Kasai Portoenterostomy (Biliary Atresia)
4770174300wRVU: 0.0 — Intraoperative cholangiogram (if performed to confirm diagnosis)47100wRVU: 12.59 — Liver biopsy (if performed at same setting)
Biliary atresia, neonatal cholestasis with [direct hyperbilirubinemia / acholic stools / HIDA scan non-excretion]
Same
Hepatic portoenterostomy (Kasai) with Roux-en-Y reconstruction
[Attending name], MD
[Resident name]
General endotracheal. NGT placed.
Patient is a [X]-week-old [male / female] presenting with neonatal cholestasis and direct hyperbilirubinemia (direct bilirubin [X] mg/dL), acholic stools, and [HIDA scan without biliary excretion / liver biopsy consistent with biliary atresia]. Evaluation complete with no correctable anatomic cause identified. Risks including cholangitis (most common postoperative complication), failure of bile flow, cirrhosis progression, and eventual liver transplant discussed with parents. Best outcomes when performed before [60 / 90] days of life. Consent obtained.
Triangular cord sign confirmed intraoperatively. Extrahepatic biliary tree fibrotic and atretic ([no identifiable lumen at common bile duct / gallbladder small and fibrotic / common hepatic duct atretic at hilum]). [Intraoperative cholangiogram confirmed no biliary drainage.] Liver [enlarged / normal size] with [early cirrhotic / mild fibrotic] changes. Hilar plate dissected to [X] mm above bifurcation.
The patient was positioned supine. A transverse right upper quadrant incision was made with midline extension. The liver was mobilized. The porta hepatis was exposed. The gallbladder was dissected free and used as a handle. [Intraoperative cholangiogram performed. No bile flow confirmed.]
The extrahepatic biliary tree was found to be completely atretic. The fibrous remnant was dissected at the porta hepatis to the level of the hilar plate. The hilar plate was dissected and the fibrous cone excised with fine scissors at the level of the bifurcation, exposing any patent ductules at the cut surface. The liver capsule was not entered.
A 40-cm Roux-en-Y jejunal limb was constructed. The Roux limb was brought up to the liver hilum in a [retrocolic / antecolic] position. A portoenterostomy was created by suturing the Roux limb to the hilar plate circumferentially with [interrupted / running 5-0 PDS], creating a wide anastomosis to any patent bile ductules.
[Liver biopsy taken from left lobe and sent to pathology.]
The hilar anastomosis was inspected. Fascia closed with [running 0-PDS]. Skin closed. Patient tolerated the procedure well.
None
[Fibrous biliary remnant and gallbladder to pathology / Liver biopsy to pathology]
[X] mL
[Jackson-Pratt drain near hilum / None]
Patient transferred to NICU/PICU intubated in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Biliary atresia with neonatal cholestasis, direct hyperbilirubinemia, acholic stools
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Hepatic portoenterostomy (Kasai) with Roux-en-Y reconstruction
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, NGT placed
INDICATIONS: The patient is a .PTAGE-old .PTSEX with neonatal cholestasis, direct bilirubin *** mg/dL, acholic stools, and HIDA scan without biliary excretion consistent with biliary atresia. Risks including cholangitis, failure of bile flow, cirrhosis, and eventual transplant discussed with parents. Informed consent obtained.
FINDINGS: Triangular cord sign confirmed. Extrahepatic biliary tree completely atretic with no identifiable lumen. [Intraoperative cholangiogram: no bile flow.] Liver [enlarged / mildly fibrotic]. Hilar plate dissected to expose patent ductules.
DESCRIPTION OF PROCEDURE:
Patient supine. Transverse RUQ incision with midline extension. Liver mobilized. Porta hepatis exposed. Gallbladder used as handle. [Intraoperative cholangiogram confirmed atresia.] Extrahepatic biliary remnant dissected at porta hepatis to hilar plate level. Fibrous cone excised with fine scissors at bifurcation. Liver capsule not entered. 40-cm Roux-en-Y jejunal limb constructed and brought [retrocolic / antecolic] to hilum. Portoenterostomy created with circumferential interrupted/running 5-0 PDS anastomosis to hilar plate. [Liver biopsy taken and sent.] Fascia closed with 0-PDS. Skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Biliary remnant and gallbladder to pathology; [liver biopsy to pathology]
COMPLICATIONS: None
DRAINS: [JP drain near hilum / None]
DISPOSITION: Patient to NICU/PICU intubated, stable.
Signed: .ME, .MYDEGREE
.TODAYVariants
Failed Kasai / transplant evaluation
Patients with inadequate bile flow post-Kasai (total bilirubin >2 mg/dL at 3 months) should be referred for liver transplant evaluation. Document bile flow response in follow-up notes.
Cholangitis after Kasai
Most common postoperative complication. Treated with IV antibiotics and steroids. Recurrent cholangitis is an indication for transplant evaluation. Operative management (revision) is rarely indicated.
Charting Tips
- Document age at time of surgery, as outcomes are significantly worse after 90 days of life
- Confirm hilar plate dissection level and that fibrous cone was excised to bifurcation
- Note bile ductule visualization or absence at cut surface
- Document Roux limb length (40 cm standard) and route (retrocolic vs. antecolic)
- Record anastomosis technique at hilum (wide, circumferential, no tension)
- Send fibrous remnant AND gallbladder to pathology to confirm biliary atresia histologically
Billing Tips
- Bill 47701 for hepatic portoenterostomy (Kasai procedure, 27.59 wRVU, 90-day global). This is the definitive code for the Kasai. No modifier or add-on is needed for the Roux-en-Y reconstruction, which is included.
- Intraoperative cholangiogram (if performed to confirm biliary atresia diagnosis at the time of the Kasai) is separately billable with 74300. Document the findings, as the cholangiogram drives the decision to proceed with the Kasai vs. close.
- Liver biopsy performed at the time of surgery is separately billable with 47100. Document it separately. The biopsy provides staging information and confirms biliary atresia histologically.
- 90-day global: cholangitis admissions, steroid protocols, and NICU/floor management are not surgical fee items within the global, but they generate separate E/M and hospital billing. Kasai revision or hepaticojejunostomy revision uses modifier -78 if within 90 days.
- Patients who fail the Kasai and proceed to liver transplant: the transplant is billed as a new procedure with its own global period. The Kasai does not affect transplant billing.