Urinary sulfated bile acids: a new simple urine test for cholestasis in infants and children

Background/Purpose: Measurement of urinary sulfated bile acid (USBA) has been reported as a simple urine test that reflects the degree of cholestasis. The authors report the diagnostic value of this new laboratory test in various cholestatic conditions affecting infants and children. Methods: A urine sample was collected from 4 surgical neonates with parenteral nutrition[ndash ]induced cholestasis and 48 patients with biliary atresia (BA). USBA was measured by direct enzymatic assay. Results: In 3 patients receiving parenteral nutrition, USBA increased with caloric gains. For one surgical patient, a decrease in calories because of liver dysfunction resulted in a decrease of USBA, closely reflecting the fluctuations of caloric intake. In patients with BA, a significant positive correlation was noted between serum bile acid and USBA (r = 0.85; P [lt ] .01). Ten of 14 febrile episodes in 6 patients with liver dysfunction and increased C-reactive protein showed elevated USBA, thus diagnosed as cholangitis. Four febrile episodes caused by viral infection showed no elevation of USBA. Conclusions: USBA is a simple and sensitive noninvasive test reflecting the degree of cholestasis in infants and children. USBA correlated highly with serum bile acid levels and may be helpful in diagnosis of cholestasis caused by cholangitis without blood sampling.     

High-dose steroids,ursodeoxycholic acid,and chronic intravenous antibiotics improve bile flow after Kasai procedure in infants with biliary atresia

Background/Purpose: Early reports suggest that the use of steroids after Kasai portoenterostomy may improve bile flow and outcome in infants with biliary atresia. Methods: Of 28 infants with biliary atresia, half received adjuvant high-dose steroids, and half received standard therapy. Infants in the steroid group (n = 14) received intravenous solumedrol (taper of 10, 8, 6, 5, 4, 3, 2 mg/kg/d), followed by 8 to 12 weeks of prednisone (2 mg/kg/d). The steroid protocol also included ursodeoxycholic acid indefinitely and intravenous antibiotics for 8 to 12 weeks followed by oral antibiotic prophylaxis. Infants in the standard therapy group (n = 14) received no steroids, occasional ursodeoxycholic acid, and perioperative intravenous antibiotics followed by oral antibiotic prophylaxis. The infants were not assigned randomly, but rather received standard therapy or adjuvant steroid therapy according to individual surgeon preference. Results: Eleven of 14 (79%) in the steroid group and 3 of 14 (21%) in the standard therapy group had a conjugated bilirubin level less than 1.0 within 3 to 4 months of surgery (P [lt ] .001). Fewer patients in the steroid group (21% v 85%) required liver transplantation or died during the first year of life (P [lt ] .001). Infants in the steroid group did better despite the fact that this group included 5 infants with biliary atresia-polysplenia-heterotaxia syndrome, a subgroup that might have been expected to have a poor prognosis. Neither bile duct size nor liver histology was a reliable predictor of success or failure in either group. Conclusions: Adjuvant therapy using high-dose steroids, ursodeoxycholic acid, and intravenous antibiotics may accelerate the clearance of jaundice and decrease the need for early liver transplantation after Kasai portoenterostomy. J Pediatr Surg 38:406-411.     

Development of intrahepatic biliary stones after excision of choledochal cysts

Background: The incidence of intrahepatic cholelithiasis and cholangitis has not yet been well studied postoperatively in patients with choledochal cysts. Methods: One hundred three patients with choledochal cysts had operative cholangiography, underwent standard excision of a choledochal cyst with Roux-en-Y hepatico-jejunal anastomosis, and were at a mean follow-up of 12[frac12] years. The incidence of intrahepatic bile duct stones was analyzed according to the 3 morphologic types of intrahepatic bile duct observed at initial operative cholangiography: type 1, no dilatation of the intrahepatic bile ducts; type 2, dilatation of the intrahepatic bile ducts but without any downstream stenosis; and type 3, dilatation of the intrahepatic bile ducts associated with downstream stenosis. Initially, there was no evidence of intrahepatic bile duct stones in any of the 103 patients. Results: Among 50 type 1 patients, intrahepatic cholelithiasis developed in only 1 patient (2%). Among 43 type 2 patients, 1 patient (2%) had intrahepatic cholelithiasis, and 2 (5%) had postoperative cholangitis. Among 10 type 3 patients, 4 (40%) had intrahepatic cholelithiasis (P [lt ] .01), and 3 (30%) had postoperative cholangitis. Time intervals between the initial surgery and the first identification of intrahepatic stones ranged from 3 to 22 years. Conclusions: One of the major causes of formation of intrahepatic cholelithiasis has been clarified; patients with intrahepatic biliary dilatation with downstream stenosis can get intrahepatic bile duct stones long after excision of a choledochal cyst.     

婴儿阻塞性黄疸的腹腔镜早期干预与治疗

目的 探讨腹腔镜胆道探查对婴儿阻塞性黄疸的诊断和治疗价值.方法 对56例经内科保守治疗2周血清胆红素水平无明显下降的阻塞性黄疸婴儿进行胆道探查及胆道造影,并对诊断明确的非先天性胆道闭锁患儿予以胆道冲洗.结果 本组56例婴儿经腹腔镜胆道探查及胆道造影后均明确诊断,其中浓缩胆栓综合征12例(21%),胆管发育不良4例(7%),胆道闭锁40例(72%).16例非先天性胆道闭锁患儿经胆囊造瘘、胆道冲洗后病情好转,黄疸消退,随访6～42个月,均恢复良好无复发.结论 利用腹腔镜早期干预阻塞性黄疸患儿可以对疾病进行早期的诊断和治疗,具有较高的临床实用价值.对浓缩胆栓综合征及先天性胆管发育不良患儿,可以在镜下造影明确诊断后行胆囊造瘘及胆道冲洗,以减轻胆汁淤积对肝脏的进一步损害;对胆道闭锁患儿可以争取到早期手术的时机.     

Multiple intrahepatic biliary cysts in children with biliary atresia

Purpose: The aim of this study was to investigate the incidence, clinical course, and outcome of multiple intrahepatic biliary cysts in patients with biliary atresia. Methods: From 1992 to 2000, 154 patients with biliary atresia were examined for intrahepatic cysts. They were followed and examined routinely using abdominal ultrasonography. Results: Twenty-three patients had single intrahepatic cysts, and 16 patients had multiple cysts. The incidence of intrahepatic cysts in these patients were 25.3% (39 of 154) for all kinds of cysts and 10.4% (16 of 154) for multiple intrahepatic cysts. Of the 16 patients with multiple cysts, 13 (81.3%) had jaundice, and 15 (93.8%) had a history of cholangitis before cysts were detected. Image studies showed multiple discrete ovoid or round intrahepatic biliary cysts with various sizes along the biliary trees. The cysts decreased in size or number in 7 patients after antibiotic treatment and disappeared in only one patient. The mortality rate was higher in patients with multiple cysts than in those with single cysts (P = .037). Conclusions: Multiple intrahepatic biliary cysts are a common complication in patients with biliary atresia and suggests a poor prognosis. Prolonged parenteral antibiotics treatment should be administered when signs of biliary infection appear. J Pediatr Surg 37:1183-1187.     

Bile ducts and ductules are positive for CD56 (N-CAM) in most cases of extrahepatic biliary atresia

The diagnosis of extrahepatic biliary atresia can be challenging as the histologic features can overlap with other pediatric cholestatic liver diseases. Several previous studies have noted that biliary epithelium is positive for CD56 in the setting of extrahepatic biliary tract disease. Thus, we explored the use of CD56 in evaluating liver biopsy specimens for extrahepatic biliary atresia. A total of 22 cases were selected and immunostained for CD56, including 14 cases of confirmed extrahepatic biliary atresia and 8 cases of other cholestatic liver diseases in which the differential diagnosis included extrahepatic biliary atresia. Bile ducts and proliferating ductules were positive for CD56 in 13 of 14 cases of extrahepatic biliary atresia. The staining intensity was generally strong with most cases showing positivity in more than two thirds of portal tracts. The one negative case was a very small biopsy (<0.3 cm), and sampling may have played a role. In contrast, 4 of 8 cases in the control group were completely negative for CD56, with the remaining cases showing weak and focal positivity. In conclusion, bile ducts and ductules are CD56 positive in most cases of extrahepatic biliary atresia, and CD56 immunostaining can be a useful supplemental stain for diagnosing extrahepatic biliary atresia in its early, ductular proliferative phase when used in conjunction with traditional hematoxylin and eosin morphology and clinical information.     

Choledochal cysts: age of presentation,symptoms, and late complications related to Todani's classification

Purpose: The aim of this study was to compare presentation, complications, diagnosis, and treatment of choledochal cysts in pediatric and adult patients. Methods: Forty-two patients were analyzed after subdivision into 3 groups: group A, less than 2 years (n = 10); group B, 2 to 16 years (n = 11); group C, greater than 16 years (n = 21). Results: The cysts were classified as extrahepatic (n = 33), intrahepatic (n = 5), and combined (n = 4). Seventy-six percent of patients presented with abdominal pain, (20 of 21 group C), and 57% with jaundice, (10 of 10 group A). Cholangiocarcinoma occurred in 6 patients, 4 of whom had previously undergone internal drainage procedures. Excision of the extrahepatic cyst was performed in 27 of 37 patients. Five patients, of whom, 4 had cholangiocarcinoma, were beyond curative treatment at the time of diagnosis. Six patients had died at the closure of this study, 5 of them had carcinoma. Conclusions: Presenting symptoms are age dependent with jaundice prevailing in children and abdominal pain in adults. In view of the high risk of cholangiocarcinoma, early resection and not internal drainage is the appropriate treatment of extrahepatic cysts. Patients who had undergone internal drainage in the past still should undergo resection of the cyst.     

Hepatic portocholecystostomy for biliary atresia.

Four infants with biliary atresia had gross obliteration of the common hepatic duct but residual patency of the gallbladder, cystic duct and common bile duct. The patients were treated by hepatic portocholecystostomy utilizing the extant bile ducts for biliary reconstruction. Bile drainage was achieved in all four infants. There was a conspicuous absence of postoperative cholangitis. Subsequent obstruction of the distal ducts in two patients necessitated reoperation and construction of a standard biliointestinal conduit. The other two children are surviving, jaundice-free, 5 1/2 and 5 years after operation with minimal sequelae of biliary atresia. Hepatic portocholecystostomy is a feasible surgical alternative to intestinal reconstruction in patients with biliary atresia in whom the disease is limited to the proximal extrahepatic bile ducts.     

Immunohistochemistry of the liver and biliary tree in extrahepatic biliary atresia.

BACKGROUND: Progressive destruction of intrahepatic bile ducts may determine outcome in extrahepatic biliary atresia (EHBA) despite successful portoenterostomy. The aim of this study was to characterize the inflammatory infiltrate of a large series of cases of biliary atresia and relate these findings to clinical outcome. METHODS: Immunohistochemical analysis was performed on frozen tissue sections of extrahepatic biliary tree and liver biopsies obtained (August 1996 to March 1998) from 28 infants with EHBA and 8 liver biopsy specimens from age-matched controls with other cholestatic liver disorders. A semiquantitative scoring system was designed to evaluate the staining with a panel of antibodies to the CD4, CD8, CD25, CD56, CD68, CD71 antigens and to HLA-DR, ICAM-1, VCAM-1, E-selectin and LFA-1. The infants then underwent followup prospectively and divided into 2 prognostic groups at 12 months postoperatively: those who had cleared their jaundice (graded as a good outcome [n = 19]), and those who required liver transplantation or who had failed to clear their jaundice (defined as > 50 micromol/L; graded as poor outcome [n = 9]). RESULTS: CD4(+) lymphocytes and CD56(+) (NK cells) predominated in the liver of infants with EHBA as compared with controls. The infiltrating cells exhibited marked proliferation (CD71 expression) and activation (particularly LFA-1 but also CD25 expression). A smaller subpopulation of the cells also expressed VCAM and E-selectin. HLA-DR was strongly expressed on Kupffer cells and to a lesser extent on proliferating bile ducts and sinusoidal endothelium. Expression of the majority of markers was lower in the remnant bile duct tissue than in the liver of EHBA (P <.05) with only HLA-DR and LFA-1 (on infiltrating cells) and ICAM (on endothelium) expressed strongly in the remnant bile duct tissue. Although quantitatively less pronounced, all of these immunohistochemical features also were noted in non-EHBA cholestatic liver tissue. A good outcome at 12 months was associated with lower CD68 (macrophage) expression in both the liver (P <.05) and biliary tree (P <.05) and with reduced expression of ICAM-1 (P =.05) on infiltrating cells in the biliary remnant. CONCLUSIONS: Immunohistochemical patterns of immune-mediated liver injury and inflammation were prevalent features at the time of portoenterostomy. They were neither exclusive to nor characteristic of EHBA. A reduction in the expression of the macrophage marker (CD68) within the liver and biliary remnants and reduction of ICAM-1 expression on infiltrating cells in the biliary remnants appear to be associated with a better postoperative prognosis.     

Cystic anomalies of biliary tree in the fetus: is it possible to make a more specific prenatal diagnosis?

Background/Purpose: Biliary tree cystic malformations (BCM) occur rarely. Current progress in ultrasonography makes it possible to identify them prenatally. The aim of this study was to analyze retrospectively prenatal ultrasound patterns of 5 consecutive subhepatic cysts in an effort to differentiate the BCM before birth and onset of symptoms. Methods: The prenatal ultrasound patterns of 5 consecutive BCM were correlated with the postnatal diagnosis. Results: Case 1 showed a hyperechogenic cyst that underwent enlargement during fetal life; the diagnosis at birth was an obstructed choledochal cyst (CC). In cases 2 and 3, an anechoic cyst with small, stable dimensions during pregnancy was identified; a biliary atresia (BA) type III-C was confirmed at birth. A slightly hyperechogenic cyst with no increase in size at repeated prenatal scans, was observed in cases 4 and 5; a CC and a cystic lesion at the confluence of the hepatic ducts (without obstruction) were diagnosed postnatally, respectively. Conclusions: The ultrasound scan pattern and size allow to make a prenatal differential diagnosis of BCM. Anechoic, small cyst in the hepatic hilum is highly suspicious for BA. Large, echoic or enlarging cyst is strongly suggestive of [ldquo ]obstructed[rdquo ] CC. Echoic, small and stable cyst is more suggestive of [ldquo ]unobstructed[rdquo ] CC. J Pediatr Surg 37:1191-1194.     

Comparative study of macro- and microsurgical extrahepatic cholestasis in the rat

The long-term (5-week) evolution of two experimental models of extrahepatic cholestasis, i.e., macrosurgical by bile duct ligation (n = 20) and microsurgical by biliary tract resection (n = 13), is studied. All cholestatic animals showed jaundice, choluria, and portosystemic collateral circulation. Macrosurgical cholestasis causes greater hepatosplenomegaly, hilar biliary pseudocysts, and ascites. Microsurgical extrahepatic cholestasis occurs with a lower degree of hepatosplenomegaly as well as with serum increase (P < 0.001) of gamma-GT and alkaline phosphatase. The bile ductular proliferation in the four hepatic lobes is very intense (P < 0.001) in both experimental models. The differences between both experimental models may be considered secondary to the increase of the predisposition to infection in rats with bile duct ligation, that complicates their evolution. The microsurgical cholestasis model could be useful in studying cholestasis secondary to biliary atresia.     

Protective effect of polyunsaturated phosphatidylcholine on liver damage induced by biliary obstruction in rats

Background/purpose: Persistent inflammatory response secondary to congenital or acquired biliary choleastasis plays an important role in the pathophysiology of hepatic tissue damage. The polyunsaturated fatty acids (PUFA) have been shown to suppress the inflammatory reactions in vivo and in vitro. PUFA has been shown also to protect againts various types of experimental liver damage in animal models and isolated hepatocytes. Therefore, the aim of this study was to investigate the protective effect of PUFA administration on liver damage using the rat chronic biliary obstruction model.Methods: Swiss albino rats of either sex were divided into 4 groups as follows: control group (group 1, 10 rats); rats with sham operation and treated with saline group 2, 10 rats); rats with biliary obstruction (group 3, 15 rats); and polyunsaturated phophatidylcholine (PPC)-treated rats with biliary obstruction (Group 4, 15 rats). Biliary obstruction was induced by double ligation and division of the common bile duct. PUFA treatment was started 2 weeks later from biliary obstruction in doses of 50 mg/d per rat and continued for 2 weeks. All animals were killed after 4 weeks of common bile duct ligation or sham operation. Liver damage and cholestasis were determined by biochemical and histologic examinations.Results: The data showed a decrease in plasma bilirubin level (both conjugated and unconjugated) and liver enzyme levels (AST, ALT, AP, GGT, 5′-NT) in group 4, when compared with group 3 (P < .05). Tissue levels of malondialdehyde (MDA) in group 4 was 20.00 ± 2.93 compared with that in group 3, 27.12 ± 2.96 (P < .05). Administration of PUFA to the biliary obstructed rats resulted in inhibition of collagen accumulation (P < .05) and ductal proliferation (P < .05).Conclusions: PUFA reduced liver damage, ductular proliferation, and fibrosis in biliary obstructed rats. These effects suggest that it might be a useful agent to preserve liver function in patients with biliary obstruction such as biliary atresia.     

Clinico-pathological studies on a transitional type between extrahepatic biliary atresia and paucity of the interlobular bile ducts

Among the neonatal and infantile cases of obstructive jaundice seen at Niigata and Yamagata University Hospitals between 1976 and 1990, extrahepatic bile ducts were visualized in 19 cases by either preoperative endoscopic retrograde cholangiopancreaticography (ERCP) or intraoperative cholangiography. Neonatal hepatitis was diagnosed in 3 of these cases by clear images of the bile duct system extending from the common bile duct to the intrahepatic bile duct. In 7 cases, the common bile duct was able to be seen, while the common hepatic duct was only slightly visualized. Four of these 7 cases were consistent with paucity of the interlobular bile ducts (PILBD) based on hepatic histology, while the remaining 3 showed fibrosis, bile ductular proliferation, and many bile plugs in the bile ductuli of the portal areas, concurrent with histological changes in extrahepatic biliary atresia (EHBA), not PILBD. In 9 cases, only the common bile duct was visualized while the common hepatic duct was not seen, 7 of these 9 cases being consistent with type III-al EHBA. In 2 cases, neither fibrosis nor proliferation of the bile ductuli was observed in the portal areas, and portal areas without any bile ductuli were also seen, in accordance with findings for PILBD. Three cases which showed similar hepatic histological findings to EHBA despite the presence of patent extrahepatic bile ducts, and 2 cases which had obstructed extrahepatic bile ducts and hepatic histological findings similar to PILBD, were thought to be of a transitional type between EHBA and PILBD. Thus, it is postulated that the entire bile duct system covering hepatocytes to extrahepatic bile ducts is affected by a certain factor, but the expression of individual disease types may be dependent upon the location of the site most seriously affected.     

Accuracy of Near Infrared-Guided Surgery in Morbidly Obese Subjects Undergoing Laparoscopic Cholecystectomy

Background

Fluorescence cholangiography represents an incisionless technique that can be applied during laparoscopic cholecystectomy to visualize bile ducts. Our objective was to evaluate and detect variances of fluorescence imaging in obese and non-obese patients.

Methods

Prospective patients were selected for laparoscopic cholecystectomies. Subjects were divided into groups based on their body mass index. Fluorescence imaging was applied preceding any dissection of extrahepatic ducts and again after dissection. Positive and negative identifications of biliary ducts were recorded.

Results

Seventy-one patients participated, with 53.5 % classified as obese. The cystic, hepatic, common bile duct, and accessory ducts were identified as follows: 100, 70.4, 87.3, and 7.0 % of patients, respectively. No differences in hepatic duct, common bile duct, and accessory duct visualization were detected in the obese and non-obese groups (p value 0.09, 0.16, and 0.66, respectively).

Conclusions

Fluorescent cholangiography is a useful technique in the obese and non-obese population. Obesity does not affect fluorescence visualization of bile ducts.

     

The portoenterostomy procedure for biliary atresia: a five year experience.

The portoenterostomy (Kasai) procedure in infants with biliary atresia has dramatically altered the outlook for this heretofore fatal disease. When performed on infants under three months of age, bile drainage can be achieved in a majority of the patients. Since 1972, 37 infants have been treated with this operation at our institution. Diagnostic operative cholangiography and liver biopsy are recommended if the cause of conjugated hyperbilirubinemia is presumed to be obstructive. When biliary atresia is encountered, identification of the atretic ducts with transection high in the porta hepatis is carried out. Thirty-two infants have had the portojejunostomy, while five, in whom the proximal hepatic ducts were atretic but the gall bladder and distal ducts were patent, underwent portocholecystostomy. Examination of the resected fibrous duct tissue revealed a statistically significant correlation between ductal histology and postoperative outcome. Extended bile drainage has been achieved in 26 of 37 patients. Seventeen exhibit near normal growth and development four months to five years postoperatively. Seven have died with progressive liver disease despite bile drainage. Two additional patients died, jaundice free, from unrelated causes. Despite bile drainage, progressive hepatic fibrosis has been confirmed by serial biopsies in 14 patients. This finding indicates that biliary obstruction is not the sole component in the development of biliary cirrhosis. These data suggest that extrahepatic biliary atresia is a dynamic obliterative process, which can be favorably modified in approximately 50% of the infants by early surgical treatment.     

胆道闭锁诊断方法价值分析

胆道闭锁是以肝内外胆管进行性炎症和纤维化为特征的疾病,是导致婴儿持续性黄疸的重要原因,如未得到及时治疗,可迅速发展为肝硬化,患儿最终因肝功能衰竭而死亡,因此胆道闭锁的早期诊断显得尤为重要。胆道闭锁主要依靠术中胆道造影以及肝组织活检确诊,但其具有侵入性、操作复杂、并发症多等缺点,不利于胆道闭锁的早期诊断,相比较而言,一些...     

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.

     

Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation

Background

Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic procedures. Bile duct injury is a rare but serious complication during this procedure, mostly caused by misidentification of the extrahepatic bile duct anatomy. Intraoperative cholangiography may be helpful to reduce the risk of bile duct injury; however, this is not a common procedure worldwide. Near-infrared fluorescence cholangiography (NIRFC) using indocyanine green (ICG) is a promising alternative for the identification of the biliary tree. This prospective observational study was designed to assess the feasibility and image quality of intermittent NIRFC during LC, using a newly developed laparoscopic fluorescence system.

Methods

Consecutive patients undergoing elective LC were included and received a single intravenous injection of ICG directly after induction of anesthesia. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized by using a dedicated laparoscope, which offers both conventional state-of-the-art imaging and fluorescence imaging. Intraoperative recognition of the biliary structures was registered at set time points, as well as the establishment of the critical view of safety.

Results

Fifteen patients were included between December 2011 and May 2012. ICG was visible in the liver and bile ducts within 20 min after intravenous administration and remained for approximately 2 h, using the fluorescence mode of the laparoscope. The common bile duct and cystic duct could be clearly identified at an early stage of the operation and, more important, significantly earlier than with the conventional camera mode. No per- or postoperative complications occurred as a consequence of ICG use.

Conclusions

Intermittent fluorescence imaging using a newly developed laparoscope and preoperative administration of ICG seems a useful aid in accelerating visualization of the extrahepatic bile ducts during laparoscopic cholecystectomy.     

Lengthening technique for long gap esophageal atresia and early anastomosis

Background/Purpose: The treatment of long gap esophageal atresia remains a major surgical challenge. Whereas many approaches have been used for this problem, none are ideal. The authors used a technique originally described by Dr John E. Foker and accomplished early repair in 3 infants with long gap atresia. Methods: Three infants with esophageal atresia underwent thoracotomy shortly after birth and had a long gap preventing primary anastomosis. External traction sutures were placed on each esophageal pouch and exteriorized through the thoracic wall. The esophageal ends were approximated 1 to 2 mm daily by traction on the sutures. Anastomosis was performed when the 2 ends came together. Results: Three infants were included (31, 34, 37 weeks gestation, weights 1.38 kg, 1.9 kg, and 2.3 kg, respectively). The esophageal gaps were 3, 5, and 4.5 cm, respectively. Definitive anastomosis was performed at 14, 17, and 10 days, respectively. Two patients had anastomotic leaks that were treated conservatively. One patient had an esophageal stenosis that required dilatation. Conclusions: This technique allowed rapid esophageal lengthening in these 3 cases and led to early repair of long gap esophageal atresia, avoiding the need for a prolonged hospitalization or eventual replacement as well as long-term swallowing difficulties. J Pediatr Surg 38:737-739. [copy ] 2003 Elsevier Inc. All rights reserved.     

Potential errors in the diagnosis and surgical management of neonatal jaundice

Despite advances and refinements in diagnostic techniques, distinguishing between cholestatic syndromes and extrahepatic biliary atresia is not always possible. Because there are inherent errors in all diagnostic studies including nuclear scanning, ultrasonography, and liver biopsy some infants presumed to have biliary atresia will come to surgery when, in fact, the bile ducts are partially or completely patent. The decision to proceed with a portoenterostomy or to terminate the procedure depends upon the appearance of the liver and histology of the biopsy.