Kasai Procedure - Surgery, Operation, Scar, Recovery & Care

Biliary Atresia (BA) affects the bile ducts, leading to a blocked or absent bile flow from the liver to the gallbladder and small intestine. During the surgery, a surgeon creates a new pathway for bile drainage by connecting the liver directly to the small intestine.

This bypasses the blocked or missing bile ducts, allowing bile to flow more freely and improve liver function. The doctor replaces the damaged duct with a segment of the child's small intestine. This segment is joined to the liver. It acts as a new extrahepatic bile duct system.

Anatomy and Physiology of the Hepatobiliary System

The biliary system helps with digestion. It makes and stores bile, which breaks down fats. Bile has water, electrolytes, cholesterol, acids, and pigments.

The main organs of the hepatobiliary tract include:

1. The Liver is the largest organ in the biliary system, producing bile to break down and absorb lipids in the small intestine. Hepatocytes break down red blood cells to produce bile.
2. The gallbladder is a small, elongated, pear-shaped organ below the liver. It stores and concentrates bile, released into the small intestine when needed.
3. Hepatic Ducts are responsible for collecting and storing bile. The right and left ducts combine to form the common hepatic duct for liver drainage.
4. The Cystic Duct joins the common hepatic duct to the gallbladder, forming the common bile duct.
5. Common Bile Duct transports bile from the liver and gallbladder to the small intestine.
6. The Sphincter of Oddi controls the release of bile and pancreatic juices into the digestive tract.
7. Pancreatic Duct carries digestive enzymes into the duodenum. It often shares an opening with the common bile duct called the Ampulla of Vater.
8. The Duodenum is the beginning area of the small intestine where bile and pancreatic enzymes facilitate digestion and nutrient absorption, particularly fats. 
9. The Small Intestine is where the released bile emulsifies fat and promotes absorption.

Kasai operation is done for newborn babies. This procedure helps in managing biliary atresia among newborns. Usually, surgeons recommend the surgery if the baby is diagnosed with BA within 2-6 weeks after birth.

The common indications implying the need for treatment include:

1. Persistent Jaundice: The first sign of the condition is excessive bile juice release, causing the baby's skin and nails to turn yellow. If this symptom worsens and cannot be managed, it may indicate BA.
2. Pale/White Stools: Since the bilirubin release is impaired in the condition. The intestinal region gets minimal to no bilirubin. It leads to discolouration or changes in stool appearance among newborns.
3. Dark-Coloured Urine: Excessive bilirubin in the bloodstream causes extensive urine yellowing. This is also an indication of worsening jaundice or BA.
4. Swollen Belly: The reversed movement of bile to the liver instead of the abdomen causes digestive issues and stomach inflammation.
5. Enlarged Liver: As the flow of bile acid is impaired in BA, it leads to the accumulation of the bile in the liver. Thus causing an extensive increase in its size (hepatomegaly) and facilitating liver diseases like cirrhosis.
6. Enlarged Spleen: If the fluid pressure increases between the hepatic veins (portal hypertension), it increases spleen size (splenomegaly).

Types of Biliary Atresia Treated with Kasai Procedure

The Kasai procedure done for BA is considered its primary treatment modality. As per the Japanese Association of Paediatric Surgery, the condition is classified into three grades:

1. Type I: The common bile duct is damaged, causing bile flow obstruction.
2. Type II a & b: The impairment can be restricted to the common hepatic duct (Type IIa). Obliteration can extend to the common bile duct, hepatic duct, and cystic duct (Type IIb).
3. Type III: This is the most common type of BA. It extensively damages the common bile, hepatic, and cystic ducts, leaving no adjacent duct for linkage.

Sometimes, there are various complexities detected with biliary atresia. It includes polysplenia (multiple small spleens), asplenia (absence of spleen), malrotation (abnormal positioning of small intestine) and heart defects. If any or all of these conditions are present, the condition is known as biliary atresia-splenic malformation syndrome (BASM).

The operation focuses on improving the bile flow and enhancing liver function. Are you curious about the other advantages of the treatment? Here are the prominent benefits of the surgery.

1. Improved Bile Flow: After the procedure, the bile gets transmitted to the abdomen by bypassing the baby's small intestine. This overcomes the issue of imbalanced biliary movement.
2. Better Digestion: The technique allows appropriate metabolic movement and bile transfer, which promotes digestive activity.
3. Enhanced Liver Function: Khayat et al., 2021 showed that among 23 patients in their study, 56% were able to survive with their native liver. This implies that the need for liver transplants was reduced after the surgery.
4. Improved Quality of Life: Early treatment of biliary atresia can prevent impaired liver function and enhance the standard of living. The progression of this congenital disorder can become a reason for poor growth and fatal diseases like liver cirrhosis.
5. Treatment Accuracy: Technological advancements have made the procedure more precise and effective. The laparoscopic technique is minimally invasive, reducing surgery complexities.

Every patient carries certain doubts regarding what happens throughout the surgery. This section sheds light on the expected surgical preparation before and on the day of the surgery.

Before the Kasai Surgery

Before any surgical process, the healthcare team abides by a protocol to ensure the patient's overall safety.

On the day of the Kasai Procedure

On the day of surgery, the patient can be expected to undergo the following. Check the

The purpose of the surgery is to create a passage to allow the bile to drain directly from the liver into the small intestine, bypassing the gallbladder and the various ducts. The doctor will:

1. Patient Positioning: Generally, a dorsal decubitus (lying on the back) on an elevated surface. This allows improved accessibility to the surgical site.
2. Incision: In an open surgery, the doctor makes a cut (2-3 cm in size) on the upper right abdominal region for bile system assessment. However, in laparoscopic surgery, the cuts are smaller (keyhole size).
3. Cholangiogram: It is used for the diagnosis of biliary atresia. The doctor uses X-rays and medication to locate the bile ducts. It also detects if the ducts are blocked along with the gallbladder.
4. Damaged Ducts Excision: Remove the damaged bile ducts and abnormal gallbladder outside the liver.
5. Bypassing Through Small Intestine: The patient's small intestine replaces the ducts. It bypasses the liver and drains directly to the duodenum.
6. Closing Wound Site: The liver is placed back into the abdominal cavity, and the surgical site is sutured (stitched or glued).

The aftercare provided and the at-home management strategies prescribed after surgery plays a significant role in patient recovery. Let’s explore the common care guidelines followed in the hospital before discharge and home remedies to abide after hospital release.

In Hospital Recovery

After the surgery, the healthcare professionals ensure the delivery of overall postoperative care. The standard care protocol includes the following:

1. Wound Dressing: The surgical site is covered with dressings after suturing. Appropriate wound management is important for infection prevention and enhanced recovery. 
2. Drainage: A urinary catheter is inserted to drain urine and measure output. Place an abdominal drain to remove excess fluid and blood from the liver.
3. Transfer: The baby will be moved to the recovery area.
4. Feeding: The parent will not be allowed to feed the baby for 48 to 72 hours. A nasogastric tube is attached from the baby's nose into the stomach and provides necessary nutrition.
5. Medications: Pain-relieving medicines are provided through the nasogastric tube during the surgery. Antibiotics are administered intravenously (IV) for three to five days.
6. Fluid Management: IVs administer fluids and blood products to balance the body's salt, sugar, and water levels.
7. Discharge: The baby is released from home after seven to ten days, depending on the baby's recovery. 

At Home Recovery

It is important to abide by the surgeon's instructions after discharge from the hospital. Some general aspects to consider during at-home recovery are:

1. Weight Monitoring: Parents are asked to weigh the baby weekly to monitor its growth appropriately. 
2. Physiological Attention: Regularly assess the baby's temperature, stool, urine, and general health for signs of infection and jaundice. 
3. Wound Management: Clean the surgical area as instructed by the doctor. 
4. Medicine Administration: Administer medications such as antibiotics, vitamins, steroids, etc., based on the baby's condition and the doctor's prescription.

First Follow-Up Appointment

The first follow-up appointment is usually scheduled two weeks after hospital discharge to monitor liver function and growth.

The baby should also see a gastroenterologist and paediatric surgeon. Post-surgery, the patient should visit their doctor for five years to monitor the liver.

During the first follow-up visit, the patient can expect:

1. Physical Assessment: This includes evaluating the abdominal region to detect fluid accumulation or tenderness. Along with the abdominal area, the surgeon also checks the vitals, like body temperature, heart rate, respiration, and more.
2. Surgical Site Evaluation: The surgeon assesses the surgical wound to detect any abnormality or infection development around it.
3. Seeking Parent's Feedback: General feedback about the recovery observed and the current hepatic functioning of the baby. It includes a discussion of an infant's stool patterns, urine colour and amount, digestive function, and any potential complications like dizziness, redness, pain, etc.
4. Blood Tests:  To detect the body's hepatic functioning and bile flow, these tests are prescribed in the first follow-up.
5. Ultrasound: Another important aspect of the Kasai procedure is its scar (hepatic fibrosis), which suggests damage progression. Thus, this test is used to measure the size of the scarring and ensure good hepatic recovery.

Like any other surgical procedure, the congenital disease treatment poses specific adverse healthcare indications. The prominent risks of the Kasai procedure include:

1. Wound Infection: The most common early complication can be treated with oral antibiotics or additional care.
2. Cholangitis: A bile duct infection can cause fever and jaundice when bile flows through the liver-bowel connection.
3. Scarring: Hepatic fibrosis is a progressive complication that can lead to complete hepatic failure. The worsening of this complication can lead to severe conditions like cirrhosis.
4. Ascites: It is a rare post-surgical risk associated with excessive lymphatic fluid release in the abdominal cavity. This leads to the development of Chylous ascites and can be managed through diuretics.
5. Procedure Failure: The procedure may fail after three months, leading to symptom recurrence and potential damage. In such cases, a liver transplant would be necessary. However, Gunadi et al. (2018) showed a success rate of 58%, allowing patients to live fully. Ensuring patient safety and process efficacy is crucial.

Early treatment of congenital issues like BA can enable newborns to live their lives to the complete capacity. The significance of the surgery can also be understood by knowing the complexities related to a delayed treatment. The most prominent risks are listed below:

1. Reduced Procedure Success: Studies have shown that the procedure is more effective within three months of the baby's birth. The complications associated with the surgery increase significantly if it is prolonged.
2. Obstructed Bile Flow: BA progression in infants is linked to restricted bile transmission, worsening jaundice symptoms, and causing cirrhosis and cholangitis.
3. Restricted Growth: Impairment of the biliary tract becomes the reason for poor digestion and nutrition absorption. Thus limiting the infant's growth and increasing hepatic damage.
4. Liver Transplant: Progressive BA with no early treatment can necessitate transplantation to ensure survival. Early Kasai surgery can limit liver damage and reduce the chances of performing a transplant.

When is Consultation with the Doctor Needed?

Contact your surgeon immediately if you observe signs of infection or liver dysfunction after surgery, such as:

1. High Fever: If the baby shows persistently increased body temperature (above 100 F).
2. Surgical Site Infection: The wound may exhibit redness, pain, or discharge, indicating an infectious reaction.
3. Dizziness: If the newborn seems confused or disoriented with frequent fainting incidents. Then, it can be an emergency to consult a doctor.
4. Pain: Constant and unbearable discomfort in the abdominal region or surgical site is another indication to be concerned about.
   
   
5. Bleeding: Unexplainable bleeding from the surgical site, stools, or vomit.
6. Irregular Bowel Movement: The absence of a bowel movement or watery stools (diarrhoea) for more than three days is a concerning symptom. Another indication includes white or pale-coloured stools.
7. Recurring Symptom: Recurrent or worsening jaundice. This can imply the failure of the surgery and requires immediate attention.

The cost of Kasai Procedure ranges from ₹2,00,000 to ₹4,00,000. The cost varies based on factors like the type of surgery (open or laparoscopic), the patient's condition and the chosen location, hospital, and surgeon.

The Kasai procedure is crucial for babies with biliary atresia as it reduces liver damage and may eliminate the need for future transplantation. However, post-surgery care and consulting a doctor for any concerning symptoms are essential.

Have concerns about how to proceed further? HexaHealth is here to provide a trustworthy solution for your baby's treatment journey. Our expert panel of doctors and consultants can assist you throughout the surgery, including guidance on insurance claims and health loans. Contact us now for assistance.