The Kasai procedure is performed in babies having biliary atresia. Biliary atresia is a congenital disability in newborn babies. In this condition, there is a blockage in the duct that carries bile from the liver to the gallbladder. The blockage happens when the bile ducts inside or outside the liver do not develop properly. This may lead to Liver Cirrhosis, i.e., liver damage, which can be fatal if left untreated.
The Kasai surgery helps to connect the liver directly to the small intestine, bypassing the damaged bile ducts. The surgery is most successful if performed before the baby is eight weeks old. Yet, some babies may require a Liver Transplant.
|Procedure Name||Kasai Procedure|
Polysplenia, Asplenia, Malrotation, Heart defects.
|Benefits of Procedure||Improves Liver Function, Life Saving|
|Treated By||Surgical Gastroenterologist|
What is Kasai Procedure?
The Kasai procedure is a surgery performed to remove the damaged or blocked bile ducts present outside the liver in babies. The doctor replaces the damaged duct with a segment of the child's small intestine. This segment is joined to the liver and acts as a new extrahepatic bile duct system.
Anatomy and Physiology of the Liver
The anatomy of the liver and biliary system is as follows:
- The liver cells secrete bile which is collected by a system of ducts flowing from inside the liver and draining into two main tubes i.e., the right and left hepatic ducts. These collect bile from the right and left lobes of the liver, respectively.
- The two ducts then drain the bile into the common hepatic duct.
- Further, the common hepatic duct joins the cystic duct that exits from the gallbladder (pear-shaped organ) to form the common bile duct. This duct runs from the liver to the duodenum (1st part of the small intestine).
- Around 50% of the bile produced by the liver gets stored in the gallbladder.
- After food intake, the gallbladder contracts and releases stored bile into the duodenum to break down and absorb fats.
Conditions treated with Kasai Procedure
A pediatric surgeon generally recommends the Kasai procedure to treat various types of biliary atresia (Type I, II, and III biliary atresias). The Kasai procedure also helps in treating the following conditions as well:
- Polysplenia (multiple small spleens)
- Asplenia (absence of spleen)
- Malrotation (the position of the small intestine is abnormal)
- Heart defects
If any or all of these conditions are present, the condition is known as biliary atresia-splenic malformation syndrome (BASM).
Who needs Kasai Procedure?
- Kasai operation is performed on newborn babies with biliary atresia and relieves symptoms like jaundice, swollen belly, and ascites (fluid in the belly) in the baby.
- In Types I and II, some of the bile ducts near the liver may be open, whereas, in type III, all the ducts outside the liver are blocked.
How is Kasai Surgery Performed?
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:
- Make a cut below the ribs on the right of the abdomen to inspect the bile ducts.
- Perform a cholangiogram to confirm the diagnosis of biliary atresia. The doctor puts a small tube into the gallbladder and injects medication to find the bile ducts using an X-ray. If the bile ducts and gallbladder are not open and the bile cannot be drained, then the baby will have biliary atresia.
- Remove the damaged bile ducts and abnormal gallbladder outside of the liver.
- Replaces them with the patient’s small intestine.
- The new small intestine bypass drains the liver directly to the duodenum.
What to expect Before and on the day of Kasai Procedure?
Before the Kasai Procedure
- Perform blood tests to check the baby’s blood group (if the baby requires blood before, during and after the surgery) and other tests like ultrasound, liver biopsy, cholangiogram (a dye injected into the gallbladder to see the main bile duct), and hepatobiliary scan.
- Explain to the parent what the surgery involves.
- Give special medicines to the baby to prepare the gut for the Kasai surgery.
- Inform the parent not to feed milk a few hours before the surgery.
- Ask the mother to speak to the nurse if you are breastfeeding for milk storage.
On the day of the Kasai Procedure
On the day of surgery, the patient must expect the following:
- The surgery may last a whole morning or afternoon.
- The doctor will administer fluids and pain-relieving medicines through the IV.
- The anesthesiologist will inject general anaesthesia to make the baby unconscious.
- The baby will be continuously monitored throughout and after the surgery.
During the Kasai Procedure
During the surgery, the doctor will:
- Assess the liver to check for any abnormalities.
- Remove a tiny piece of the liver for liver biopsy.
- Carry out the Kasai operation and make a new tube for bile passage, by using a small loop of the intestine as a replacement.
- One end will be connected to the liver, and the other end of the tube will drain the bile from the liver directly into the small intestine part called the duodenum.
- Remove the gallbladder and all the abnormal bile ducts outside the liver.
What to expect after the Kasai Procedure?
After the surgery, the doctor will:
- Cover the wound with dressing for the first few days.
- Insert a urinary catheter to drain urine from the bladder. This measures the urine output to ensure that the kidneys are working properly.
- Place an abdominal drain to drain the excess fluid and blood from the liver.
- The baby will be moved to the recovery area.
- Notify the parents about the nasogastric tube that runs from the baby’s nose into the stomach. The parent will not be allowed to feed the baby for a few days.
- Inform the parents to keep the baby’s stomach empty for 48 to 72 hours.
- Give pain-relieving medicines through the small tube inserted into the baby’s nose during the surgery.
- Give antibiotics through an intravenous (IV) for three to five days. Fluid and blood products are given through the IV too. The fluids balance the salt, sugar, and water level in the body.
- Allow taking the baby home after seven to ten days, depending on the baby’s recovery.
The parents should:
- Ask the parents to weigh the baby every week to monitor weight gain.
- Tell the parents to check the baby's temperature, stool, urine, and general health for signs of infection and jaundice.
- Clean the surgical area as instructed by the doctor.
- Give medications, like antibiotics, vitamins, steroids, Ursodeoxycholic acid (URSO), ranitidine, etc., as per the baby’s condition.
- If the baby develops a fever, stops eating, has fewer wet diapers, or feels weak, parents should consult their doctor.
First follow-up appointment
The doctor will discuss the follow-up plan with the parents. The first follow-up appointment is mostly scheduled two weeks after the discharge from the hospital to monitor liver function and its growth.
The baby should also follow up with their pediatric gastroenterologist and pediatric surgeon. After the surgery, the patient must visit their doctor for the first five years to monitor the liver.
Benefits of Kasai Procedure
The benefits of the Kasai surgery are that the procedure:
- Helps lower the symptoms of biliary atresia.
- Prevents liver damage and cirrhosis.
- Reduces the chances of needing a liver transplant.
Risk and complications of Kasai Procedure
The risks and complications that can occur during the Kasai procedure include:
- Hole in the intestine
- Acute kidney injury
When is consultation with the Doctor needed?
Parents should consult the doctor if they notice any side effects and complications. Possible risks/complications that may occur after the surgery include:
- Bleeding from the surgical site
- Kasai procedure scar causing intestinal blockage
- Infection of the liver and bile ducts (cholangitis)
- Hole in the intestine, causing leakage of the intestinal contents into the stomach.
- Itching of the skin
- Portal hypertension (high blood pressure in the portal vein that carries blood from the stomach to the liver).
Cost of the Procedure
The cost of Kasai Procedure ranges from ₹2,00,000 to ₹4,00,000. The cost varies based on the following factors:
- Type of Kasai surgery
- Age of the patient
- The medical condition of the patient
- The type of hospital facility availed - individual room or shared.
|Procedure Name||Cost Value|
|Kasai Procedure||₹2,00,000 to ₹4,00,000|
Frequently Asked Questions on Kasai Procedure
What are some Myths and Facts about Kasai Procedure?
Some of the myths related to Kasai surgery are:
- Myth: The child will be hospitalized for several weeks after the Kasai operation.
Fact: After the Kasai surgery, parents can take their baby home after 7-10 days.
- Myth: There is no treatment for biliary atresia.
Fact: There is no medical cure for biliary atresia; however, Kasai surgery is the primary treatment for biliary atresia. This surgery helps remove the damaged bile ducts and replace them with a small piece of the intestine.
- Myth: Kasai surgery is not successful.
Fact: The Kasai surgery is a successful procedure in most cases. However, there are chances of the surgery failing, just like any other surgery can, which may result in liver damage which continues to deteriorate liver functions and general health.
- Myth: There are no risks involved in the Kasai operation.
Fact: Like other surgeries, even Kasai surgery has risks/complications like bleeding, itching, infection of the liver and bile ducts, etc. However, the surgery is primarily extremely safe.
- Myth: Biliary atresia is inherited from the parents.
Fact: Biliary atresia is not inherited from the parents. The exact cause of biliary atresia is unknown but it might occur due to viral infection, scarring and inflammation due to problems with the immune system, exposure to toxic chemicals, or changes in the genes (which are not related to genetics).
What happens after Kasai operation?
If there is no problem after the Kasai surgery, the baby can go home after around seven to ten days. The hospital staff will ensure that the surgical site is healing and shows no signs of infection. Further, the doctor will guide you for your first follow-up appointment.  The baby’s symptoms of jaundice and fever start resolving after the operation, and baby starts gaining healthy weight.
How long does the Kasai procedure last?
The Kasai surgery can last the entire morning or afternoon, depending on your baby’s condition.
What is the most common complication associated with the Kasai procedure?
Some of the complications of the Kasai surgery include bleeding, intestinal blockage, gall bladder inflammation, and a hole in the intestine resulting in leakage of intestinal content into the belly.
How do you know Kasai is successful?
If the Kasai surgery is a success, the bile drainage starts and gradually, the stool colour changes to yellow/brown/green, and the urine becomes pale from dark yellow. Further, jaundice gradually fades, and blood tests are done to confirm the bilirubin levels have dropped to a normal level. Furthermore, regular check-ups are done to assess recovery. In the follow-up appointment scheduled after two weeks, the doctor monitors the liver function and overall growth and development of the baby.
Is the Kasai procedure permanent?
After the Kasai surgery, how long a child lives without a liver transplant depends on the condition of the liver at the time of surgery and when the procedure was done. Even after successful surgery, some patients require a liver transplant at some point in their lives.
What happens if the Kasai procedure fails?
What is failed Kasai?
A failed Kasai surgery is when bile produced in the liver builds up even after creating the bypass for it, causing liver damage and cirrhosis. It may also show side effects like infection of the bile ducts and liver, bleeding from the surgical site, blockage in the intestine, etc.
Is the Kasai procedure curative?
The Kasai procedure is not curative but aids in lowering the symptoms caused by biliary atresia.
When is Kasai done?
The Kasai surgery is done when a baby is diagnosed with biliary atresia. It is a condition in babies where the bile gets blocked from flowing to the small intestine through the liver.
Is the Kasai procedure safe?
The Kasai surgery is safe and successful in most cases. However, unlike other surgeries, Kasai surgery may have certain risks and show complications like postoperative infection, bleeding from the surgical site, intestinal blockage, etc.
How long can you live after the Kasai procedure?
After the Kasai surgery, how long the child lives depends on the condition of the liver during the surgery and when the surgery was done.
How do you care for a biliary drain tube?
You will have a drain placed in your biliary system, which you must take utmost care of until removed. This will be instructed to you by your doctor. The care includes daily flushing, cleaning the tube site, and changing the dressing.