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The early diagnosis of biliary atresia
158
ABSTRACTS
acidosis, and salt wasting. Another was the accidental passage of a urethral catheter through the fistula into the lower bowel during perineal anoplasty. The fourth was a pseudodiverticulum after division of rectourethral fistula, with infection and incontinence. The fifth was a urethral stricture after a pullthrough procedure. The authors emphasize the importance of investigation prior to any surgery and meticulous surgery to minimize these complications. S. Kim ABDOMEN
Repair of Burst Abdominal Incisions. Donald Young. Br. J. Surg. 61:457, 1974. Burst abdominal incisions are not unknown in pediatric surgery, and the author stresses the importance of healing of the peritoneal and muscular layers both in preventing disruption and also in operative repair of burst abdomen. The usual type of tension sutures are not always effective. The technique described by the author ensures that the sutures passing through the deeper part of the wound come out through the skin on each side and are fastened round rubber catheters running along the length of the wound. Consequently when tension within the abdomen rises there is a tendency for the deeper layers to be brought together rather than separated.--R. B. Zachary Racial Influence on the Incidence of Biliary Atresia. W. K. T. Shim, M. Kasal, and M. A. Spence. Prog. Pediatr. Surg. 6:53-62, 1974. The incidence of biliary atresia in the seven major ethnic groups in Hawaii was determined as 0.6 :e 0.2 per 10,000 births for Caucasians, 0.8 ~ 0.3 for Japanese, 2.0 • 0.9 for Filipinos, and 3.0 • 1.6 for Chinese. The incidence for Japanese in Sendal is similar to that for Japanese in Hawaii. Of particular note is first, the similarity (contrary to popular belief) between the Caucasian and Japanese incidence and second, the possibility that 4800 children with biliary atresia may be born annually in C h i n a . - - R . C. M. Cook The Early Diagnosis of Biliary Atresia. S. Kimura. Prog. Pediatr. Surg. 6:91-112, 1974.
Irreversible cirrhosis was found in patients operated on over 90 days of age, and no cures were recorded. The differential diagnosis between biliary atresia and neonatal hepatitis must, therefore, be made between 6 and 10 wk of age (the critical period). The clinical and
laboratory findings in 12 cases of hepatitis and 34 cases of biliary atresia between these ages showed no single specific tests for each diagnosis. Serial weekly bilirubin levels on average rose in biliary atresia and fell in hepatitis. Serum alkaline phosphatase levels and serum leueine amino peptidase activity were higher in atresia; transaminase levels higher in hepatitis. Duodenal drainage done seven times showed no bile in three infants with atresia and one with hepatitis. Bile was recovered in three infants with hepatitis. Rose Bengal Studies tried in 25 infants with biliary atresia and nine with hepatitis were valid in 20 of the former and eight of the latter and showed less than 5 ~ fecal excretion in 17 infants with atresia and between 6 ~ and 25~o fecal excretion in all eight with hepatitis. Scintigrams were also helpful. Uncomplicated needle biopsies were done in 20 infants. Five cases showed equivocal bistologic features and five were temporarily misdiagnosed. Operative cholangiography and liver biopsy proved definitive diagnoses. Of four infants with hepatitis thus studied, one died postoperatively and two developed cirrhosis. Of the eight infants with hepatitis not explored surgically, only one developed cirrhosis. C. M. Cook Treatment of Biliary Atresia With Special Reference to Hepatic Porto-Enterostomy and its Modifications. M. Kasai. Prog. Pediatr. Surg. 6:5-52, 1974. In 116 cases of biliary atresia, 40 were "correctable" (i.e., an apparently patent portion of the common bile or hepatic ducts was found). 76 were "non-correctable" (i.e., no extrahepatic duct system was found at operation). All cases showed on histology that portions of the ducts were replaced by dense scar tissue though the tissue from the region of the porta hepatis of noncorrectable cases showed tiny bile ducts in almost all cases. Surgical inspection of the biliary system was supplemented by cholangiography when a suitable duct could be identified. The entire extrahepatic biliary system was systematically dissected and its fibrous remnants excised. If no adequate duct was identified, dissection was continued into the porta hepatis. A choledocbojejunostomy (Roux-en-Y) was made when possible. For noncorreetable cases, a Roux loop was anastomosed direct to the porta hepatis. Collected Japanese cases show only 18 successes out of 82 correctable patients, failure
ABSTRACTS
acidosis, and salt wasting. Another was the accidental passage of a urethral catheter through the fistula into the lower bowel during perineal anoplasty. The fourth was a pseudodiverticulum after division of rectourethral fistula, with infection and incontinence. The fifth was a urethral stricture after a pullthrough procedure. The authors emphasize the importance of investigation prior to any surgery and meticulous surgery to minimize these complications. S. Kim ABDOMEN
Repair of Burst Abdominal Incisions. Donald Young. Br. J. Surg. 61:457, 1974. Burst abdominal incisions are not unknown in pediatric surgery, and the author stresses the importance of healing of the peritoneal and muscular layers both in preventing disruption and also in operative repair of burst abdomen. The usual type of tension sutures are not always effective. The technique described by the author ensures that the sutures passing through the deeper part of the wound come out through the skin on each side and are fastened round rubber catheters running along the length of the wound. Consequently when tension within the abdomen rises there is a tendency for the deeper layers to be brought together rather than separated.--R. B. Zachary Racial Influence on the Incidence of Biliary Atresia. W. K. T. Shim, M. Kasal, and M. A. Spence. Prog. Pediatr. Surg. 6:53-62, 1974. The incidence of biliary atresia in the seven major ethnic groups in Hawaii was determined as 0.6 :e 0.2 per 10,000 births for Caucasians, 0.8 ~ 0.3 for Japanese, 2.0 • 0.9 for Filipinos, and 3.0 • 1.6 for Chinese. The incidence for Japanese in Sendal is similar to that for Japanese in Hawaii. Of particular note is first, the similarity (contrary to popular belief) between the Caucasian and Japanese incidence and second, the possibility that 4800 children with biliary atresia may be born annually in C h i n a . - - R . C. M. Cook The Early Diagnosis of Biliary Atresia. S. Kimura. Prog. Pediatr. Surg. 6:91-112, 1974.
Irreversible cirrhosis was found in patients operated on over 90 days of age, and no cures were recorded. The differential diagnosis between biliary atresia and neonatal hepatitis must, therefore, be made between 6 and 10 wk of age (the critical period). The clinical and
laboratory findings in 12 cases of hepatitis and 34 cases of biliary atresia between these ages showed no single specific tests for each diagnosis. Serial weekly bilirubin levels on average rose in biliary atresia and fell in hepatitis. Serum alkaline phosphatase levels and serum leueine amino peptidase activity were higher in atresia; transaminase levels higher in hepatitis. Duodenal drainage done seven times showed no bile in three infants with atresia and one with hepatitis. Bile was recovered in three infants with hepatitis. Rose Bengal Studies tried in 25 infants with biliary atresia and nine with hepatitis were valid in 20 of the former and eight of the latter and showed less than 5 ~ fecal excretion in 17 infants with atresia and between 6 ~ and 25~o fecal excretion in all eight with hepatitis. Scintigrams were also helpful. Uncomplicated needle biopsies were done in 20 infants. Five cases showed equivocal bistologic features and five were temporarily misdiagnosed. Operative cholangiography and liver biopsy proved definitive diagnoses. Of four infants with hepatitis thus studied, one died postoperatively and two developed cirrhosis. Of the eight infants with hepatitis not explored surgically, only one developed cirrhosis. C. M. Cook Treatment of Biliary Atresia With Special Reference to Hepatic Porto-Enterostomy and its Modifications. M. Kasai. Prog. Pediatr. Surg. 6:5-52, 1974. In 116 cases of biliary atresia, 40 were "correctable" (i.e., an apparently patent portion of the common bile or hepatic ducts was found). 76 were "non-correctable" (i.e., no extrahepatic duct system was found at operation). All cases showed on histology that portions of the ducts were replaced by dense scar tissue though the tissue from the region of the porta hepatis of noncorrectable cases showed tiny bile ducts in almost all cases. Surgical inspection of the biliary system was supplemented by cholangiography when a suitable duct could be identified. The entire extrahepatic biliary system was systematically dissected and its fibrous remnants excised. If no adequate duct was identified, dissection was continued into the porta hepatis. A choledocbojejunostomy (Roux-en-Y) was made when possible. For noncorreetable cases, a Roux loop was anastomosed direct to the porta hepatis. Collected Japanese cases show only 18 successes out of 82 correctable patients, failure