with the patient's own liver makes it difficult to compare the excellent outcome reported by Martinez-Ferro et al. 10 with our results. 12
In conclusion, we failed to observe a significant benefit of laparoscopic portoenterostomy on subsequent liver transplantation. Therefore, we do not recommend laparoscopic Kasai portoenterostomy in the general treatment of BA patients. Patients undergoing laparoscopic Kasai portoenterostomy should be included in a prospective, controlled trial.
Footnotes
Disclosure Statement
No competing financial interests exist.