Impact of Kasai portoenterostomy on liver transplantation outcomes: A retrospective cohort study of 347 children with biliary atresia

Abstract

Biliary atresia (BA) is the main diagnosis leading to liver transplantation (LT) in children. When diagnosed early in life, a Kasai portoenterostomy (Kasai‐PE) can prevent or postpone LT. Instances of previous operations can result in difficulties during the LT. We hypothesized that a previous Kasai‐PE could affect LT outcomes. A retrospective cohort study of 347 BA patients submitted to LT between 1995 and 2013 at Hospital Sírio‐Libanês and A. C. Camargo Cancer Center was conducted. Patients were divided into those with a previous Kasai portoenterostomy early failure (K‐EF), Kasai portoenterostomy late failure (K‐LF), and those with no Kasai portoenterostomy (No‐K). Primary outcomes were patient and graft survival. A total of 94 (27.1%) patients had a K‐EF, 115 (33.1%) had a K‐LF, and 138 (39.8%) had No‐K before LT. Children in the K‐LF group were older and had lower Pediatric End‐Stage Liver Disease (PELD) scores. Patients in both K‐EF and K‐LF groups had more post‐LT biliary complications. After Cox‐multivariate analysis adjusting for confounding factors to determine the influence of Kasai‐PE on patient and graft survival, the K‐LF group had an 84% less probability of dying and a 55% less chance to undergo retransplantation. The K‐LF group had a protective effect on posttransplant patient and graft survival. When properly performed, the Kasai procedure can postpone LT and positively affect outcomes. Having a K‐EF and having not performed a Kasai‐PE had the same effect in patient and graft survival; however, a previous Kasai‐PE can increase post‐LT complications as biliary complications and bowel perforations. Liver Transpl 21:922‐927, 2015. © 2015 AASLD.

Bowel perforation after liver transplantation for biliary atresia: a retrospective study of care in the transition from children to adulthood

“…In a retrospective cohort study of 347 pediatric patients, it was reported that the patients who were underwent KPE and required LT after the first year of age showed better patient and graft survival than those who required LT within the first year of age [11]. Although some BA patients reached adulthood with their native livers, there has been limited evidence of the impact of LT on the outcome of patients who reach adulthood after KPE.…”

“…Bowel perforation is a noteworthy complication that occurs after LT in BA patients [8–11]. The incidence of this complication after pediatric LT is reported to be 6.4–20% [17, 19–23].…”

“…However, LT remains the ultimate surgery for BA and two-third of BA patients will require LT due to the progression of chronic liver disease [5, 7]. Many reports that have investigated the outcomes of LT for BA have evaluated the patients in childhood [8–11]. More than 50 years have passed since Kasai introduced KPE in 1959 [3]; thus in some cases, patients reached adulthood with their native liver [12, 13].…”

“…Complications after LT are common and result in significant mortality among BA patients [8–11]. Bowel perforation is associated with high rates of morbidity and mortality (2.5–20 and 30–50%, respectively) [17].…”

“…Bowel perforation is associated with high rates of morbidity and mortality (2.5–20 and 30–50%, respectively) [17]. Previous studies reported that the risk factors for bowel perforation after liver transplantation (BPLT) included the pre-LT model for end-stage liver disease (MELD) score [18], a prolonged operative time for LT (duration of hepatectomy) [17, 19], previous laparotomy [11, 19–22], young age [23, 24], intra-abdominal bleeding requiring relaparotomy, early portal vein thrombosis[19], the use of high doses of steroids in immunosuppressive therapy [25] and cytomegalovirus infection [26]. …”