JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 00, Number 00, 2017 2016 IPEG Meeting

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2016.0202

Does the Level of Transection of the Biliary

Remnant Affect Outcome After Laparoscopic Kasai
Portoenterostomy for Biliary Atresia?

Hiroki Nakamura, MD, PhD, Hiroyuki Koga, MD, PhD, Go Miyano, MD, PhD,
Manabu Okawada, MD, PhD, Takashi Doi, MD, PhD, and Atsuyuki Yamataka, MD, PhD

Abstract

Background: 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.
Methods: 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.
Results: 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.
Conclusions: The level of transection of the biliary remnant and suturing techniques would appear to not
directly influence the outcome of LKP.

Keywords: biliary atresia, laparoscopy, transection, portoenterostomy

Introduction Materials and Methods

T here have been numerous publications about tech-

niques for anastomosis during portoenterostomy with
the level of transection of the biliary remnant at the porta
hepatis and the size of the anastomosis reported to be crucial
factors for treating biliary atresia (BA) successfully.1–5 Kasai
himself performed a shallow transection with a narrow anas-
tomosis during his original open procedure, and since then
some surgeons have followed his approach using a shallow
transection with relatively narrow anastomosis,4,5 while
others have advocated a deeper transection with wider
anastomosis.1–3 Surprisingly, no one to date has thought to
review intraoperative videos to confirm whether the level of
transection of the biliary remnant is a factor that influences
postoperative outcome despite potential cure being a major
indication for surgery in BA.
In this study, intraoperative video recordings were assessed
to confirm what influence the level of transection of the biliary
remnant at the porta hepatis during laparoscopic Kasai por-
toenterostomy (LKP) has on postoperative outcome in BA.
There were 14 consecutive BA patients treated by LKP at
our institute between 2009 and 2014. Classification of BA
was isolated type, that is, nonsyndromic type III BA (n = 12),
syndromic type III BA (n = 1), and isolated type II BA (n = 1).
Syndromic type III BA and type II BA were excluded,
leaving only nonsyndromic isolated BA (n = 12) as subjects
for this study.
LKP was indicated based on a patient’s capacity to tolerate
surgery and size determined by the patient’s clinical status
and weight at the time of planned surgery. These two pa-
rameters provide a good indication of a patient’s ability to
tolerate longer surgery and size. Thus, heavier patients in
better clinical condition can generally tolerate longer surgery,
and LKP is usually chosen. Staff availability may also affect
choice of procedure to an extent because 2 of the coauthors,
A.Y. and H.K., are more experienced with LKP.
We compared outcome of cases who survived with native
livers (NLs) with those who did not survive with native livers
(NNLs) with respect to birth weight, weight and age at LKP,

Department of Pediatric Surgery, Juntendo University School of Medicine, Tokyo, Japan.

1
2 NAKAMURA ET AL.

duration between onset of symptoms and LKP, jaundice Postoperative management

disappearance ( JD) ratio, size of microbile ducts, and pre-
operative biochemistry (aspartate aminotransferase: AST,
alanine aminotransferase: ALT, alkaline phosphatase: ALP,
total bilirubin: T-Bil, and cholinesterase: ChE). In this study,
age at onset of symptoms was defined as the age when an
acholic stool was passed or when jaundice or abnormal bio-
chemistry was detected.
Details of our LKP procedure may be found elsewhere.4
Dissection of the porta hepatis is confined to the area around
the base of the biliary remnant. In our series, because the level
of transection of the biliary remnant was shallow, there was
no need to retract the right and left portal veins and hepatic
arteries; sutures placed at the 2 and 10 O’clock positions were
for reinforcement only.
Four board-certified specialist pediatric surgeons (2 from
our institute and 2 from elsewhere with no knowledge of our
subjects) who had each performed a total of at least 30 open
and LKPs reviewed intraoperative video recordings of each
LKP blindly. Each reviewer was asked to assess the level of
transection of the biliary remnant at the porta hepatis as being
very shallow if above an imaginary plane between the right
and left portal veins, that is, furthest from the porta hepatis;
shallow if below this plane, that is, closer to the porta hepatis;
deep if the liver parenchyma was visible through the trans-
ected biliary remnant without lateral dissection; and very
deep if the liver parenchyma was visible through the trans-
ected biliary remnant with lateral dissection (Fig. 1). Suturing
at the anastomosis such as the depth and location of sutures
was also reviewed.
All cases were managed by the same standard postopera-
tive management protocols for antibiotics, corticosteroids,
and cholagogues, details of which may be found elsewhere.6
Statistical analyses
Survival rates of patients with NLs were calculated by the
Kaplan–Meier method with end points of death or liver
transplantation (LTx). The Student’s t test and Chi-squared
test were used for statistical analysis. A P value <.05 was
considered to be statistically significant.
Ethics
This study was approved by the Ethics Committee of
Juntendo University School of Medicine and complies with
the Helsinki Declaration of 1975 (revised 1983).
Results
Results are summarized in Table 1. JD was achieved ini-
tially in all 12 subjects. However, 4 required LTx for relapse
of jaundice (NNL group) and 8 remain anicteric with native
livers (NL group) after mean follow-up of 4.6 years (range
1.3–7.0 years). On comparing the 8 NL cases with the 4 NNL
cases, mean birth weight was 2.7 kg (range 2.2 to 3.4 kg) for
NL and 2.8 kg (range 2.7–3.0 kg) for NNL (P = NS); mean
weight at LKP was 4.0 kg (range 3.3–4.6 kg) for NL and
4.7 kg (range 4.5–5.0 kg) for NNL (P = NS); mean age at LKP
was 59.6 days (range 29–79 days) for NL and 81.0 days

FIG. 1. (A) The level of transection of the biliary remnant at the porta hepatis is classified as being very shallow if it is
above an imaginary plane (top dotted line) between the right and left portal veins; shallow if it is below this plane; deep if
the liver parenchyma is visible through the transected biliary remnant (bottom dotted line) without lateral dissection; and
very deep if the liver parenchyma is visible through the transected biliary remnant with lateral dissection. (B) Intraoperative
photograph showing shallow transection. An arrow indicates the biliary remnant. Arrowheads indicate the portal vein.
BILIARY ATRESIA AND TRANSECTION LEVEL 3

Table 1. Comparison Between NL Cases and NNL Cases

NL (n = 8) NNL (n = 4) P
Mean birth weight (range), kg 2.7 (2.2–3.4) 2.8 (2.7–3.0) .35: NS
Mean age at LKP (range), days 59.6 (29–79) 81.0 (58–119) .10: NS
Mean durationa (range), days 31.3 (11–53) 60.3 (15–110) .10: NS
Mean microbile duct size (range), lm 91.3 (0–200) 212.5 (100–400) .06: NS
Mean weight at LKP (range), kg 4.0 (3.3–4.6) 4.7 (4.5–5.0) .07: NS
Jaundice disappearance ratio (%) 100 100 1.0: NS
AST (range), IU/L 192.5 (71–370) 188.0 (128–228) .93: NS
ALT (range), IU/L 113.4 (36–259) 116.0 (80–144) .94: NS
ALP (range), IU/L 1603.4 (479–3470) 1619.0 (1309–1772) .97: NS
T-Bil (range), mg/dL 8.8 (6.7–11.8) 9.1 (7.5–11.6) .76: NS
ChE (range), IU/L 366.8 (187–841) 659.2 (218–1372) .26: NS
Level of transection Shallow (all cases) Shallow (all cases) 1.0: NS
Depth of suturing Shallow (all cases) Shallow (all cases) 1.0: NS
a
Duration: between onset of symptoms and LKP.
AST, aspartate transaminase; ALT, alanine transaminase; ALP, alkaline phosphatase; ChE, cholinesterase; NL, native liver; NNL,
non-NL; LKP, laparoscopic Kasai portoenterostomy; NS, not significant; T-Bil: total bilirubin.

(range 58–119 days) for NNL; mean duration between onset
of symptoms and LKP was 31.3 days (range 11–53 days) for
NL and 60.3 days (range 15–110 days) for NNL; and mean
microbile duct size was 91.3 lm (range absent to 200 lm) for
NL and 212.5 lm (range 100–400 lm) for NNL. Differences
in mean age at KP, mean duration between onset of symp-
toms and age at KP, and mean microbile duct size did not
reach statistically significant levels but were less in the NL
group probably because of the small number of subjects in
each cohort. JD after LKP was 100% for both NL (8/8) and
NNL (4/4) (P = NS). Results for postoperative biochemistry
such as AST, ALT, ALP, T-Bil, and ChE were similar. Each
reviewer assessed the level of transection as being shallow,
and suturing at the anastomosis to be identical in all 12 cases.
Rates for survival with the NL calculated by the Kaplan–
Meier method for the 12 cases in our series with end points of
death or LTx were 95.2%, 79.6%, 79.6%, and 66.3% at 0.5, 1,
3, and 5 years after LKP, respectively (Fig. 2). Currently, at
just under 5 years, survival with the NL in this series is 8/12
(66.6%).
For reference, results for the syndromic type III and iso-
lated type II BA cases excluded in this study were the syn-
FIG. 2. Kaplan–Meier analysis showing survival rates of
patients with native livers. Survival rates were calculated
with end points of death or liver transplantation.
dromic type III case did not achieve JD and required LTx and
the isolated type II BA case achieved JD and remains anic-
teric at the time of writing.
Discussion
In this study, we excluded syndromic BA and type II BA
cases, and used only nonsyndromic BA cases because the
postoperative outcome of syndromic BA is worse than non-
syndromic BA and isolated BA,7 and type I and type II BA
have better prognosis than type III BA,8,9 and we wished to
focus on assessing the level of transection and depth of su-
turing. Thus, by excluding types of BA with poorer progno-
sis, bias related to differences in histopathology that might
affect outcome would be eliminated, allowing a direct com-
parison of surgical technique to be performed. Most studies
on outcome of BA surgery assess a mix of types of BA, which
may give rise to a spectrum of results. Ideally, research on
outcome of BA surgery should be reported with respect to
each type of BA, or at least be divided into syndromic (iso-
lated) and nonsyndromic, respectively. In this study, only
isolated type III BA data were analyzed, thus, we feel our
conclusions are not biased by the presence of syndromic BA
and other BA types.
Mean microbile duct size was 91.3 lm (range absent to
200 lm) for NL and 212.5 lm (range 100–400 lm) for NNL.
This is interesting because NNL group cases eventually had
liver transplants but had larger microbile ducts at the porta
hepatis than NL cases, although the difference was not sta-
tistically significant (P = .06). This finding is very similar to
the results of an article we published previously, which in-
cluded open Kasai portoenterostomy10 cases. The size of
microbile ducts would generally be accepted as a predictor of
postoperative JD, with larger microbile ducts expected to
contribute to better bile flow, which, in turn, would suggest
that bile drainage over a wide area of the liver should be
better; however, this study and our previous article10 showed
that the size of microbile ducts does not appear to be a
prognostic factor in BA patients.
In this study, we used intraoperative video recordings of
LKP to assess the level of transection of the biliary remnant
and suturing techniques at the anastomosis, a first for BA
4 NAKAMURA ET AL.
research. A limitation of our study is that we were not able to
make any comparison with laparoscopic transection of the
biliary at a deep margin, which makes it difficult to draw
meaningful conclusions about the depth of transection as a
variable that influences outcome. What we did confirm here
is that despite the level of transection of the biliary remnant
and suturing being the same in all 12 cases, postoperative
outcome varied. Thus, outcome would not appear to be re-
liant on surgical factors alone because the level of transection
and suturing was the same in all our subjects.
Although our series is small, we are the first to show that if
the level of transection of the biliary remnant is kept shallow,
outcome of LKP would appear to be influenced by nonsur-
gical factors rather than surgical technique. Shallow tran-
section would appear to be associated with JD, but factors
affecting final outcome are still a mystery and treating BA
continues to be difficult, causing considerable dilemma to
pediatric surgeons.
10. Koga H, Wada M, Nakamura H, et al. Factors influenc-
Disclosure Statement
No competing financial interests exist.
References
1. Ohi R. Surgery for biliary atresia. Liver 2001;21:175–182.
2. Kobayashi H, Yamataka A, Urao M, et al. Innovative modi-
fication of the hepatic portoenterostomy. Our experience of
treating biliary atresia. J Pediatr Surg 2006;41:e19–e22.
3. Endo M, Katsumata K, Yokoyama J, et al. Extended dis-
section of the portahepatis and creation of an intussuscepted
ileocolic conduit for biliary atresia. J Pediatr Surg 1983;
18:784–793.
4. Wada M, Nakamura H, Koga H, et al. Experience of treating
biliary atresia with three types of portoenterostomy at a
single institution: Extended, modified Kasai, and laparo-
scopic modified Kasai. Pediatr Surg Int 2014;30:863–870.
5. Yamataka A. Laparoscopic Kasai portoenterostomy for bil-
iary atresia. J Hepatobiliary Pancreat Sci 2013;20:481–486.
6. Nakamura H, Koga H, Wada M, et al. Reappraising the
portoenterostomy procedure according to sound physiologic/
anatomic principles enhances postoperative jaundice clear-
ance in biliary atresia. Pediatr Surg Int 2012;28:205–209.
7. Davenport M. Biliary atresia: Clinical aspects. Semin Pediatr
Surg 2012;21:175–184.
8. Nio M, Sano N, Ishii T, et al. Long-term outcome in type I
biliary atresia. J Pediatr Surg 2006;41:1973–1975.
9. Altman RP, Lilly JR, Greenfeld J, et al. A multivariable
risk factor analysis of the portoenterostomy (Kasai) pro-
cedure for biliary atresia: Twenty-five years of experience
from two centers. Ann Surg 1997;226:348–353; discuss
353–345.
ing jaundice-free survival with the native liver in post-
portoenterostomy biliary atresia patients: Results from a
single institution. J Pediatr Surg 2013;48:2368–2372.
Address correspondence to:
Hiroki Nakamura, MD, PhD
Department of Pediatric Surgery
Juntendo University School of Medicine
2-1-1 Hongo
Bunkyo-ku, Tokyo 113-8421
Japan
E-mail: hinakamu@juntendo.ac.jp