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Error Traps and Culture of Safety in Biliary Atresia

Video Published 2019-11-19 Updated 2024-02-10

Timestops (10)

The June issue of seminars on pediatric surgery focused on a…

The June issue of seminars on pediatric surgery focused on a topic that's important to every pediatric surgeon, improvin…

The first potential error trap in biliary tresia is not cons…

The first potential error trap in biliary tresia is not considering biliary tresia in the differential diagnosis of any …

Alpha one antitrypsin deficiency needs to be ruled out prior…

Alpha one antitrypsin deficiency needs to be ruled out prior to proceeding to the operating room, as this can be a confu…

Findings on pathology such as bridging fibrosis

Findings on pathology such as bridging fibrosis, bile duct plugging, and proliferation of bile ductres are all suggestiv…

This is because age at the time of Kasai is the primary dete…

This is because age at the time of Kasai is the primary determinant of outcome in these patients. The next potential err…

To avoid this, we have adopted the technique of mobilizing the gallbladder off of the gallbladder fossa, amputating the …

More commonly but still rare are confusing branching pattern…

More commonly but still rare are confusing branching patterns of the hepatic artery and the portal vein. It is recommend…

The most reliable determinant of where the hilar plate exist…

The most reliable determinant of where the hilar plate exists is between the bifurcation of the right and left portal ve…

We try to choose a plane that is flush with the capsule of t…

We try to choose a plane that is flush with the capsule of the liver so that we are not dissecting into the substance of…

The use of antibiotics prophylactically to prevent cholangit…

The use of antibiotics prophylactically to prevent cholangitis is also a controversial topic. We currently are using pro…

Topic Overview

A surgical teaching video on biliary atresia management, focusing on error prevention across diagnosis, workup, operative technique, and postoperative care. Dr. Jonathan Roach reviews diagnostic thresholds (direct bilirubin >20% of total or >1.0), preoperative workup including alpha-1 antitrypsin exclusion and liver biopsy findings, and emphasizes that age at Kasai procedure is the primary outcome determinant. Operative teaching covers cholangiogram technique modifications, recognition of vascular variants at the porta hepatis, and proper transection plane selection flush with the liver capsule. Postoperative discussion notes the START trial ended routine steroid use, while prophylactic antibiotic practice remains institution-dependent.

Key Takeaways

Direct bilirubin >20% of total or >1.0 in newborns >2 weeks warrants biliary atresia workup including alpha-1 antitrypsin exclusion. (0:30)
Age at Kasai is the primary outcome determinant; proceed to OR when workup is suggestive without waiting for all esoteric tests. (1:41)
Transect biliary remnants flush with liver capsule at portal vein bifurcation—not too deep into parenchyma, not too shallow. (3:10)
START trial ended routine postoperative steroid use; prophylactic antibiotic practice remains institution-dependent. (4:00)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Speaker 2 — host
Speaker 3 — host
Speaker 4 — host
Dr. Jonathan Roach — guest

Chapters

0:00Introduction — Series introduction to culture of safety in pediatric surgery subspecialties, introducing guest reviewer Dr. Jonathan Roach.
0:30Diagnostic Error Traps — Diagnostic thresholds for biliary atresia, preoperative workup including labs and imaging, and timing considerations for proceeding to surgery.
1:56Intraoperative Error Traps — Cholangiogram technique, recognition of vascular variants at the porta hepatis, dissection landmarks, and proper transection plane selection.
3:52Postoperative Error Traps and Follow-up — Postoperative steroid use based on START trial, prophylactic antibiotic controversy, and need for long-term multidisciplinary follow-up.

Key claims

0:30Biliary atresia should be considered in the differential diagnosis of any newborn greater than 2 weeks of life with hyperbilirubinemia — Dr. Jonathan Roach
0:40A direct bilirubin greater than 20% of the total or greater than 1.0 prompts further workup for biliary atresia — Dr. Jonathan Roach
0:58Alpha one antitrypsin deficiency needs to be ruled out prior to proceeding to the operating room, as this can be a confusing picture intraoperatively — Dr. Jonathan Roach
1:07Ultrasound findings in biliary atresia workup include abnormalities in the gallbladder and the triangular cord sign — Dr. Jonathan Roach
1:17Liver biopsy findings suggestive of biliary atresia include bridging fibrosis, bile duct plugging, and proliferation of bile ductules — Dr. Jonathan Roach
1:41There is no need to wait for the result of every esoteric test prior to proceeding to the operating room if workup is suggestive of biliary atresia — Dr. Jonathan Roach
1:50Age at the time of Kasai is the primary determinant of outcome in biliary atresia patients — Dr. Jonathan Roach
2:04Some gallbladders in biliary atresia do not have lumen, and in these patients further exploration and likely Kasai is performed — Dr. Jonathan Roach
2:19To avoid contrast extravasation during cholangiogram, the technique involves mobilizing the gallbladder off the fossa, amputating the dome, inserting the catheter directly into the lumen, and tying off with silk ligature — Dr. Jonathan Roach
2:40Vascular variants in biliary atresia may include a preduodenal portal vein, which is rare — Dr. Jonathan Roach
2:43Confusing branching patterns of the hepatic artery and portal vein are more common but still rare — Dr. Jonathan Roach
2:51It is recommended to carry out dissection to the secondary branching of the right and left hepatic arteries — Dr. Jonathan Roach
2:51When hepatic artery branching is quite early, dissection needs to occur up to the substance of the liver — Dr. Jonathan Roach
3:10The most reliable determinant of where the hilar plate exists is between the bifurcation of the right and left portal vein — Dr. Jonathan Roach
3:19It is important to dissect the fibrous cone of the biliary remnants down into the bifurcation of the portal vein where small portal branches must be tied off — Dr. Jonathan Roach
3:37The transection plane of biliary remnants should be flush with the capsule of the liver, not dissecting into the substance of the liver nor remaining too shallow into the fibrous cone — Dr. Jonathan Roach
4:00Due to the results of the START trial, steroids are no longer routinely used in postoperative care for biliary atresia — Dr. Jonathan Roach
4:08The use of antibiotics prophylactically to prevent cholangitis is a controversial topic — Dr. Jonathan Roach
4:15The speaker's institution currently uses prophylactic antibiotics on all patients after Kasai — Dr. Jonathan Roach
4:23Biliary atresia patients require long-term follow-up care either with the pediatric surgeon or with the pediatric hepatologist — Dr. Jonathan Roach

Open questions

What is the optimal prophylactic antibiotic regimen after Kasai procedure to prevent cholangitis?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Keywords

biliary atresia hyperbilirubinemia alpha one antitrypsin deficiency cholangitis Kasai procedure cholangiogram percutaneous liver biopsy ultrasound steroids antibiotics

Hashtags

#biliaryatresia #pediatricsurgery #errortraps #cultureofsafety #pediatrichepatology #kasai #hyperbilirubinemia #KasaiProcedure #PatientSafety

Transcript

The June issue of seminars on pediatric surgery focused on a topic that's important to every pediatric surgeon, improving the healthcare we deliver to children around the world. Follow along with our latest video series as we highlight articles that help enhance the culture of safety in various pediatric surgical subspecialties. And you might recognize a few well-known faces and names along the way. Here's a quick summary of air traps and culture of safety in Bay Area Tresia with guest video reviewer Dr. Jonathan Roach. The first potential error trap in biliary tresia is not considering biliary tresia in the differential diagnosis of any newborn greater than 2 weeks of life with hyperbilirubinemia. We consider a direct bilirubin that is greater than 20% of the total or greater than 1.0 to prompt further workup for biliarytresia. The next potential error trap is an incomplete or inappropriate lab and radiographic workup for biliaryresia. Alpha one antitrypsin deficiency needs to be ruled out prior to proceeding to the operating room, as this can be a confusing picture intraoperatively. Furthermore, we obtained ultrasounds on all these patients to look for abnormalities in the gallbladder as well as the triangular cord sign. Lastly, these patients will receive a percutaneous liver biopsy. Findings on pathology such as bridging fibrosis, bile duct plugging, and proliferation of bile ductres are all suggestive of biliary atresia. With this workup complete, we then proceed to the operating room for cholangiogram should the diagnosis of biliary atresia be thought of as likely. If your workup is suggestive of biliary atresia, there's no need to wait for the result of every esoteric test prior to proceeding to the operating room. This is because age at the time of Kasai is the primary determinant of outcome in these patients. The next potential error trap are intraoperative error traps. First, there can be difficulty performing a chalangiogram. Some gallbladders do not have lumen, and in these patients we will proceed with further exploration and likely cassa. Another problem is extravasation of the contrast through the hole in the gallbladder. To avoid this, we have adopted the technique of mobilizing the gallbladder off of the gallbladder fossa, amputating the dome of the gallbladder, and inserting the changia catheter directly into the lumen of the gallbladder, and simply tying this off with a silk ligature. The next potential error trap in the operating room is the failure to recognize vascular variants. There may be a preduodenal portal vein, which is rare. More commonly but still rare are confusing branching patterns of the hepatic artery and the portal vein. It is recommended to carry out dissection to the secondary branching of the right and left hepatic arteries, but sometimes this branching can be quite early, and the dissection needs to occur up to the substance of the liver. There can also be various branching patterns in the portal vein which can confuse the picture. The most reliable determinant of where the hilar plate exists is between the bifurcation of the right and left portal vein. It is also important to dissect the fibrous cone of the biliary remnants down into the bifurcation of the portal vein where small portal branches must be tied off. The last potential air trap within the operating room is an inappropriate transection plane of the biliary remnants. We try to choose a plane that is flush with the capsule of the liver so that we are not dissecting into the substance of the liver nor remaining too shallow into the fibrous cone for the amputation of the biliary remnants. Potential post-operative air traps include the use of steroids or antibiotics. Due to the results of the START trial, we no longer routinely use steroids in our post-operative care. The use of antibiotics prophylactically to prevent cholangitis is also a controversial topic. We currently are using prophylactic antibiotics on all patients after Kasai. The last potential error trap is in long-term follow up. These patients require long-term follow-up care either with the pediatric surgeon or with the pediatric hepatologist. Thank you very much.

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