Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Single Port Laparoscopic Assisted Cholangiogram for Suspected Biliary Atresia

Iftikhar A Jan, Anwarul Haq, Mudassar Gondal, Ubaidullah Khan, Mohammad Asif,

Department of Pediatric Surgery, The Children’s Hospital, PIMS

Islamabad, Pakistan

 

 

Correspondence:

Professor Iftikhar A Jan

FCPS, FRCS Eng, FRCS Ed, FACS, FEBPS

Professor of Pediatric Surgery & HOD

National Institute of Rehabilitation Medicine

G-8/2, Islamabad, Pakistan Email: This email address is being protected from spambots. You need JavaScript enabled to view it. m

 

Abstract

Background: Early diagnosis in babies with suspected biliary atresia is important for better outcome of definitive surgery. The most reliable investigation is Cholangiogram which gives an accurate diagnosis of biliary atresia in most cases. Laparoscopic assisted cholangiogram has now replaced the open cholangiogram to achieve this goal.

Materials and Methods: We performed Single Port Laparoscopic Assisted Cholangiogram (SPLAC) in ten babies with suspected BA where other investigations failed to confirm the diagnosis. In babies with good passage of contrast in the duodenum trucut liver biopsy was also performed under laparoscopic vision.

Results: Biliary atresia was confirmed in 5 babies. Of the other five babies, four had neonatal hepatitis and one had biliary hyoplasia confirmed by liver biopsy. In one patient we needed a second port for liver retraction for visualization of gall bladder. In another baby the contrast was injected in the peri-gall bladder area and needed exploration. He had neonatal hepatitis. Two babies had excessive bleeding from the trucut biopsy site. One needed blood transfusion and other fresh frozen plasma and both revived.

Conclusions: Single port Laparoscopic Assisted Cholangiogram is thus a reliable modality for the diagnosis of biliary atresia. Trucut biopsy however may be performed with caution and after appropriate correction of any coagulopathy as babies may be more prone to bleed from the biopsy site due to pneumo-peritoneum and deranged coagulation profile.

Key words: Biliary atresia, diagnosis, single port, Cholangiogram

  

Introduction

Cholangiogram has remained the gold standard for the diagnosis of biliary Atresia (BA) [1,2]. Traditionally it has been performed by open surgery. Open Cholangiogram has the disadvantage of major surgical procedure but does have advantage that if BA is confirmed then definitive surgery may be proceeded by extending the same incision. Cholangiogram may also be performed percutaneously under ultrasound guidance but may not be possible in contracted gall bladder [3]. Laparoscopic assisted cholangiogram (LAC) has the advantages of minimally access procedure, direct visualization of liver and gall bladder and a simultaneous liver biopsy helps in diagnosing other causes of cholestatic jaundice like biliary hypoplasia and neonatal hepatitis [4]. Traditionally two or more ports are used for LAC [5]. Single Port laparoscopic assisted cholangiogram (SPLAC) decreases trauma to the patient and also decreases the operating time. We reviewed our cases of SPLAC with a view to understand difficulties encountered during the procedure and feasibility of the procedure.

Material and Methods

Patients with the suspicion of biliary atresia from June 2005 to June 2007 were included in the study. Babies with persistent jaundice were evaluated clinically and investigated thoroughly. Age ranged from 6 weeks to 4 months with median age of 13 weeks. Investigations included liver function tests. HIDA scan was performed in all babies and was suggestive of BA. Pre & post feeding ultrasound after 6 hours of fasting was performed by an experienced ultrasonologist. Babies showing distended gall bladder with contraction after feeds were excluded from the study and referred for evaluation of medical causes. SPLAC was performed in all suspected cases of biliary atresia where other investigations could not give a definitive diagnosis. Informed consent was taken from the parents for the possible failure of procedure and conversion into open technique. Injection vitamin K 1mg/kg was started on admission to all babies. Patients were placed in 15-20 degree head elevated supine position. Operator being on the left side of the baby, an infra-umbilical incision was made and pneumoperitoneum created by closed technique using baby Verres needle. A single 3 mm or 5mm umbilical port was inserted for visualization of the gall bladder and liver. If gall bladder was easily identified with smooth liver surface cholangiogram was performed (fig. 1). Aspiration of green bile confirmed the patency of upper channels. Omnipaque 2-4 ml was then instilled and x-ray taken on the pre-placed x-ray film. If the Cholangiogram showed free flow of contrast in the duodenum and upper channels, biliary atresia was excluded (fig. 2) and trucut biopsy was performed from the right lobe under laparoscopic control. In babies having small contracted gall bladder and liver showing signs of cirrhosis, cholangiogram was attempted by the above mentioned technique. Absence of lumen and failure to pass the contrast in the gall bladder confirmed BA. Single port was used in most patients however in one baby a second port was placed for liver retraction and proper gall bladder visualization. In babies who had confirmed BA definitive surgery was either performed in the same sitting or next list.

Results

Ten babies had SPLAC. Of these 5 had biliary atresia, four had neonatal hepatitis and one had biliary hypoplasia. Of the five babies with BA three had definitive surgery, one had serious cardiac anomalies and parents decided not to go ahead with definitive surgery. In one baby who was about 4 months of age we performed portal dissection but could not find any biliary channels, a drain kept for a week for biliary drainage. As no bile drainage occurred therefore baby was referred for liver transplantation. Complications were noted in two babies after SPLAC and liver trucut biopsy. Both these babies had neonatal hepatitis. Bleeding occurred from the biopsy sites, one needed blood transfusion and other improved after fresh frozen plasma transfusion. Two babies had prolonged ileus and feeding was delayed for one day. None of the babies had any major leak from the gall bladder puncture site. Injection of the thick contrast was a problem due to the small size of the injecting needle but with gentle pressure using 10 ml syringe it was possible to inject the contrast into the gall bladder. Conversion to open Cholangiogram was done in one baby where contrast was injected into the peri-gall bladder tissue. The baby had neonatal hepatitis.

single port 1 single port 2
Figure 1. SPLAC in progress showing the percutaneously inserted needle in a small gall bladder.

Figure 2. SPLAC showing free flow of contrast in the distal channels.

Proximal ducts are also visualized.

Discussion

Diagnosis of biliary atresia may be difficult in babies with neonatal cholestatic jaundice. Various clinical and diagnostic modalities have been used to confirm the diagnosis however it remains a diagnostic dilemma. Early diagnosis and definitive surgery in cases of BA can significantly improve the outcome of surgery in these babies. Among the non operative techniques for diagnosis of BA, ultrasonography [3], MRCP [6], Technetium-99m Hepatobiliary Scintigraphy [7], needle Liver Biopsy [8], duodenal aspirate [9], and various scoring systems [10,11] have shown variable degree of diagnostic accuracy but none of these investigations are universally accepted for definitive diagnosis in all cases of BA. Ultasonographic evaluation of the hepatobiliary channels has shown high accuracy for the diagnosis of BA. Takamizawa S et al have shown nearly 100 percent accuracy of ultrasound diagnosis of BA if a combination of triangular cord sign, gall bladder length and gall bladder contractility were examined [12]. Humphrey and Stringer showed that US has a high accuracy if multiple US features are carefully evaluated [13]. US evaluation is however highly operator dependent and other studies give a variable sensitivity and specificity percentages [11].

Cholangiogram has been used as a gold standard for the definitive diagnosis of BA. This has shown a high accuracy in various studies. Traditionally it has been performed by a small sub costal laparatomy by open surgery. Non operative techniques like percutaneous cholecystocholangiography (PCC) under US guidance have been practiced with good results by many authors. Meyers RL and colleagues showed that accurate diagnosis was possible by PCC in all nine babies studied [14]. This was further studied by Nwomeh BC and colleagues who showed that in 35 babies with cholestatic jaundice, it was possible to exclude biliary atresia accurately in 9 babies by PCC thus avoiding a laparatomy [1]. PCC is however possible in babies with a recognizable gall bladder on US and has a limited role when gall bladder is poorly visualized.

The role of laparoscopy in the diagnosis of BA has been established since the introduction of minimally invasive techniques [2]. It has the advantage of visual evaluation of hepatobiliary system, peroperative Cholangiogram and a liver biopsy. The accuracy of combined approach is more than 95%. Costa F et al in 1983 showed that percutaneous transhepatic cholangiography with laparoscopic assistance may exclude biliary atresia in most cases [2]. LAC is practiced using various techniques by many authors. Two to three ports may be used for the technique. Okazaki T et al. exteriorize the gall bladder (GB) from the port site to ensure proper cholangiogram when good size GB is visualized but not in cases with atretic GB [4]. In our study we evaluated the results of single port LAC. We found that the procedure had a shorter operative time than open Cholangiogram. It excluded BA patients in four of the five babies not having BA. In one baby the contrast was instilled in peri-gall bladder tissue and needed exploration and open Cholangiogram. The procedure has a shorter operative time although we were not able to confirm it by a comparative analysis.Complications are negligible after SPLAC and important complications were bleeding in two patients after trucut live biopsy. Both had marginally deranged coagulation profile which was corrected. The excessive bleeding after LAC may be due to pneumoperitoneum which may prevent the parietal peritoneum to seal the liver rent. Fine needle (21 G) trucut biopsy may therefore be more appropriate in babies with BA. We had two patients who vomited feeds after LAC and feed was started on the next day. One problem was to use 3 mm port as we do not have the smaller telescope. We therefore used the cystoscope for the procedure and it worked well. Over all the results were most satisfying. Another advantage of LAC is the dissection in the porta hepatic in patients with BA. The concept is to perform the dissection in the porta hepatic till portal plate, keep a drain and then perform definitive surgery after few days if significant bile is produced in the drain. In one patient we performed the portal dissection and two more ports were inserted to facilitate dissection. As baby did not produce any bile so parents were advised for liver transplantation.

In summary single port LAC is a feasible, safe and reliable technique for early diagnosis of BA. The procedure is especially beneficial for babies with neonatal hepatitis where single port will exclude BA, cause minimal surgical trauma and early recovery. Laparoscopic assisted trucut liver biopsy however shall be performed with caution after proper correction of any coagulopathic state and gas shall be completely removed from the abdomen to facilitate hemostasis after trucut biopsy. Lastly, now it is possible to exclude biliary atresia in most cases by non invasive investigations and SPLAC shall be performed in selected cases where other investigations have failed to exclude biliary atresia.

 

 

REFERENCES

1. Nwomeh BC, Caniano DA, Hogan M. Definitive exclusion of biliary atresia in infants with cholestatic jaundice: the role of percutaneous cholecysto-cholangiography. Pediatr Surg Int 2007;23 :845-9.

2. Hirsig J, Rickham PP.Early differential diagnosis between neonatal hepatitis and biliary atresia. J Pediatr Surg 1980;15 :13-5.

3. Takamizawa S, Zaima A, Muraji T, Kanegawa K, Akasaka Y, Satoh S, Nishijima E.Can biliary atresia be diagnosed by ultrasonography alone? J Pediatr Surg 2007;42 :2093-6.

4. Okazaki T, Miyano G, Yamataka A, Kobayashi H, Koga H, Lane GJ, Miyano T. Diagnostic laparoscopy-assisted cholangiography in infants with prolonged jaundice. Pediatr Surg Int 2006;22 :140-3.

5. Hay SA, Soliman HE, Sherif HM, Abdelrahman AH, Kabesh AA, Hamza AF. Neonatal jaundice: the role of laparoscopy. J Pediatr Surg 2000; 35 :1706-9.

6. Takaya J, Nakano S, Imai Y, Fujii Y, Kaneko K. Usefulness of magnetic resonance cholangiopancreatography in biliary structures in infants: a four-case report. Eur J Pediatr 2007; 166 :211-4.

7. Cox KL, Stadalnik RC, McGahan JP, Sanders K, Cannon RA, Ruebner BH. Hepatobiliary scintigraphy with technetium-99m disofenin in the evaluation of neonatal cholestasis. J Pediatr Gastroenterol Nutr 1987;6 :885-91.

8. Aktas S, Diniz G, Ortac R. Quantitative analysis of ductus proliferation, proliferative activity, Kupffer cell proliferation and angiogenesis in differential diagnosis of biliary atresia and neonatal hepatitis. Hepatogastroenterology 2003;50 :1811-3.

9. Larrosa-Haro A, Caro-López AM, Coello-Ramírez P, Zavala-Ocampo J, Vázquez-Camacho G. Duodenal tube test in the diagnosis of biliary atresia. J Pediatr Gastroenterol Nutr. 200;32 :311-5.

10. Gupta DK, Srinivas M, Bajpai M. AIIMS clinical score: a reliable aid to distinguish neonatal hepatitis from extra hepatic biliary atresia. Indian J Pediatr. 2001;68 :605-8.

11. Lai MW, Chang MH, Hsu SC, Hsu HC, Su CT, Kao CL, Lee CY. Differential diagnosis of extrahepatic biliary atresia from neonatal hepatitis: a prospective study. J Pediatr Gastroenterol Nutr. 1994;18 :121-7.

12. Takamizawa S, Zaima A, Muraji T, Kanegawa K, Akasaka Y, Satoh S, Nishijima E. Can biliary atresia be diagnosed by ultrasonography alone? J Pediatr Surg. 2007;42 : 2093-6.

13. Humphrey TM, Stringer MD. Biliary atresia: US diagnosis. Radiology. 2007;244 :845-51.

14. Meyers RL, Book LS, O’Gorman MA, et al Percutaneous cholecysto-cholangiography in the diagnosis of obstructive jaundice in infants. J Pediatr Surg 2004;39 :16-8.