Tsukasa Nakamura

A Modification of Hepatic Portoenterostomy (Kasai Operation) for Biliary Atresia

BACKGROUND Although the proportion of patients with biliary atresia remaining jaundice-free after hepatic portoenterostomy (i.e., Kasai operation) has recently been increasing, in many cases repeated reoperation is required to achieve this result. Also, with assessment of jaundice using 2.0 mg/dL of serum total bilirubin as the cutoff, progressive liver fibrosis has occurred in longterm survivors, making liver transplantation necessary. Reoperations result in difficulty in removing the liver for this purpose and cause an increase in the probability of sequelae. STUDY DESIGN We have performed a new modification of the Kasai operation on a series of patients using the Cavitron ultrasonic suction aspirator (CUSA) for obtaining persistent biliary drainage. We assessed the results using <1.5 mg/dL of serum total bilirubin as the criterion for jaundice-free patients. RESULTS Since 1988, 39 patients were available for review of their clinical results to evaluate our new modification. Thirty patients (77%) were completely and continuously free of jaundice, without living-related liver transplantation or reoperation, and the maximum level of total bilirubin was <1.1 mg/dL. CONCLUSIONS Our new approach to Kasai operations using CUSA as an integral aid to freeing the biliary remnants and facilitating enteric anastomosis is effective for persistent and complete disappearance of jaundice, without complicated reconstruction or reoperation, and decreases the need for liver transplantation.

Formation of a Fatal Arterioportal Fistula Following Needle Liver Biopsy in a Child with a Living-Related Liver Transplant : Report of a Case

A 2 1/2-year-old girl underwent a living-related liver transplantation for biliary atresia, following which four percutaneous liver biopsies were performed uneventfully during her hospital stay for the evaluation of recurrent rejection. Her condition improved without any complications, and she was discharged from hospital in a stable condition on postoperative day (POD) 51. However, 3 months later she was readmitted with marked ascites and a moderate elevation of her liver function tests. A color Doppler ultrasound (US) confirmed hepatofugal portal blood flow, and selective celiac arteriography demonstrated an intrahepatic arterioportal (A-P) fistula. An attempt to embolize the fistula failed and a surgical approach was attempted without success. The patient died from irreversible liver failure on POD 152. A review of the previous histologic analyses revealed that arterial components were present in the fourth biopsy specimen; for this reason it was hypothesized that this procedure may have led to the development of the A-P fistula.