Expedited Laparoscopic Cholangiogram and Liver Biopsy in the Workup of Biliary Atresia

Abstract

Purpose: Recent studies demonstrate the success of Kasai portoenterostomy for biliary atresia (BA) is linearly-related to infant age at time of Kasai. We sought to review the feasibility and safety of laparoscopic needle micro-puncture cholangiogram with concurrent core liver biopsy (if needed) for expedited exclusion of BA in patients with direct conjugated hyperbilirubinemia. Methods: Expedited laparoscopic cholangiogram and liver biopsy were instituted at our facility for infants with direct hyperbilirubinemia for whom clinical exam and laboratory workup failed to diagnose. A retrospective chart review was performed in infants < 1 year with hyperbilirubinemia from 2016-2021. Demographics, preoperative evaluation, procedure details, and complications were reviewed. Results: 297 infants with unspecified jaundice were identified, of which, 86 (29%) required liver biopsy. 47 percutaneous liver biopsies were obtained including 8 (17%) in whom BA could not be excluded. Laparoscopic cholangiogram was attempted in 47 infants following basic workup; BA was diagnosed in 22 infants (47%) of which 3 were < 18 days old. Biliary patency was demonstrated laparoscopically in 22 of 25 (88%); 3 (12%) required conversion to open cholangiogram. Infants with percutaneous liver biopsy had an average delay of 3 days (range:2-36) to cholangiogram. Preoperative studies and liver biopsy alone did not reliably exclude the diagnosis of BA. Conclusion: Laparoscopic cholangiogram with liver biopsy is a safe procedure resulting in the confirmation or exclusion of BA in infants. 47% of infants who underwent laparoscopic cholangiogram were found to have BA; those who were surgical candidates underwent Kasai during the same operation.