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Indian Pediatr 2017;54: 690-691 |
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Outcome of Biliary Atresia After Kasai’s
Portoenterostomy: Few Concerns: Authors Reply
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Rajeev Gurunath Redkar
Department of Pediatric Surgery, Lilawati Hospital,
Bandra (West) Mumbai, Maharashtra, India.
Email: [email protected]
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The points raised by these readers include utilization of liver biopsy
rather than HIDA scan for diagnosis of biliary atresia. We would like to
clarify that as mentioned in our methods, all patients underwent
clinical examination, stool color examination, liver function tests and
ultrasonography of abdomen. While TORCH serology and a HIDA scan were
done in most patients [1], we have relied on intra-operative
cholangiogram as the diagnostic test for BA, which is still considered
the gold-standard for its diagnosis [2]. In addition, the interpretation
of a biopsy can be difficult and needs an experienced pathologist as
there is a lot of overlap in the histological findings of biliary
atresia and neonatal hepatitis [3]. Infact, lack of expertise in
histopathology has also refrained us from incorporating histological
findings in our study report. We have accepted that as one of the
limitations in our study [1].
The reviewer also pointed on testing for TORCH
serology and treatment for the same. As mentioned above, TORCH serology
was done in most (n=78/121) patients as a part of workup for
neonatal cholestasis. Ganciclovir was started after a CMV-PCR
confirmation (not mentioned in the article), without alteration or delay
in the usual workup and management of biliary atresia. CMV positive
biliary atresia patients have poorer outcome with reduced jaundice
clearance, native liver survival and increased mortality [4]. We usually
treat patients of BA associated with CMV with ganciclovir.
In our study, although 14% of patients presented with
clinical ascites, most of them (n= 11/14, 78.6%) had normal or
borderline albumin levels with normal bleeding parameters. Out of these,
four patients had jaundice clearance, and were alive at 1 year. This
cannot be considered as a poor outcome, especially considering the
non-feasibility of primary liver transplantation in our country. Factors
like scarcity of organs and centers offering pediatric liver transplant
programs, financial constraints and need for lifelong immunosuppression,
make Kasai’s Portoenterostomy as the initial procedure of choice, even
for patients with late presentations [1,5].
References
1. Redkar R, Karkera PJ, Raj V, Bangar A, Hathiramani
V, Krishnan J. Outcome of biliary atresia after Kasai’s portoenterostomy:
A 15-year experience. Indian Pediatr. 2017;54:291-4.
2. Wildhaber BE. Biliary Atresia: 50 Years after the
First Kasai. ISRN Surgery. 2012;2012:132089. doi:10.5402/2012/132089.
3. Sinha CK, Davenport M. Biliary atresia . J Indian
Assoc Pediatr Surg 2008; 13:49-56.
4. Zani A, Quaglia A, Hadziæ N, Zuckerman
M, Davenport M. Cytomegalovirus-associated biliary atresia: An
aetiological and prognostic subgroup. J Pediatr Surg. 2015;50:1739-45.
5. Govindrajan KK. Biliary Atresia: current trends in outcome and
management. Indian Pediatr. 2017;54:277.
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