Laparoscopic vs. Open Portoenterostomy for Biliary Atresia: Pediatric Surgical Outcomes

Abstract

Biliary atresia is a rare, but serious neonatal liver disease in which the bile ducts are progressively fibro-obliterated, causing cholestasis and liver failure if left untreated. Portoenterostomy, often called the Kasai procedure, is still the mainstay surgical intervention that allows for bile flow restoration, which delays or even prevents the need for liver transplantation. The alternative to traditional open portoenterostomy has been the emergence of minimally invasive laparoscopic portoenterostomy over the years. The debate concerning the comparative effectiveness of these practices continues. However, this review article would collate a synthesis of pediatric outcomes after surgical LPE compared to OPE and focus on their survival with the native liver, postoperative morbidity, operating time, and success in achieving bile drainage while considering the overall long-term outcome.

Introduction

Biliary atresia is a life-threatening hepatobiliary disorder that necessitates early intervention to optimize patient outcomes. Kasai portoenterostomy is performed for the establishment of bile drainage; however, the success rate depends on multiple factors, including age at surgery, surgical technique, and post-operative management. In pediatric surgical practice, the use of laparoscopic surgery has gained popularity with its potential benefits of reduced post-operative pain and faster recovery. However, there are some technical issues, with the efficiency of biliary drainage, and the overall success rate of this procedure with laparoscopic portoenterostomy as compared to open surgery. The article reviews the strengths and limitations of each approach and makes a critical comparison based on current literature and clinical outcomes.

Surgical Techniques

The traditional approach involves a right subcostal or upper transverse incision to access the biliary tract. The fibrotic bile duct remnant is excised and a jejunal loop is anastomosed to the porta hepatis for bile drainage. The direct visualization of the porta hepatis helps achieve meticulous dissection and anastomosis, which is crucial in optimizing surgical outcomes. On the contrary, laparoscopic portoenterostomy (LPE) is a small-incision surgery with the use of a laparoscopic camera for visualization. Fine dissectors and electrocautery allow for dissection and reconstruction. Anastomosis is made extracorporeally or intracorporeally according to the experience of the surgeon. The reduction in postoperative pain, faster recovery, and better cosmetic results have therefore been factors that have made many opt for laparoscopic approaches.

Comparative Analysis of Outcomes

One important indicator of the success of portoenterostomy is survival with the native liver. From the conducted studies, OPE has been observed to be at a relatively higher rate for SNL in comparison to LPE, with an average difference at one year and five years after surgery. The main causes for lower rates of SNL among LPE patients are mainly the increased frequency of failed bile drainage and the early need for LT. Another area that plays a very important role in outcome assessment is postoperative morbidity and complications. Both procedures share a common complication of post-operative cholangitis, although some studies have reported higher rates of bile leaks and postoperative infections in LPE. This may be attributed to the technical difficulties associated with precise dissection and anastomosis in a minimally invasive setting. While OPE patients tend to have more post-operative pain and longer hospital stays, they usually have better bile flow restoration, which is an important factor in delaying the progression of the disease and reducing the need for early liver transplantation. The technical limitations of LPE, such as restricted maneuverability and limited visualization, can compromise the precision of the anastomosis and lead to suboptimal restoration of bile flow. Operative time is also an important factor. LPE typically demands a longer operative time because intracorporeal suturing is complex and the mobility of the instruments is limited. Surgeons with higher levels of expertise in pediatric laparoscopy achieve better results, indicating that the learning curve influences the outcomes of LPE.

Cosmetic and recovery benefits are the most touted advantages of LPE. Given the smaller incisions and less scarring, it is superior in cosmetic outcomes as compared to OPE. Given its quicker recovery period and decreased post-operative pain, LPE appeals to families who are sensitive about post-operative aesthetics and hospital stays. However, long-term results and liver transplant rates are still the core of assessing the effectiveness of these procedures. Although surgical techniques have improved, portoenterostomy is not a curative procedure for biliary atresia, and most patients eventually undergo liver transplantation. OPE patients have longer survival without transplants compared to LPE patients. Earlier requirements for transplantation in LPE patients are often ascribed to the ineffective drainage of bile and progression of fibrosis, thus the need for proper anastomotic techniques that will optimize the long-term results.

Discussion and Future Perspectives

Although LPE presents benefits in the reduction of pain and hospital stay along with cosmetic effects, its efficacy in the long term is something that is a concern. Technical difficulties due to poor visualization and maneuverability during LPE may lead to suboptimal bile drainage thus increasing the transplant rates. Success rates of LPE may rise shortly with increased refinement in techniques of laparoscopy and robotic-assisted surgery along with better training programs. The increasing trend of robotic surgery, which will provide more precise and dexterous surgery, may help solve some of the technical issues in LPE. Further research among pediatric surgeons would also help develop standardized protocols for LPE to make it an alternative to OPE for more patients.

Conclusion

Open portoenterostomy is still the gold standard for biliary atresia treatment due to its better results in terms of bile drainage, survival of the native liver, and long-term prognosis. However, laparoscopic portoenterostomy is an emerging alternative that offers advantages over post-operative recovery and cosmesis. Advancements in the field of minimally invasive pediatric surgery and the experience of the surgeons may further enhance the outcomes of LPE and make it an option in some cases. The optimal approach for surgical treatment of biliary atresia will require more multicenter randomized studies to achieve standardized guidelines for the management. As pediatric surgery progresses, evolving more specific techniques that combine the benefits with the limitations will be important for optimizing outcomes for patients with biliary atresia.