Portal Plate Research Articles

Cystic plate approach combined with ICG fluorescence in laparoscopic anatomical hepatectomy.

The in-depth understanding of the fine anatomy of the liver has promoted the development of modern liver surgery. With the rapid popularity of laparoscopic hepatectomy, the membrane structure of the liver and its ability to dissect the intrahepatic and extrahepatic vascular system more conveniently and accurately has been gradually emphasized. Exploring the value of extrahepatic sheath dissection of the hepatic pedicle in minimally invasive anatomical hepatectomy with cystic plate approach. This study aims to assess the benefits of integrating the cystic plate approach with real-time guided laparoscopic anatomical hepatectomy, in comparison with conventional laparoscopic anatomical hepatectomy. Based on the theory of cystic plate and hepatic portal plate, the authors have pioneered the fluorescence real-time guided cystic plate approach in hepatectomy. The article focuses on the anatomical knowledge and technical difficulties of anatomical hepatectomy with fluoroscopic laparoscopic cystic plate approach and explores the safety and practicality of the cystic plate approach in laparoscopic anatomical hepatectomy. Additionally, a retrospective cohort study was also conducted to compare the operation time, intraoperative blood loss, and postoperative complications between the cystic plate approach and the conventional approach during fluoroscopic laparoscopic hepatectomy. A total of 38 patients who met the inclusion criteria underwent laparoscopic hepatectomy between January 2019 and November 2022. No significant disadvantages were found in terms of operation time and intraoperative blood loss during the surgeries. Furthermore, the postoperative indications, including liver function indexes on the first postoperative day, WBC, and the postoperative hospital stay, were also not affected, thus proving the safety of the cystic approach. Importantly, through the cystic plate approach, the target liver pedicle was fully freed, and then the segments to be resected were precisely marked by positive or negative staining, followed by hepatectomy under real-time fluoroscopic guidance. This approach is extremely advantageous in anatomical liver segment resections, especially in right posterior lobe or hemi-hepatectomy, without increasing intraoperative bleeding or postoperative complication rates. This technique allows for easy and safe freeing of the target liver pedicle using membrane structures, and also allows for precise anatomical hepatectomy in combination with real-time fluoroscopic laparoscopic navigation.

Assessment of a novel biliary-specific near-infrared fluorescent dye (BL-760) for intraoperative detection of bile ducts and biliary leaks during hepatectomy in a preclinical swine model.

Postoperative bile leakage is a common complication of hepatobiliary surgery and frequently requires procedural intervention. Bile-label 760 (BL-760), a novel near-infrared dye, has emerged as a promising tool for identifying biliary structures and leakage, owing to its rapid excretion and strong bile specificity. This study aimed to assess the intraoperative detection of biliary leakage using intravenously administered BL-760 compared with intravenous (IV) and intraductal (ID) indocyanine green (ICG). Laparotomy and segmental hepatectomy with vascular control were performed on two 25-30 kg pigs. ID ICG, IV ICG, and IV BL-760 were administered separately, followed by an examination of the liver parenchyma, cut liver edge, and extrahepatic bile ducts for areas of leakage. The duration of intra- and extrahepatic fluorescence detection was assessed, and the target-to-background (TBR) of the bile ducts to the liver parenchyma was quantitatively measured. In Animal 1, after intraoperative BL-760 injection, three areas of leaking bile were identified within 5 min on the cut liver edge with a TBR of 2.5-3.8 that was not apparent to the naked eye. In contrast, after IV ICG administration, the background parenchymal signal and bleeding obscured the areas of bile leakage. A second dose of BL-760 demonstrated the utility of repeated injections, confirming two of the three previously visualized areas of bile leakage and revealing one previously unseen leak. In Animal 2, neither ID ICG nor IV BL-760 injections showed obvious areas of bile leakage. However, fluorescence signals were observed within the superficial intrahepatic bile ducts after both injections. BL-760 enables the rapid intraoperative visualization of small biliary structures and leaks, with the benefits of fast excretion, repeatable intravenous administration, and high-fluorescence TBR in the liver parenchyma. Potential applications include the identification of bile flow in the portal plate, biliary leak or duct injury, and postoperative monitoring of drain output. A thorough assessment of the intraoperative biliary anatomy could limit the need for postoperative drain placement, a possible contributor to severe complications and postoperative bile leak.

FEATURES OF THE STRUCTURE OF THE CONNECTIVE TISSUE LOCATED IN THE PORTAL OF THE LIVER

Authors studied the connective tissue on the basis of the obtained results. In the transverse sulcus of the liver and the left sagittal sulcus. They concluded that separation of the portal plate (along with the right and left portal equity portal complexes) and the liver parenchyma by the blunt method, does not have the risk of damage for the small portal tracts, portal plate and the liver parenchyma.

Features of Ductular Reaction in Rats with Extrahepatic Cholestasis.

Ductular reaction develops during liver regeneration, fibrosis, and carcinogenesis. However, the types, stages of formation, and topography of ductular profiles in various pathologies remain insufficiently studied. Using the model of common bile duct occlusion, we showed that the number and topography of ductular profiles are closely related to the duration of biliary obstruction. The ductular profiles can be located inside the portal tract, along the existing bile ducts, and/or intramurally, around the portal vein, periportally, inside the lobules, in the portocaval fibrous connections, in the adventitia of the hepatic veins, in the septs connecting the portal tracts, and also in the "portal plate" of the liver. The ductular profiles can be formed as a result of expansion of existing bile ducts, cholangiocyte proliferation, as well as transdifferentiation of hepatocytes and activation of mesenchymal stem cells.

Portal plate bile duct diameter in biliary atresia is associated with long-term outcome.

Kasai portoenterostomy (KPE) is the only treatment currently available for biliary atresia (BA). Age at KPE and surgical experience are prognostic factors for a successful KPE. Here, we aimed to assess whether the size of bile ductules at the porta hepatis during KPE correlates with KPE success and transplant-free survival (TFS). A retrospective analysis of patients diagnosed with BA during 2000-2019. Porta hepatis biopsies were reviewed for diameters of five representative ducts, and a mean ductal diameter (MDD) was calculated. Laboratory values including pre- and postoperative bilirubin levels were analyzed. The cohort included 77 patients; for 33, ductal plate biopsy was available. KPE was successful in six of eight patients with MDD ≥ 50µm, and in five of 25 with MDD < 50µm, p = 0.008, OR = 12.0 (95% CI 1.83-78.3). Ten-year survival with native liver was higher in patients with MDD ≥ 50µm than in patients with MDD < 50µm, p < 0.001, HR 0.038 (95% CI 0.007-0.207). Direct bilirubin < 1mg/dl 3months post-KPE was associated with improved 2-year post-KPE TFS (27.7% vs. 13.9%, p < 0.0001). MDD ≥ 50µm correlates with KPE success and a higher rate of TFS. Direct bilirubin < 1mg/dl 3months post-operation may serve as a marker of successful biliary excretion, and a predictor of 2-year TFS.

Biliary atresia liver histopathological determinants of early post-Kasai outcome

BackgroundA retrospective chart review of liver histologies in Kasai biliary atresia BA patients operated 1/2017- 7/2019 at our institution was conducted to identify histologic prognostic factors for biliary outcome. MethodsPatients with wedge liver biopsies and portal plate biopsies (n = 85) were categorized into unfavorable and favorable outcome, based on a 3-month serum total bilirubin level of <34 μM or mortality. Hepatocellular histologies, presence of ductal plate malformation (DPM) and of large bile duct of ≥ 150 μm diameter size at the portal plate were evaluated. ResultsTotal Bilirubin levels> 34 μM correlates with worse 1-year survival. Age at surgery, histologic fibrosis or inflammation does not predict outcome. Potential adverse predictors are severe hepatocellular swelling, severe cholestasis, presence of DPM (n = 24), and portal plate bile duct size < 150 µm (n = 28). In multivariate analyses adjusting for age at Kasai and postop cholangitis, bile duct size and severe hepatocellular swelling remain independent histologic prognosticators (OR 3.25, p = 0.039 and OR 3.26, p = 0.006 respectively), but not DPM. ConclusionAdvanced histologic findings of portal plate bile duct size of <150 µm and severe hepatocellular damage predict poor post-Kasai jaundice clearance and short-term survival outcome, irrespective of Kasai timing.Level of Evidence: Level III

Developmental histology of the portal plate in biliary atresia: observations and implications.

The key characteristic of biliary atresia (BA) is obliteration of the extrahepatic bile ducts at the level of the porta hepatis. We aimed to relate the immunohistochemical features of remnant biliary ductules at the porta hepatis with clinical features and outcomes. Samples were immunostained with anti-cytokeratin 20 (CK20), vimentin and alpha-smooth muscle actin (aSMA). Primary outcome was set as clearance of jaundice (bilirubin ≤ 20μmol/L) following Kasai portoenterostomy (KPE). Eighty-two cases were classified into syndromic BA (n = 10), cystic BA (n = 7), CMV IgM+ BA (n = 9) and isolated BA (n = 56). CK20 expression was confirmed in 40/82 (49%), and vimentin expression in 19/82 (23%). aSMA was negative in all cases studied. CK20 expression was less common in isolated BA (n = 20/56, 36%) compared to CMV IgM+ BA (n = 8/9, 89%), cystic BA (n = 7/7, 100%) (isolated BA vs non-isolated BA, P = 0.0008). There was no difference in vimentin expression among the sub-groups (isolated BA vs. non-isolated BA; P = 0.39). CoJ was achieved in 52/82 (63%) overall with significant difference depending simply on sub-group [e.g. syndromic BA 9/10 (90%)]. CK20 expression was associated with a diminished rate of CoJ in the entire cohort [CK20+ 32/56 (57%) vs. CK20- 20/26 (77%); P = 0.04]. By contrast no correlation was observed between vimentin expression and CoJ (P = 0.13). CK20+ expression was associated with reduced clearance of jaundice in BA and a trend towards reduced native liver survival.

Research progress in the Hepatobiliary Surgery operation of hepatic hilar plate system

An estimate of about 50% of new liver cancer cases worldwide occur in China every year.Surgical resection is still the major treatment choice for longer survival of patients with hepatocellular carcinoma. Blocking hepatic blood flow and reducing intraoperative bleeding ensure the success of the operation. Anatomic separation of hepatic hilar region is the precondition of hepatic inflow occlusion. The hepatic hilar plate system involves a thick layer of connective tissue covering the hepatic inflow ducts of hepatic hilar region. The descending part of hilar plate assists in reducing the anatomical difficulty of the hepatic hilar region. The "forth porta hepatis" that is hidden in the hepatic hilar plate system involves the accumulation area of "short hepatic portal veins" .The communicating branch vessels between the hepatic inflow vessels form the anatomical basis in reducing the indocyanine green fluorescence stain effect.The relatively fixed position of the hepatic portal plate is considered as a positioning marker for accurate liver resection. The intrahepatic Glisson sheath is connected with thick connective tissue of the hepatic portal panel system, and is regarded as the physical barrier in limiting the proliferation and hypertrophy of hepatocytes and continuation of hepatic portal panel system in the liver.This paper summarizes the anatomy and application of hepatic hilar plate system during hepatobiliary surgery.

Liver stiffness measurement predicts the difficulty of Kasai procedure in biliary atresia: a single center retrospective analysis of 199 patients

BackgroundKasai procedure is the standard initial treatment of infants with biliary atresia. The key to perform a successful surgery is to accurately remove the fibrous portal plate near the liver hilum. Yet how to estimate surgical difficulty pre-operatively remains unclear. This study aims to design an algorithm that predicts the difficulty of Kasai procedure using liver stiffness measurement (LSM).MethodsOne hundred ninety-nine patients were included from April 2012 to December 2016. The patients were all surgically diagnosed with biliary atresia. Group A comprised of patients with porta hepatis retraction (the angle between the plane of the fibrous porta plate and the plane of the medial liver closest to the plate was equal to or smaller than 90°), group B comprised of patients without porta hepatis retraction (the angle between the plane of the fibrous porta plate and the plane of the medial liver closest to the plate was greater than 90°). Liver function measurements and LSM were measured for all patients within three days before surgery.ResultsOur study included 19 cases in group A (9 males, 10 females) and 180 cases in group B (87 males, 93 females). LSM had statistical differences between the two groups, 28.10(14.90) kPa VS 10.89(7.10) kPa, P = 0.000. There was a significant relationship between LSM and operative age, TBA, AST, GGT (P = 0.000, 0.003, 0.003, 0.012, correlation coefficient = 0.323, 0.213, 0.207, 0.179). The AUROC of LSM was 0.919. When the cutoff value was 15.15 kPa(OR = 3.989; P = 0.000), the sensitivity, specificity, PPV, NPV and diagnostic accuracy were 0.947, 0.750, 0.285, 0.992 and 0.768, respectively. When the value was 23.75 kPa(OR = 3.483; P = 0.000), the sensitivity, specificity, PPV, NPV and diagnostic accuracy were 0.631, 0.950, 0.571, 0.960 and 0.919, respectively.ConclusionsLSM can be used to predict the difficulty in dissecting fibrous portal plate, and in turn, the difficulty of Kasai procedure. LSM > 23.75 kPa suggests a more complicated surgery.

Surgical modifications of the Kasai hepatoportoenterostomy minimize invasiveness without compromising short- and medium-term outcomes

BackgroundBiliary atresia (BA) causes progressive fibrosis and obliteration of the biliary tree, resulting in bile stasis and eventual liver dysfunction. It affects 1 in 10,000–18,000 infants, and if left untreated, universally leads to liver failure. The Kasai hepatoportoenterostomy (KPE) was developed as an effective surgical therapy for BA and can restore bile drainage into the intestine. Traditionally, the KPE procedure extra-corporealizes the liver to expose the portal plate. Here, we describe modifications to the procedure via a smaller incision in which the liver remains within the abdominal cavity and we compare the outcomes of this technique to previous institutional outcomes and to contemporary international series. Materials and methodsWe identified all patients who underwent KPE for BA at a single institution between 1994 and 2012. Patient outcomes after the modified KPE performed from 2004 to 2012 were compared to data from infants who underwent the traditional KPE from 1994 to 2003. ResultsNinety-nine patients were identified. Fifty-two were in the traditional KPE group and 47 in the modified KPE group. There was no difference in mean age at surgery. Median follow-up was 64 months (traditional KPE) and 46 months (modified KPE). The rate of native liver survival (39.1% vs 48.5%), overall survival (89.2% vs 97.8%), liver transplant occurring under one year of age (36.5% vs 40.4%) and median time to liver transplant (188 vs 172 days) were not statistically different between groups (p > 0.05 for all comparisons). The results of the modified KPE compared favorably to published outcomes. ConclusionThe described modifications to the KPE appear to yield equivalent outcomes when compared to the traditional KPE procedure and compare well with published outcomes in the literature. It is possible that the procedure described here results in less scarring and technically easier liver transplant procedures. Level of EvidenceLevel III.

Biliary Atresia: Laparoscopic Kasai Portoenterostomy

Introduction: Biliary atresia is an obliterating disease of the extrahepatic biliary system that must be corrected surgically through a hepatoportoenterostomy. This procedure was developed by Dr. Morio Kasai in the 1950s and was classically performed as an open surgery.1 In 2002, the first laparoscopic portoenterostomy was reported.2 This approach is described in this video. Materials and Methods: This video shows a laparoscopic Kasai procedure done in a 6-week-old female infant who presented with jaundice and acholic stools. A 10 mm trocar was introduced into the scar of the umbilicus using a modified Hasson technique. Pneumoperitoneum was established using 5 L/min of carbon dioxide under 10 mm Hg of pressure. A 30° telescope camera was inserted into the peritoneal cavity for proper observation. Two 3 mm ports were placed in the right side of the abdomen, whereas 3 and 5 mm ports were placed in the left side. The atretic gallbladder was observed. The grasper was used to retract the fundus of the gallbladder while the area was dissected with hook diathermy. The lymph node at the neck of the gallbladder was dissected and removed so the cystic duct could be followed to its entry into the common bile duct. The atretic gallbladder was then released from the liver bed and used as a retractor while the atretic common bile duct was dissected out to the point it entered the duodenum and divided at its lowest point of entry. The area beneath the duct was further dissected up to the portal plate and carried out on either side until we identified the first branch of the right hepatic artery on the right side and the umbilical point on the left side (where the umbilical vein enters the left branch of the portal vein). The atretic common hepatic duct was excised flat with the liver. Bile was observed flowing from the cut surface. Next, the ligament of Treitz was identified. The small bowel was followed distally to a length of ~25 cm. A 25 cm Roux-en-Y loop was constructed extracorporally after pulling the bowel out through the umbilical incision, then reduced back into the peritoneal cavity. A window was made behind the colon so the Roux limb could be placed in a retrocolic direction. Anastomosis of the Roux limb was then made with the biliary plate. The defect in the colon mesentery was closed, the peritoneal cavity was desufflated, and ports were withdrawn and closed with 2-0 vicryl on UR-6 needles. The skin was reapproximated with Dermabond glue. Total operative time was ~4.5 hours. Results and Conclusions: There were no postoperative complications. The patient started to tolerate oral feeds on post-operative day #4 and was discharged on post-operative day #7 after passing yellow stools. At her 3-month follow-up visit, she was tolerating feeds and passing yellow stools and had normal liver laboratories with a decrease in conjugated bilirubin from 6.6 to 1.8 mg/dL. No competing financial interests exist. Runtime of video: 5 mins 26 secs

Variability of diagnostic approach, surgical technique, and medical management for children with biliary atresia in Canada — Is it time for standardization?

BackgroundThe Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA. MethodsGastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices. ResultsOf gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20–50cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation. ConclusionIn Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes. Level of evidenceSurvey study. Level IV evidence.

Type I choledochal cyst &amp;ndash; an atypical presentation and an unusual association with single umbilical artery

Type I choledochal cyst &ndash; an atypical presentation and an unusual association with single umbilical artery Telema Nga,1,2 Neelofar Abdullah,1,2 Garrett Levin1,2 1Department of Pediatrics, Texas Tech University Health Sciences Center, El Paso, TX, USA; 2El Paso Children&#39;s Hospital, El Paso, TX, USA Abstract: A unique case of an asymptomatic newborn with type I choledochal cyst and a single umbilical artery is reported. Ultrasound imaging was used as a screening tool and magnetic resonance cholangiopancreatography as a method of adequate visualization. On day 8 of life, the patient had a laparotomy with resection of choledochal cyst, cholecystectomy, and reconstruction using a jejunal Roux-en-Y to portal plate. Keywords: choledochal cyst, single umbilical artery, cholecystectomy

Preduodenal portal vein

Fig. Preduodenal portal vein identified during exploration for biliary atresia. Duo, Duodenum; P, pancreas; L, liver; S, stomach; PDPV, preduodenal portal vein. AN 11-WEEK-OLD FEMALE INFANT presented with jaundice and hyperbilirubnemia. Her mother reported a history of yellow-colored eyes, lightcolored stools, and dark urine since shortly after birth. She was a full-term infant with an initial admission to the neonatal intensive care unit for bradycardia. An echocardiogram showed a noncompaction cardiomyopathy. A hepatic panel preformed at her primary pediatrician’s office was significant for total bilirubin of 7.3 mg/dL and direct bilirubin 4.2 mg/dL; she was referred for further evaluation. Preoperative abdominal ultrasonography showed a shrunken gallbladder and no other abnormality. A percutaneous liver biopsy was performed and revealed bile ductular proliferation and cholestasis, which was thought to be consistent with biliary atresia. A Kasai Roux-en-Y hepatoportoenterostomy for a presumptive diagnosis of biliary atresia was therefore recommended. After the patient’s abdomen was entered, inspection of the left upper quadrant was notable for the absence of the spleen and further exploration showed intestinal malrotation and a preduodenal portal vein (Figure). The dissection of the portal plate was accomplished without difficulty. The narrowed base of the mesentery was broadened as much as possible, and an appendectomy was performed. Construction of the Roux limb and the hepatoportoenterostomy was then performed.

Histologic features of the portal plate in extrahepatic biliary atresia and their impact on prognosis—a Danish study

Background/Purpose The aims of this study are as follows: 1. To evaluate the outcome of the patients with extrahepatic biliary atresia (EHBA), operated at the Rigshospitalet, Denmark, during the last 24 years. 2. To relate the histologic findings of the portal plate to the outcome. 3. To compare the histologic findings in the portal plate of children affected by EHBA with those found at the porta hepatis in age-matched children dead from other causes. Method From 1979 to 2003, 57 children have been operated by the Kasai procedure. Only 40 of these have had their portal plate removed for histologic examination. We divided the patients according to clinical outcome into a successful and a failure group and compared the histologic features of the portal plates in the 2 groups. Afterward, the portal plate histology from EHBA was compared with the porta hepatis area from patients dead from other causes. Results A significant difference between the success and the failure group was found with regard to the number of bile ducts, the maximal length measurable in any direction for bile duct structures, and the proliferation, but not for any type of diameter. The normal portal plate was different from the portal plate of children with biliary atresia by always having 2 large biliary structures and the cells being mucinous and columnar in the largest bile ducts. Only 1 of 4 normal portal plates showed signs of proliferation. There was no significant difference between the normal and the success group with respect to the number, maximal length, and proliferation of the bile ducts. A difference in the diameter between the normal group and the entire EHBA group was significant for the maximal internal diameter but not for the other types of diameter measurements. Conclusion The present study shows the following: 1. In portal plates from patients with EHBA, the longest measurable length of the bile duct structures, the number of bile duct structures, and less proliferation are positively correlated to prognosis. 2. Patients with EHBA have a more favorable prognosis when the histology of the portal plate resembles the normal portal plate regarding the number of bile ducts, proliferation, and maximal measurable length.

Histologic oddities at the porta hepatis in biliary atresia

Purpose Highly unusual histologic findings at the porta hepatis in 3 infants who underwent Kasai portoenterostomy for biliary atresia are reported. Methods Portoenterostomy was performed using a standard operative technique. Serial transverse sections of the excised portal plate were examined by light microscopy along with sections from the distal extrahepatic biliary remnants, gallbladder, and liver biopsy. Results Of 61 consecutive infants who underwent Kasai portoenterostomy for biliary atresia, 3 were found to have highly unusual histologic features at the porta hepatis. All had type 3 biliary atresia. Two had hilar biliary ductules lined in part by squamous epithelium, and the third had a focus of mature hyaline cartilage surrounded by perichondrium adjacent to biliary ductules. In each case, these unusual histologic features were localized to the porta hepatis in the region of the transected portal plate. Conclusions The presence of hyaline cartilage at the portal plate is likely to be an expression of defective morphogenesis, thus supporting the concept of disordered embryogenesis in the etiology of biliary atresia. Squamous epithelium within biliary ductules might also reflect a similar mechanism but could alternatively be an unusual metaplastic response to inflammation at this site.

Biliary atresia

Biliary atresia (BA) is a cholangiodestructive disease affecting biliary tract, which ultimately leads to cirrhosis, liver failure and death if not treated. The incidence is higher in Asian countries than in Europe. Up to 10% of cases have other congenital anomalies, such as polysplenia, asplenia, situs inversus, absence of inferior vena cava and pre-duodenal portal vein, for which we have coined the term Biliary Atresia Splenic Malformation (BASM) syndrome. For these infants the aetiology lies within the first trimester of gestation. For others affected with BA, aetiology is more obscure and perinatal destruction of fully-formed ducts perhaps by the action of hepatotropic viruses has been suggested. Whatever the cause, the lumen of the extrahepatic duct is obliterated at a variable level and this forms the basis for the commonest classification (Types I, II, III). All patients with BA present with varying degree of conjugated jaundice, pale non-pigmented stools and dark urine. Key diagnostic tests include ultrasonography, biochemical liver function tests, viral serology, and (in our centre) a percutaneous liver biopsy. In some centres, duodenal intubation and measurement of intralumenal bile is the norm. Currently BA is being managed in two stages. The first stage involves the Kasai operation, which essentially excises all extrahepatic biliary remnants leaving a transected portal plate, followed by biliary reconstruction using a Roux loop onto that plate as a portoenterostomy. If bile flow is not restored by Kasai procedure or life-threatening complications of cirrhosis ensue then consideration should be given to liver transplantation as a second stage. The outcome following the Kasai operation can be assessed in two ways: clearance of jaundice to normal values and the proportion who survive with their native liver. Clearance of jaundice (<2 mg/dL or <34 µmol/L) after Kasai has been reported to be around 60%, whereas five years survival with native liver ranges from 40% to 65%.

Increased CXCR3 expression associated with CD3-positive lymphocytes in the liver and biliary remnant in biliary atresia

Background Lymphocyte-mediated inflammatory damage of the bile ducts has been proposed as a potential mechanism in the pathogenesis of biliary atresia (BA). Chemokines regulate leukocyte migration and act as critical organizers of cell distribution in inflammatory responses. The aim of this study was to analyze the infiltration of T lymphocytes and the expression of a chemokine receptor, CXCR3, predominantly expressed on type 1 polarized T cells (T H1, T C1) in the liver and excised biliary remnants in infants with BA. Methods Immunohistochemistry for CD3, CD8, and CXCR3 was performed using liver biopsy specimens collected from the following 3 age-matched groups of patients: group 1, BA (nonsyndromic) at the time of Kasai portoenterostomy (n = 10); group 2, congenital choledochal dilatation (n = 2); and group 3, other cholestatic diseases including paucity of intrahepatic bile ducts and cholestasis (n = 3) related to total parenteral nutrition. Cellular staining on each section was graded from 0 to 4 and compared using nonparametric statistics. Results Infiltrating CD3 + and CD8 + lymphocytes in the portal tracts were significantly increased in group 1 (3.1 ± 0.4, 2.8 ± 0.4), compared with groups 2 (1.0 ± 0.0, 1.0 ± 0.0) and 3 (1.7 ± 0.3, 1.5 ± 0.5) ( P < .01, P < .05). CXCR3 + mononuclear cells were significantly increased in group 1 (2.6 ± 0.3) compared with groups 2 (0.5 ± 0.5) and 3 (0.7 ± 0.3) ( P < .05). They were mainly found in the portal tracts with a similar distribution to CD3 + cells. CXCR3 + cells and CD3 + cells also showed a similar distribution in specimens of biliary remnants from just below the portal plate. Conclusions Increased expression of CXCR3 associated with a significantly increased CD3 and CD8 T-cell infiltration suggests that CXCR3 + lymphocytes in a type 1 (T H1, T C1) cytokine milieu may play a role in the pathogenesis of BA.

Facilitating the operative exposure of the portal plate in cases of biliary atresia by dislocating the whole liver onto the abdominal wall

Obtaining adequate exposure of the portal plate in cases with biliary atresia can tax the ingenuity of the surgeon. The successful completion of a hepatic portoenterostomy depends on it. Mobilising the liver and dislocating it into an ex vivo-like position on the anterior abdominal wall simplifies this step of the operation. It achieves maximal visualisation and access to the anatomy of the liver port. When used correctly by the surgeon this technique is not complicated by hepatic or caval blood flow occlusion. Its use in over 40 clinical cases has not resulted in any major mishap.