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Delphi Method Analysis and Consensus of Prevalent Distinctive Practices for Biliary Atresia Management after Kasai
Sravanthi Vutukuru1, Shailesh Solanki2, Ravi Prakash Kanojia2
1Department of Pediatric Surgery, Siddhartha Medical College, Vijayawada, Andhra Pradesh, India.
Insights
Postoperative management for biliary atresia (BA) after Kasai portoenterostomy (KPE) lacks a standard protocol. A Delphi survey revealed expert consensus on drug use, with many willing to adapt their practices.
Area of Science:
- Pediatric surgery
- Gastroenterology
- Neonatal care
Background:
- Biliary atresia (BA) is a neonatal condition requiring Kasai portoenterostomy (KPE).
- Post-KPE management involves medications to improve bile flow and prevent complications.
- Current postoperative protocols for BA vary significantly among surgeons and institutions.
Purpose of the Study:
- To survey expert opinions on current postoperative management of BA.
- To assess expert willingness to modify practices based on Delphi survey results.
Main Methods:
- A Delphi process involving a two-round questionnaire survey.
- Data collection from 25 pediatric surgical experts on BA management.
- Analysis of survey responses to identify consensus and areas for practice change.
Main Results:
- Expert practices vary regarding antibiotic duration (6-12 weeks for 40%, >12 weeks for 30%).
- Phenobarbitone use is common (<3 months for ~50%), as is UDCA (duration varies).
- Steroids are used by ~50%, and antivirals are given for CMV IgM positivity in ~60%.
Conclusions:
- The Delphi survey provides an overview of current BA postoperative management.
- A significant portion of experts indicated a willingness to change their practice based on consensus.
- Multicenter studies are needed to establish a uniform protocol for BA postoperative care.
Background:
Extrahepatic biliary atresia (BA) is seen in infants, with an incidence of 1 in 15,000 live births. The presentation is progressive jaundice, dark-colored urine, and clay-colored stools. Kasai portoenterostomy (KPE) is the commonly performed surgical procedure in these patients. Postoperatively, phenobarbitone, ursodeoxycholic acid (UDCA), steroids, and other drugs are given to improve bile drainage and prevent inflammation and fibrosis. However, a definitive protocol regarding the need for different drugs, dosage, and duration varies across individual surgeons and centers. No universally accepted protocol exists for postoperative management after KPE.
Aim:
The aim of this study was to know the prevailing postoperative management of BA by subject experts and use the Delphi process to know if the experts want to change their practice based on the results from the survey.
Material And Methods:
A questionnaire was made after discussing with two experts in the field of BA. The questionnaire was mailed to 25 subject experts. The first survey data were analyzed and shared with all responders. In the second survey, change in the management based on the results from the first survey was assessed.
Results:
The Delphi questionnaire was answered by 17 experts. Postoperatively, prophylactic antibiotics are prescribed for 6-12 weeks by around 40% and >12 weeks by 30% of respondents. Phenobarbitone is prescribed for <3 months by nearly 50%. UDCA is prescribed for <3 months, ≤6 months, and 6 months-1 year by 47.1%, 23.5%, and 23.5% responders, respectively. Nearly 50% prescribe steroids (mostly prednisolone), and among them, two-thirds prescribe it for 6-12 weeks. Approximately 60% give antiviral drugs to children who are cytomegalovirus immunoglobulin M positive. In our survey, 50% of experts perform 5-10 KPE per year, and 25% each perform 10-15 and >15 KPE per year. The second survey noted that a significant percentage of responders want to change their practice according to consensus.
Conclusion:
From our Delphi survey, an overview of the postoperative management of BA could be made. However, multicentric studies are required for uniform protocol on the postoperative management of BA.
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