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The importance of hepatic lymph drainage in experimental biliary atresia. Effect of omentopexy on prevention of cholangitis
The Importance of Hepatic Lymph Drainage in Experimental Biliary Atresia. Effect of Omentopexy on Prevention of Cholangitis By J. Hirsig, P. P. Rickham, and J. Briner Zurich, Switzerland 0 It is believed that partial destruction of the hepatic lymph drainage during the operation of hepato-portoenterostomy is probably the cause of postoperative attacks of cholangitis. Experimental evidence is described that appears to show that omentopexy to the porta hepatis will aid hepatic lymph drainage and may thus prevent postoperative cholangitis. INDEX WORDS: Postoperative cholangitis; hepatic portoenterostomy: omentopexy; hepatic lymph drainage: neonatal obstructive cholangiopathy: biliary atresia.
CLEAR ITsiaHASis notBECOME simply a congenital
that biliary atremalformation of the bile passages, but part and parcel of a chronic peri- and postnatal liver disease. Although there is as yet no direct proof, one suspects that the etiology is similar to that of neonatal hepatitis, the most probable cause being a virus. Landing’ believes that biliary atresia is a special form of the so-called neonatal obstructive cholangiopathy with special involvement of the bile ducts. This explains why biliary atresia has an uncertain long-term prognosis. Although surgical attempts to reconstitute the flow of bile from the liver into the intestinal tract are very important, these operations cannot be regarded as definitely curative. During the last 10 yr, a large amount of work has been done in pediatric surgical centers in order to develop better operative procedures for biliary atresia. In spite of a number of ingenious new operative methods, the prognosis has not From the Department of Paediatric Surgery and the Department of Pathology, University of Zurich. Zurich. Switzerland. Presented before the I I th Annual Meeting of the Pacific Association of Pediatric Surgeons, Osaka, Japan. Muy 30-June 3.1978. Address reprint requests to J. Hirsig, M.D., Chief Research Assistant, Department of Paediatric Surgery, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich. Switzerland. 01979 by Grune & Stratton. Inc. 0022-3468/79/1402-0005$01 .OOfO
142
improved very much. Kasai’s introduction of portoenterostomy2 in 1959 has enabled us to connect the intrahepatic bile ducts with the intestinal tract. In many cases, the symptoms of biliary atresia, especially the icterus, disappeared after this operation. Unfortunately, the long-term prognosis has been marred by the frequent occurrence of postoperative cholangitis. This cholangitis that will be followed by rapid development of biliary cirrhosis is, we believe, probably not due to ascending infection of bacteria from the intestinal tract. It is probably caused by bacteria in the blood stream damaging the hepatic cells which have become susceptible to infection because of the interruption of the hepatic lymph drainage. In 1977, we3 were able to show in animal experiments that in cases with cholestasis with progressive biliary cirrhosis (Fig. I), cholangitis will not develop if the bile duct alone has been tied. If, however, in addition to ligature of the bile duct the lymph drainage from the liver is interrupted by resecting the lymphatic tissues in the porta hepatis and hepatoduodenal ligament, biliary cirrhosis will not only develop much more rapidly, but there will be a superadded infection with necrosis, abscess formation and cholangitis (Fig. 2). It is, therefore, very important that when carrying out a portoenterostomy operation, the lymphatic tissues in the hepato-duodenal ligament should, if possible, not be injured. A microsurgical dissection of the porta hepatis, as suggested by Suruga in 1976,4 has much to recommend it. In addition, we have recently carried out a hepato-porto-omentopexy hoping to improve the hepatic lymph drainage. The experiments described below were designed in order to find out whether this operation was of some practical use. MATERIALS AND METHODS Minipigs, anesthetized
8 wk old, weighing 5 kg were used. They were and a ligature
was placed round the common
bile duct. At the same time, the whole of the hepatoduodenal
Journal of Pediatric Surgery, Vol. 14, No. 2 (April), 1979
143
HEPATIC LYMPH DRAINAGE
Fig. 1.
Liver biopsy 8 wk after ligation of the common bile duct shows marked cirrhosis (100X 1.
ligament was resected, care been taken not to damage the portal vein and the hepatic artery. All lymph glands were removed as far as possible. A raw area was then created in the region of the porta hepatis and the greater omentum was sewn to this area with a few interrupted chromic sutures (Fig. 3). Following this operation, liver biopsies were taken at weekly intervals with the aid of the laparoscope. Ten animals with operated upon. Four animals died shortly after operation as a direct result of it. This high mortality shows
the severity of the intervention. The remaining 6 animals survived and could be controlled regularily for a period of 4 mo. They were then sacrificed. During the observation period, no attacks of cholangitis or liver abscesses were observed on clinical, laboratory or histologic examinations (Fig. 4). Histologic examination of the porta hepatis region in the animals with omentopexy showed massive pre-stenotic dilatation of the intrahepatic lymph vessels (Fig. 5). It was assumed that omentopexy allowed for an incomplete, but
Fig. 2. Liver biospy 4 wk after ligation on the common bile duct and additional interruption of the lymphatic flow from the liver shows marked cirrhosis and massive inflsmmatory infiltration with abscess formation (83X).
HIRSIG, RICKHAM, AND BRINER
xwto-omento-
a form of lopathy and ative recon-
the liver and
HEPATIC LYMPH
Fig. 5. (8X).
145
DRAINAGE
Histologic examination of the porta hepatis region shows massive dilatation of the interahepatic lymph vessels
struction of bile drainage into the gastrointestinal canal is essential. Portoenterostomy first introduced by Kasai is today the method of choice for previously called inoperable cases of biliary atresia and the immediate results have not been unsatisfactory. This operation does, however, entail considerable destruction of the hepatic lymph drainage in the porta hepatis and this is probably the cause of the postoperative
cholangitis which so often complicates recovery. Animal experiments as well as clinical experience have convinced us that improvement of the lymph drainage by omentopexy will improve the results of hepato-portoenterostomy that should in any case be carried out with the greatest possible care in order to avoid unnecessary damage to the lymphatics.
REFERENCES 1. Landing BH: Considerations of pathogenesis of neonatal hepatitis, biliary atresia and choledochal cyst. The concept of infantile obstructive cholangiopathy. Prog Pediatr Surg 6:113, 1974 2. Kasai M, Suzuki S: A new operation for “non-correctable” biliary atresia: Hepatic porto-enterostomy. Shujutsu 13:733, 1959
3. Hirsig J, Kara 0, Rickham PP: Experimental investigations into the etiology of cholangitis following operation for biliary atresia. J Pediatr Surg 13:55, 1978 4. Suruga K, Kono S, Myano T. et al: Treatment of biliary atresia: Microsurgery for hepatic portoenterostomy. Surgery 80558, 1976
CLEAR ITsiaHASis notBECOME simply a congenital
that biliary atremalformation of the bile passages, but part and parcel of a chronic peri- and postnatal liver disease. Although there is as yet no direct proof, one suspects that the etiology is similar to that of neonatal hepatitis, the most probable cause being a virus. Landing’ believes that biliary atresia is a special form of the so-called neonatal obstructive cholangiopathy with special involvement of the bile ducts. This explains why biliary atresia has an uncertain long-term prognosis. Although surgical attempts to reconstitute the flow of bile from the liver into the intestinal tract are very important, these operations cannot be regarded as definitely curative. During the last 10 yr, a large amount of work has been done in pediatric surgical centers in order to develop better operative procedures for biliary atresia. In spite of a number of ingenious new operative methods, the prognosis has not From the Department of Paediatric Surgery and the Department of Pathology, University of Zurich. Zurich. Switzerland. Presented before the I I th Annual Meeting of the Pacific Association of Pediatric Surgeons, Osaka, Japan. Muy 30-June 3.1978. Address reprint requests to J. Hirsig, M.D., Chief Research Assistant, Department of Paediatric Surgery, University Children’s Hospital, Steinwiesstr. 75, 8032 Zurich. Switzerland. 01979 by Grune & Stratton. Inc. 0022-3468/79/1402-0005$01 .OOfO
142
improved very much. Kasai’s introduction of portoenterostomy2 in 1959 has enabled us to connect the intrahepatic bile ducts with the intestinal tract. In many cases, the symptoms of biliary atresia, especially the icterus, disappeared after this operation. Unfortunately, the long-term prognosis has been marred by the frequent occurrence of postoperative cholangitis. This cholangitis that will be followed by rapid development of biliary cirrhosis is, we believe, probably not due to ascending infection of bacteria from the intestinal tract. It is probably caused by bacteria in the blood stream damaging the hepatic cells which have become susceptible to infection because of the interruption of the hepatic lymph drainage. In 1977, we3 were able to show in animal experiments that in cases with cholestasis with progressive biliary cirrhosis (Fig. I), cholangitis will not develop if the bile duct alone has been tied. If, however, in addition to ligature of the bile duct the lymph drainage from the liver is interrupted by resecting the lymphatic tissues in the porta hepatis and hepatoduodenal ligament, biliary cirrhosis will not only develop much more rapidly, but there will be a superadded infection with necrosis, abscess formation and cholangitis (Fig. 2). It is, therefore, very important that when carrying out a portoenterostomy operation, the lymphatic tissues in the hepato-duodenal ligament should, if possible, not be injured. A microsurgical dissection of the porta hepatis, as suggested by Suruga in 1976,4 has much to recommend it. In addition, we have recently carried out a hepato-porto-omentopexy hoping to improve the hepatic lymph drainage. The experiments described below were designed in order to find out whether this operation was of some practical use. MATERIALS AND METHODS Minipigs, anesthetized
8 wk old, weighing 5 kg were used. They were and a ligature
was placed round the common
bile duct. At the same time, the whole of the hepatoduodenal
Journal of Pediatric Surgery, Vol. 14, No. 2 (April), 1979
143
HEPATIC LYMPH DRAINAGE
Fig. 1.
Liver biopsy 8 wk after ligation of the common bile duct shows marked cirrhosis (100X 1.
ligament was resected, care been taken not to damage the portal vein and the hepatic artery. All lymph glands were removed as far as possible. A raw area was then created in the region of the porta hepatis and the greater omentum was sewn to this area with a few interrupted chromic sutures (Fig. 3). Following this operation, liver biopsies were taken at weekly intervals with the aid of the laparoscope. Ten animals with operated upon. Four animals died shortly after operation as a direct result of it. This high mortality shows
the severity of the intervention. The remaining 6 animals survived and could be controlled regularily for a period of 4 mo. They were then sacrificed. During the observation period, no attacks of cholangitis or liver abscesses were observed on clinical, laboratory or histologic examinations (Fig. 4). Histologic examination of the porta hepatis region in the animals with omentopexy showed massive pre-stenotic dilatation of the intrahepatic lymph vessels (Fig. 5). It was assumed that omentopexy allowed for an incomplete, but
Fig. 2. Liver biospy 4 wk after ligation on the common bile duct and additional interruption of the lymphatic flow from the liver shows marked cirrhosis and massive inflsmmatory infiltration with abscess formation (83X).
HIRSIG, RICKHAM, AND BRINER
xwto-omento-
a form of lopathy and ative recon-
the liver and
HEPATIC LYMPH
Fig. 5. (8X).
145
DRAINAGE
Histologic examination of the porta hepatis region shows massive dilatation of the interahepatic lymph vessels
struction of bile drainage into the gastrointestinal canal is essential. Portoenterostomy first introduced by Kasai is today the method of choice for previously called inoperable cases of biliary atresia and the immediate results have not been unsatisfactory. This operation does, however, entail considerable destruction of the hepatic lymph drainage in the porta hepatis and this is probably the cause of the postoperative
cholangitis which so often complicates recovery. Animal experiments as well as clinical experience have convinced us that improvement of the lymph drainage by omentopexy will improve the results of hepato-portoenterostomy that should in any case be carried out with the greatest possible care in order to avoid unnecessary damage to the lymphatics.
REFERENCES 1. Landing BH: Considerations of pathogenesis of neonatal hepatitis, biliary atresia and choledochal cyst. The concept of infantile obstructive cholangiopathy. Prog Pediatr Surg 6:113, 1974 2. Kasai M, Suzuki S: A new operation for “non-correctable” biliary atresia: Hepatic porto-enterostomy. Shujutsu 13:733, 1959
3. Hirsig J, Kara 0, Rickham PP: Experimental investigations into the etiology of cholangitis following operation for biliary atresia. J Pediatr Surg 13:55, 1978 4. Suruga K, Kono S, Myano T. et al: Treatment of biliary atresia: Microsurgery for hepatic portoenterostomy. Surgery 80558, 1976