- Email: [email protected]
Histologic study of biliary fibrous remnants in 48 cases of extrahepatic biliary atresia: Correlation with postoperative bile flow restoration
November 1976
704
TheJournalofPEDIATRICS
Histologic study of biliary fibrous remnants in 48 cases of extrahepatic biliary atresia." Correlation with postoperative bile flow restoration The fibrous remnants of bile ducts that were removed at surgery for extrahepatic biliar~ atresia were studied by serial section. Forty-eight specimens were classified into three types on the basis of histopathologic changes in the proximal portions of the specimens from the vicinity of the porta hepatis: (1) connective tissue without glands or other epithelial structures (15 cases)," (2) connective tissue containing glands lined with cuboidal epithelium (15 cases)," (3) connective tissue containing central biliary ducts and periioheral glands (18 cases). Histopathologie changes in sections J?om distal portions of the specimens did not conform to this classification. A precise correlation of prognostic significance couM not be established between these histologie data and postoperative restoration of bile flow, although failure to restore flow was encountered most frequently in cases without demonstrable ducts' or glands (Type 1),
M a r t h e Gautier, M.D.,* Patrick Jehan, M.D., and Michel Odi~vre, M.D., with the technical assistance of R. N. H u g o n , Bicbtre, F r a n c e
T rt E BA SI S of Kasai's surgical procedure (hepato-portojejunostomy or hepato-porto-cho!ecystostomy) for extrahepatic biliary atresia is the persistence of patent biliary ducts in the fibrous remnants at the porta hepatis. This study was undertaken to characterize histologically the changes in the extrahepatic biliary tree and to correlate the histologic findings with the postoperative restoration of bile flow.
MATERIAL AND METHODS Fibrous remnants were removed from the porta hepatis of 48 infants during surgery for extrahepafic biliary atresia. The operation was performed by the same surgeon (J. Valayer) in each case. In 26 patients, the remnants were complete and included residual gallbladder (used as a surgical leader), common hepatic duct, and a fibrous cone at the p0rta hepatis. In 22 patients, only the fibrous cone could be removed. The specimens were studied by the same pathologist (M. Gautier), who did not know the clinical evolution of, From the Unitb de Recherche d'Hbpatologie lnfanlile, 1NSERM U 56, Hbpital d" Enfants. *Reprint address: Unitb de Recherche d'Itepato[ogie Infantile, Hbpital d'Enfants, F G4270. Bicbtre, France.
VoL 89, No. 5, lop. 704-709
the patients. The specimens were fixed in Bouin's alcoholic solution (Duboscq-Brasil) and dehydrated according to the usual techniques, cleared in xylene, embedded in molten paraffin, and cut into serial blocks which were embedded again according to the technique of Kasai.' Serial sections were stained with hematoxylin-eosin, modified trichrome, orcein, periodic acid-Schiff, and alcian blue. Ten extrahepatic bile ducts, taken at autopsy from infants with congenital heart disease, were studied as controls according to the same techniques. Clinical evolution of bile flow restoration was estimated from stool color (dark versus clay-colored stools) and frequent liver function tests (serum albumin, lipids, total cholesterol, alkaline phosphatase concentrations, and sulfobromophthalein retention test).'-' In two cases, evidence of bile drainage was further obtained by visualization of a patent biliary-enteric anastomosis by transhepatic cholangiography. RESULTS
Microscopic findings. Control subjects (Figs. 1A and lB.) The connective tissue at the porta hepatis had a concentric arrangement.
Volume 89 Number 5
Histologic study of biliary fibrous remnants
PORTA
Fig 1A. Control sections at porta hepatis. Size of the lumen 900/x (X2.5). No inflammatory cells were observed. The bile duct was central, and its lumen was usually less than 1.2 mm in diameter. The epithelium of the bile duct was columnar and slightly irregular. Theile's glands were sometimes observed. Glandular formations were observed at the level of the porta hepatis and around the hepatic duct; they always numbered fewer than 10, The size of the lumen ranged from 50 to 70/x. Epithelium was cuboidal and was stained by alcian blue and PAS. Glands and bile ducts contained no bile.
Extrahepatic biliary atresia. PORTA HEPATIS. Three histologic patterns were identified. Type 1 (15 cases; Table I) specimens consisted of connective tissue, sometimes concentrically arranged. Neither lumen nor epithelium could be li~und (Figs. 2A and 2B). A few inflammatory cetis were seen in two cases. Nerves and dilated lymphatic vessels were present peripherally. In Type 2 (15 cases; Table II) connective tissue was abundant, without particular arrangement, in central and peripheral areas. However, one or several clusters of small glands lined with cuboidal epithelium were seen peripherally. The lumens were empty, and their sizes ranged from
705
HEPATIS
Fig. lB. Diagram of biliary tree in control subjects, arrow indicates level of section.
50 to 80 /~ (Figs 3A and 3B). Many mononuclear and polymorphonuclear inflammatory cells were seen, essentially around the clusters. In Type 3 (18 cases; Table III) bile ducts were easily found at the center of concentrically arranged connective tissue (Figs. 4A and 4B). They were lined with columnar epithelium, which was usually incomplete. Bile containing macrophages and particles of collagen were seen in the ducts. Glandular formations varied in number and were usually less numerous than in Type 2. Some glands were dilated, measuring as much as 350~, and contained bile plugs. Many inflammatory ceils surrounded both biliary ducts and glandular formations. DISTAL SECTIONS. Sections of the distal portions of the fibrous remnants showed all the findings (connective tissue, glandular formations, inflammatory cells, biliary formations), and the three types couid not be differentiated. Serial sections in Types 2 and 3 sometimes showed a proliferation of glandular formations in a pseudoangiomatous pattern. Serial sections confirmed the diagnosis of biliary atresia in each of the 48 cases by identification of complete ductal occlusion at some level of the extrahepatic biliary tree.
706
Gautier, Jehan, and OdiOvre
The Journal of Pediatrics November 1976
PORTA HEPATIS
Fig. 2A. Type 1. Neither lumen nor epithelium can be seen. Connective tissue with concentric orientation. (x 2.5.)
Table I. Type 1 Histologic findings Biliary formation with Case patent ~ L y m p h a t i c ~ vessels ~ No. lumen 1
0
2 3
0 0
4
0
5 6 7
0 0 0
8
0
9 10 11 12 13 14 15
0 0 0 0 0 0 0
*No anastomosis.
0 0 0 0 0 0 o 0 o 0 o o 0 o o
++ ++ 0 + +_ • + 0 ++ ++ ? ++ • o o
0 0 +_ +_ ++ o +_ 0 o ++ o o • 0 o
Bile flow restoration + + + +
Fig. 2B. Diagram of fibrous remnants in Type 1; arrow indicates level of section.
Bile flow restoration. Bile flow was restored postoperatively in 31 of 43 infants who had hepatic portoenterostomy or hepatic portocholecystostomyY Bile excretion began during the first two postoperative weeks in 14 infants and between the fifteenth and forty-fifth postoperative days in l 1: in the remaining six, bile was excreted intermittently for several months. As shown in Table I, 6 of 13 cases of Type 1 had postoperative bile flow, despite the absence of any biliary structure. Thirteen of 15 cases of Type 2 and 12 of 15 cases of Type 3 had evidence of bile drainage after operation (Tables II and liD. Fibrous remnants from the oldest anicteric patients (3 to 5 years of age) were classified as Type 1 (l case), Type 2 (4 cases), and Type 3 (2 cases). DISCUSSION
+
+
Periductal glands are thought normally to be present in the extrahepatic biliary tract. A precise description can only be found in the textbooks of the nineteenth century. Sappey:' studied three different animal species and wrote: "in h u m a n species, glandular formations are
Volume 89 Number 5
Histologic study o f biliary fibrous remnants
707
PORTA HEPATIS
<:'":;':'.','!'Fig. 3A. Type 2. Numerous glandular-like formations. (• 2.5.) usually observed." However, he did not determine the number of them communicating with extrahepatic bile duct. Ranvier ~ thought that epithelium had to be differentiated in biliary and in glandular formations. Our study shows a pattern of true biliary atresia: complete occlusion of the extrahepatic biliary tree is observed at some level in each of the 48 cases. The occlusion in Type 3 was either segmental or distal to the areas in which the bile duct remnants were found. The presence of ducts at the porta hepatitis does not contradict the diagnosis of atresia. The lack of lumen excludes "biliary hypoplasia," a term suggested by Koop ~that to us means patent but narrowed extrahepatic ducts. Kasai 1 recently studied 116 cases with special regard to the histology of the porta hepatis, since the presence of ducts at this site, that of anastomosis, might have bearing on prognosis. However, he did not distinguish different types of epithelial structures, calling all lumens "biliary." We challenge this opinion and think that "biliary" and "glandular" formations have to be separated; the glandular formations seen in Type 2 are so large (reaching 350/,) that they may conceivably have been mistaken for the true biliary formations observed in Type 3.
Fig. 3B. Diagram of fibrous remnants in Type 2; arrow indicates level of section,
Table 1I. Type 2 Histologic findings' Biliary l formation Glan-dular Inflamwith Case patent [ for[ Lymphatic I matory ves,els No. lumen
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
0 0 0
0 0 0 0 0 0 0 0 0, 0 0 0
Bile
Jtow restoration
+ +++ +++ +++
0 0 • +
+_ + 0 +_
+ + +
+++ ++ ++
0 0 +
++ + ++
+++ ++ +
0 + ++
++ 0 +_
+ + q+
+ + ++ +++ +++
0 0 0 0 0
+++ + ++ +++ +
+ + + + + +
708
Gautier, Jehan, and Odikvre
The Journal of Pediatrics November 1976
PORTA
HEPATIS
"2 * ' , ' . 2 : ' . ' " . ' " " ' " . ' . ' : : - 7 . * . . . . . ".2 2 . ' . ' . ; ." ~ .
,'
2
9
9";.: ; ,;:)';'21" .' ,':": : ".:..!.(.: ,~ .i.... f.~ ."
,.
"';
. ,,:
,,...':
...
Fig. 4B, Diagram of fibrous remnants in Type 3; arrow indicates level of section. Fig. 4A. Type 3. Open biliary formation surrounded by inflammatory cells. (X 2.5.)
Table III. Type 3
Histologic findings Our study provides no histologic basis for the reestablishment of bile flow through residual ducts in cases o f Type 1 and Type 2. The role o f lymphatic vessels in cases o f Type 1 should be considered; however, it is significant that in two infants there was postoperative bile drainage, although the specimens contained no visible lymphatic vessels. Because o f these paradoxical results we have not performed histologic examination o f the resected hepatic duct r e m n a n t s immediately prior to p e r f o r m i n g the anastomosis. W h e t h e r or not more extensive dissection into the liver substance provides a better chance o f finding biliary structures with a lumen, as suggested in other reports, ~.7 remains to be confirmed. The apparently good results obtained in cases o f Type 2 should be explained by the existence o f connections between glandular formations and the u p p e r biliary tract. A poor result was obtained in three infants with Type 3, in spite o f the fact that ductal r e m n a n t s were identified; p e r m a n e n t or progressive distortion o f the interlobular bile ducts could also be o f importance for bile flow restoration in these infants, and secondarily affect prognosis adversely in all infants.
Biliary formation with Case patent No. lumen 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
+ + ++ + ++ + ++ ++ + ++ + + + + + + + + +
*No anastomosis.
Glandular formations
Lymphatic vessels
+ 0 0 + 0 _+ ++ 0 0 0 + ++ + 0 0 0 + + 0
0 0 0 0 _+ 0 + 0 0 0 0 0 0 0 0 0 _+ 0
lnflammatory cells + _+ ++ + + .+++ + + ++ ++ 0 ++ ++ ++ + +++ ++++ + + + 0
Bile flow resloration + + + + + + + + + + + + * * *
Volume 89 Number 5 Inflammatory cells were seen in numerous specimens; this inflammatory reaction may be of p a r a m o u n t imPortance in understanding the pathologic course of events in biliary atresia. An initial inflammatory process with wellpreserved bile ducts (Type 3) could be followed by progressive obstruction of biliary formations, disappearance of inflammatory cells, and cicatricial changes (Type 1); transitory proliferation of glandular formations (Type 2) could represent an intermediate stage. This course might not take place' all along the biliary tree, explaining the irregular picture observed by serial sections at the time of surgery. This hypothesis supports the possibility of an acquired etiology 8 with a progressive course, and if confirmed, would strengthen the need fo r early surgery. We are indebted to Drs. Jay Bernstein and Richard Grant for their editorial help and constructive criticisms. REFERENCES
1. Kasai M: Treatment of biliary atresia with special reference to hepatic porto-enterostomy and its modifications, Prog Pediatr Surg 6:5, 1974.
Histologic study of biliary fibrous remnants
709
2. Odi6vre M, Valayer J, Razemon-Pinta M, Habib EC, and Aiagille D: Hepatic porto-enterostomy orcholecystostomy in the treatment of extrahepatic biliary atresia, J PEDIATR 88:774, 1976. 3. Sappey PC: Trait6 d'anatomie descriptive, Paris, 1877, Adrien Delahage & Cie, p 331. 4. Ranvier L: Trait6 technique d'histologie. Fast. I to VI, Nancy, 1875-1882, Librairie Ancienne et Moderne, HussonLemoine, pp 1-976. 5. Koop CE: Biliary atresia and the Kasai operation, Pediatrics 55:9, 1975.' 6. Lilly JR, and Altman RP: Hepatic porto-enterostomy (the Kasai Operation) for biliary atresia, Surgery 78.'76, 1975. 7. Altman' RP, Chandra R, and Lilly JR: Ongoing cirrhosis after successful portico-enterostomy in infants with biliary atres~a, J Pediatr Surg 10:685, 1975. 8. Gubern-Salisachs L: La maladie atr6siante des voies biliaires extrah6patiques, Arch Fr P6diatr 25"415, 1968.
704
TheJournalofPEDIATRICS
Histologic study of biliary fibrous remnants in 48 cases of extrahepatic biliary atresia." Correlation with postoperative bile flow restoration The fibrous remnants of bile ducts that were removed at surgery for extrahepatic biliar~ atresia were studied by serial section. Forty-eight specimens were classified into three types on the basis of histopathologic changes in the proximal portions of the specimens from the vicinity of the porta hepatis: (1) connective tissue without glands or other epithelial structures (15 cases)," (2) connective tissue containing glands lined with cuboidal epithelium (15 cases)," (3) connective tissue containing central biliary ducts and periioheral glands (18 cases). Histopathologie changes in sections J?om distal portions of the specimens did not conform to this classification. A precise correlation of prognostic significance couM not be established between these histologie data and postoperative restoration of bile flow, although failure to restore flow was encountered most frequently in cases without demonstrable ducts' or glands (Type 1),
M a r t h e Gautier, M.D.,* Patrick Jehan, M.D., and Michel Odi~vre, M.D., with the technical assistance of R. N. H u g o n , Bicbtre, F r a n c e
T rt E BA SI S of Kasai's surgical procedure (hepato-portojejunostomy or hepato-porto-cho!ecystostomy) for extrahepatic biliary atresia is the persistence of patent biliary ducts in the fibrous remnants at the porta hepatis. This study was undertaken to characterize histologically the changes in the extrahepatic biliary tree and to correlate the histologic findings with the postoperative restoration of bile flow.
MATERIAL AND METHODS Fibrous remnants were removed from the porta hepatis of 48 infants during surgery for extrahepafic biliary atresia. The operation was performed by the same surgeon (J. Valayer) in each case. In 26 patients, the remnants were complete and included residual gallbladder (used as a surgical leader), common hepatic duct, and a fibrous cone at the p0rta hepatis. In 22 patients, only the fibrous cone could be removed. The specimens were studied by the same pathologist (M. Gautier), who did not know the clinical evolution of, From the Unitb de Recherche d'Hbpatologie lnfanlile, 1NSERM U 56, Hbpital d" Enfants. *Reprint address: Unitb de Recherche d'Itepato[ogie Infantile, Hbpital d'Enfants, F G4270. Bicbtre, France.
VoL 89, No. 5, lop. 704-709
the patients. The specimens were fixed in Bouin's alcoholic solution (Duboscq-Brasil) and dehydrated according to the usual techniques, cleared in xylene, embedded in molten paraffin, and cut into serial blocks which were embedded again according to the technique of Kasai.' Serial sections were stained with hematoxylin-eosin, modified trichrome, orcein, periodic acid-Schiff, and alcian blue. Ten extrahepatic bile ducts, taken at autopsy from infants with congenital heart disease, were studied as controls according to the same techniques. Clinical evolution of bile flow restoration was estimated from stool color (dark versus clay-colored stools) and frequent liver function tests (serum albumin, lipids, total cholesterol, alkaline phosphatase concentrations, and sulfobromophthalein retention test).'-' In two cases, evidence of bile drainage was further obtained by visualization of a patent biliary-enteric anastomosis by transhepatic cholangiography. RESULTS
Microscopic findings. Control subjects (Figs. 1A and lB.) The connective tissue at the porta hepatis had a concentric arrangement.
Volume 89 Number 5
Histologic study of biliary fibrous remnants
PORTA
Fig 1A. Control sections at porta hepatis. Size of the lumen 900/x (X2.5). No inflammatory cells were observed. The bile duct was central, and its lumen was usually less than 1.2 mm in diameter. The epithelium of the bile duct was columnar and slightly irregular. Theile's glands were sometimes observed. Glandular formations were observed at the level of the porta hepatis and around the hepatic duct; they always numbered fewer than 10, The size of the lumen ranged from 50 to 70/x. Epithelium was cuboidal and was stained by alcian blue and PAS. Glands and bile ducts contained no bile.
Extrahepatic biliary atresia. PORTA HEPATIS. Three histologic patterns were identified. Type 1 (15 cases; Table I) specimens consisted of connective tissue, sometimes concentrically arranged. Neither lumen nor epithelium could be li~und (Figs. 2A and 2B). A few inflammatory cetis were seen in two cases. Nerves and dilated lymphatic vessels were present peripherally. In Type 2 (15 cases; Table II) connective tissue was abundant, without particular arrangement, in central and peripheral areas. However, one or several clusters of small glands lined with cuboidal epithelium were seen peripherally. The lumens were empty, and their sizes ranged from
705
HEPATIS
Fig. lB. Diagram of biliary tree in control subjects, arrow indicates level of section.
50 to 80 /~ (Figs 3A and 3B). Many mononuclear and polymorphonuclear inflammatory cells were seen, essentially around the clusters. In Type 3 (18 cases; Table III) bile ducts were easily found at the center of concentrically arranged connective tissue (Figs. 4A and 4B). They were lined with columnar epithelium, which was usually incomplete. Bile containing macrophages and particles of collagen were seen in the ducts. Glandular formations varied in number and were usually less numerous than in Type 2. Some glands were dilated, measuring as much as 350~, and contained bile plugs. Many inflammatory ceils surrounded both biliary ducts and glandular formations. DISTAL SECTIONS. Sections of the distal portions of the fibrous remnants showed all the findings (connective tissue, glandular formations, inflammatory cells, biliary formations), and the three types couid not be differentiated. Serial sections in Types 2 and 3 sometimes showed a proliferation of glandular formations in a pseudoangiomatous pattern. Serial sections confirmed the diagnosis of biliary atresia in each of the 48 cases by identification of complete ductal occlusion at some level of the extrahepatic biliary tree.
706
Gautier, Jehan, and OdiOvre
The Journal of Pediatrics November 1976
PORTA HEPATIS
Fig. 2A. Type 1. Neither lumen nor epithelium can be seen. Connective tissue with concentric orientation. (x 2.5.)
Table I. Type 1 Histologic findings Biliary formation with Case patent ~ L y m p h a t i c ~ vessels ~ No. lumen 1
0
2 3
0 0
4
0
5 6 7
0 0 0
8
0
9 10 11 12 13 14 15
0 0 0 0 0 0 0
*No anastomosis.
0 0 0 0 0 0 o 0 o 0 o o 0 o o
++ ++ 0 + +_ • + 0 ++ ++ ? ++ • o o
0 0 +_ +_ ++ o +_ 0 o ++ o o • 0 o
Bile flow restoration + + + +
Fig. 2B. Diagram of fibrous remnants in Type 1; arrow indicates level of section.
Bile flow restoration. Bile flow was restored postoperatively in 31 of 43 infants who had hepatic portoenterostomy or hepatic portocholecystostomyY Bile excretion began during the first two postoperative weeks in 14 infants and between the fifteenth and forty-fifth postoperative days in l 1: in the remaining six, bile was excreted intermittently for several months. As shown in Table I, 6 of 13 cases of Type 1 had postoperative bile flow, despite the absence of any biliary structure. Thirteen of 15 cases of Type 2 and 12 of 15 cases of Type 3 had evidence of bile drainage after operation (Tables II and liD. Fibrous remnants from the oldest anicteric patients (3 to 5 years of age) were classified as Type 1 (l case), Type 2 (4 cases), and Type 3 (2 cases). DISCUSSION
+
+
Periductal glands are thought normally to be present in the extrahepatic biliary tract. A precise description can only be found in the textbooks of the nineteenth century. Sappey:' studied three different animal species and wrote: "in h u m a n species, glandular formations are
Volume 89 Number 5
Histologic study o f biliary fibrous remnants
707
PORTA HEPATIS
<:'":;':'.','!'Fig. 3A. Type 2. Numerous glandular-like formations. (• 2.5.) usually observed." However, he did not determine the number of them communicating with extrahepatic bile duct. Ranvier ~ thought that epithelium had to be differentiated in biliary and in glandular formations. Our study shows a pattern of true biliary atresia: complete occlusion of the extrahepatic biliary tree is observed at some level in each of the 48 cases. The occlusion in Type 3 was either segmental or distal to the areas in which the bile duct remnants were found. The presence of ducts at the porta hepatitis does not contradict the diagnosis of atresia. The lack of lumen excludes "biliary hypoplasia," a term suggested by Koop ~that to us means patent but narrowed extrahepatic ducts. Kasai 1 recently studied 116 cases with special regard to the histology of the porta hepatis, since the presence of ducts at this site, that of anastomosis, might have bearing on prognosis. However, he did not distinguish different types of epithelial structures, calling all lumens "biliary." We challenge this opinion and think that "biliary" and "glandular" formations have to be separated; the glandular formations seen in Type 2 are so large (reaching 350/,) that they may conceivably have been mistaken for the true biliary formations observed in Type 3.
Fig. 3B. Diagram of fibrous remnants in Type 2; arrow indicates level of section,
Table 1I. Type 2 Histologic findings' Biliary l formation Glan-dular Inflamwith Case patent [ for[ Lymphatic I matory ves,els No. lumen
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
0 0 0
0 0 0 0 0 0 0 0 0, 0 0 0
Bile
Jtow restoration
+ +++ +++ +++
0 0 • +
+_ + 0 +_
+ + +
+++ ++ ++
0 0 +
++ + ++
+++ ++ +
0 + ++
++ 0 +_
+ + q+
+ + ++ +++ +++
0 0 0 0 0
+++ + ++ +++ +
+ + + + + +
708
Gautier, Jehan, and Odikvre
The Journal of Pediatrics November 1976
PORTA
HEPATIS
"2 * ' , ' . 2 : ' . ' " . ' " " ' " . ' . ' : : - 7 . * . . . . . ".2 2 . ' . ' . ; ." ~ .
,'
2
9
9";.: ; ,;:)';'21" .' ,':": : ".:..!.(.: ,~ .i.... f.~ ."
,.
"';
. ,,:
,,...':
...
Fig. 4B, Diagram of fibrous remnants in Type 3; arrow indicates level of section. Fig. 4A. Type 3. Open biliary formation surrounded by inflammatory cells. (X 2.5.)
Table III. Type 3
Histologic findings Our study provides no histologic basis for the reestablishment of bile flow through residual ducts in cases o f Type 1 and Type 2. The role o f lymphatic vessels in cases o f Type 1 should be considered; however, it is significant that in two infants there was postoperative bile drainage, although the specimens contained no visible lymphatic vessels. Because o f these paradoxical results we have not performed histologic examination o f the resected hepatic duct r e m n a n t s immediately prior to p e r f o r m i n g the anastomosis. W h e t h e r or not more extensive dissection into the liver substance provides a better chance o f finding biliary structures with a lumen, as suggested in other reports, ~.7 remains to be confirmed. The apparently good results obtained in cases o f Type 2 should be explained by the existence o f connections between glandular formations and the u p p e r biliary tract. A poor result was obtained in three infants with Type 3, in spite o f the fact that ductal r e m n a n t s were identified; p e r m a n e n t or progressive distortion o f the interlobular bile ducts could also be o f importance for bile flow restoration in these infants, and secondarily affect prognosis adversely in all infants.
Biliary formation with Case patent No. lumen 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
+ + ++ + ++ + ++ ++ + ++ + + + + + + + + +
*No anastomosis.
Glandular formations
Lymphatic vessels
+ 0 0 + 0 _+ ++ 0 0 0 + ++ + 0 0 0 + + 0
0 0 0 0 _+ 0 + 0 0 0 0 0 0 0 0 0 _+ 0
lnflammatory cells + _+ ++ + + .+++ + + ++ ++ 0 ++ ++ ++ + +++ ++++ + + + 0
Bile flow resloration + + + + + + + + + + + + * * *
Volume 89 Number 5 Inflammatory cells were seen in numerous specimens; this inflammatory reaction may be of p a r a m o u n t imPortance in understanding the pathologic course of events in biliary atresia. An initial inflammatory process with wellpreserved bile ducts (Type 3) could be followed by progressive obstruction of biliary formations, disappearance of inflammatory cells, and cicatricial changes (Type 1); transitory proliferation of glandular formations (Type 2) could represent an intermediate stage. This course might not take place' all along the biliary tree, explaining the irregular picture observed by serial sections at the time of surgery. This hypothesis supports the possibility of an acquired etiology 8 with a progressive course, and if confirmed, would strengthen the need fo r early surgery. We are indebted to Drs. Jay Bernstein and Richard Grant for their editorial help and constructive criticisms. REFERENCES
1. Kasai M: Treatment of biliary atresia with special reference to hepatic porto-enterostomy and its modifications, Prog Pediatr Surg 6:5, 1974.
Histologic study of biliary fibrous remnants
709
2. Odi6vre M, Valayer J, Razemon-Pinta M, Habib EC, and Aiagille D: Hepatic porto-enterostomy orcholecystostomy in the treatment of extrahepatic biliary atresia, J PEDIATR 88:774, 1976. 3. Sappey PC: Trait6 d'anatomie descriptive, Paris, 1877, Adrien Delahage & Cie, p 331. 4. Ranvier L: Trait6 technique d'histologie. Fast. I to VI, Nancy, 1875-1882, Librairie Ancienne et Moderne, HussonLemoine, pp 1-976. 5. Koop CE: Biliary atresia and the Kasai operation, Pediatrics 55:9, 1975.' 6. Lilly JR, and Altman RP: Hepatic porto-enterostomy (the Kasai Operation) for biliary atresia, Surgery 78.'76, 1975. 7. Altman' RP, Chandra R, and Lilly JR: Ongoing cirrhosis after successful portico-enterostomy in infants with biliary atres~a, J Pediatr Surg 10:685, 1975. 8. Gubern-Salisachs L: La maladie atr6siante des voies biliaires extrah6patiques, Arch Fr P6diatr 25"415, 1968.