Elsevier

Journal of Surgical Research

Volume 251, July 2020, Pages 180-186
Journal of Surgical Research

Pediatric/Congenital/Developmental
A Morphology-based Analysis of Biliary Ductules After Kasai Procedure and a Review of the Literature

https://doi.org/10.1016/j.jss.2019.11.013Get rights and content

Abstract

Objective

To explore the distribution of biliary ductules in biliary remnants of patients with biliary atresia and to investigate the relationship between the ductules and the prognosis after Kasai portoenterostomy.

Patients and methods

From October 01, 2015 to September 30, 2017, 46 patients who were diagnosed as type 3 biliary atresia were enrolled in this study. Continuous sections of biliary remnants were stained with cytokerantin 19 antibody. The number, area, and distribution of micro-biliary ductules of each section were recorded. According to the number of ductules in the most proximal section (n ≥ 20 or n < 20), patients were divided into two groups (A or B) and followed up for 1-3 y, including cholangitis, jaundice clearance, and survival with native liver.

Results

Four patients had no micro-biliary ductules. In 17 patients with ductules, the numbers at bilateral parts were similar (P > 0.05), while the ductules in the middle part were significantly less than bilateral parts (P < 0.05). Starting from 2 mm from the proximal end of remnants, the number of ductules significantly and gradually decreased (P < 0.05). The total area of ductules in Group A was significantly increased compared to that in Group B (P < 0.05). Patients in Group A had significantly higher jaundice clearance rate and better survival rate with native liver than patients in Group B (both, P < 0.05). Patients had significantly higher incidence of cholangitis in Group A compared to Group B (P < 0.05).

Conclusions

The number/area of ductules yielded by technical precision is closely related to effective bile drainage, jaundice clearance, and first onset of cholangitis in patients after Kasai procedure.

Introduction

Biliary atresia (BA) is a destructive inflammatory obstructive cholangiopathy of neonates that affects varying lengths of both intrahepatic and extrahepatic bile ducts. If untreated, progressive liver cirrhosis usually leads to death by the age of 2 y.1 According to the position of obliterative bile ducts, Japan association of pediatric surgery classified BA into three types: type 1 (5%), type 2 (3%) and type 3 (>90%).2 Kasai portoenterostomy was adopted for treating type 3 BA, which was based on the theory that although the extrahepatic ducts were atretic, micro-biliary ductules in the remnant of porta hepatis retained continuity of the hepatic biliary system. If the fibrous remnant was resected adequately, these micro-biliary ductules were exposed and could help re-establish persistent bile flow, which finally alleviated hepatic cholestasis.3 On the other hand, if the fibrous remnant was resected insufficiently, there would be no effective biliary drainage.

Some scholars have preliminarily investigated the micro-biliary ductules in the fibrous remnants,4,5 focusing on the number and total area of the micro-biliary ductules. However, there was no histopathological study of the spatial distribution of hyperplastic bile ducts, as well as its related prognosis so far. Nio et al.6 suggested that the transection level of the fibrous remnant at porta hepatis should be consistent with the hepatic capsule without injuring it; however, they had no description on how “deeply” and “widely” the surgeons should anatomize the biliary remnant.

In the current prospective study, 46 patients with BA who underwent Kasai procedure were consecutively enrolled. The number, area, and horizontal and vertical distribution of the micro-biliary ductules in the fibrous remnants were investigated. We further studied the relationship of the characteristics of micro-biliary ductules and the prognosis of patients with BA who underwent Kasai procedure. In this way, we aim to confirm the depth and width of the transection of the fibrous remnant during anatomizing and to provide theoretical basis for modified Kasai's operation. Additionally, we try to provide some scientific evidence to explore and discuss the possible roles of existence of ductules in predicting postoperative prognosis.

Section snippets

Patients and methods

From October 01, 2015 to September 30, 2017, 46 patients (19 females and 27 males) who underwent Kasai procedure at our department were consecutively enrolled in this study. This study was approved by the Institutional Review Board, and informed consent forms were signed by parents. All patients were diagnosed as type 3 BA during the operation. During this period, the same group of surgeons performed the operation, with consistent operative techniques and postoperative management. We adopted

Horizontal distribution

Six patients had no micro-biliary ductules in the remnant and further gave up therapy or underwent liver transplantation during follow-up. These patients were excluded in the further comparison of ductule distribution, onset of cholangitis, clearance rate, and survival.

The remaining 40 cases had micro-biliary ductules in the remnants without a significant difference between the right and the left part in the number of ductules (10.5 ± 8.5 versus 10.9 ± 11.7, P = 0.890). However, the number of

Discussion

The outcomes of Kasai procedure are usually variable, due to different ages at operation, operative techniques, severity of hepatic fibrosis, postoperative prevention of cholangitis, and the development of biliary tree and portal plate.8 Although the Kasai procedure provides potential cure, many patients continue to progress from fibrosis to cirrhosis for unknown reasons.9 To investigate the possible reasons, Chung et al.10 reported in their retrospective study that laparoscopic surgery and

Ethical statement

Written informed consent was obtained from the guardians of the patients included in this study. The Institutional Review Board of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology approved the protocol of the study (Permit Number 2014-HP066, Wuhan, China). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki

Acknowledgment

The authors wish to thank Prof. Ping Yin and Dr Hongyu Li (Department of Preventive Medicine, Tongji Medical College, Huazhong University of Science and Technology) for their help in analyzing the data in this paper.

This work is supported by National Natural Science Foundation of China, China (Grant No. 81401240, 81571478, 81601330).

Authors’ contributions: J.Y. was involved in conception and design, interpretation of the data, drafting the article, revising article critically for intellectual

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