Morio Kasai

Surgical treatment of biliary atresia

Abstract Among 87 proven cases of biliary atresia, 20 were of “correctable” types and the remaining 67 of “incorrectable” types. Complete cure was obtained in 3 of 16 “correctable” cases on which an anastomosis was carried out. Postoperative excretion of bile was poor or absent in many cases of “correctable” types. Fifty-three of 67 cases of the “incorrectable” type underwent hepatic portoenterostomy. Nineteen of them showed excellent or fair excretion of bile after operation and 6 are living and well without jaundice from 1 year, 2 months to 13 years after operation. The histologic study of extrahepatic bile ducts showed that tiny but patent bile duct exists in the porta hepatis of nearly all cases of “incorrectable” types examined and that good excretion of bile was obtained usually in cases which had bile ducts with a diameter of more than 200 μ in the porta hepatis. From these results, it was concluded that “correctable” cases of biliary atresia are not necessarily curable while not a few cases of “incorrectable” types might be cured by hepatic portoenterostomy if the operation is performed before 4 months of age.

Histologic classification of liver-cell carcinoma in infancy and childhood and its clinical evaluation. A study of 70 cases collected in Japan.

Clinical data and morphological materials from 70 cases of liver‐cell carcinoma in infants and children in Japan were collected and studied. The cases were classified into 4 types according to the histopathologic appearance of the epithelial components: 1. adult type; 2. anaplastic type; 3. embryonal type; and 4. fetal type. The study confirmed the existence of a distinct correlation beween the histologic type of the tumor, its gross appearance, and the clinical course of the disease. Twenty‐seven of the 70 cases underwent radical surgery. Postoperative prognosis was studied in these cases according to histologic types of tumor. Of 9 long‐term survivors (i.e., surviving more than 2 years), 7 were found to belong to the fetal type. No difference was found in prognosis between the cases with and without osteoid tissue in tumor. The benign character of the fetal type, as compared with other types of hepatoblastoma, was demonstrated even in infants under 12 months of age.

Possible cancerous change of intraductal papillomas of the breast. A 3‐D reconstruction study of 25 cases

Surgical specimens from 25 patients with intraductal papilloma were subjected to 3‐dimensional (3‐D) reconstruction studies of their mammary ducts. Papillomas of the multiple type (15 cases) always originated in the terminal duct lobular units (TDLU), whereas all papillomas of the solitary type (10 cases) originated in the large ducts except for one. In 6 of the 25 (24%) patients ductal carcinomas were accidentally found during specimen reconstruction. Two of the six patients harbored microscopic carcinoma as small as 3 mm or less. Three‐D reconstructions revealed that carcinomas with multifocal origins in the TDLUs were connected with peripheral papilloma. Papilloma preceding carcinoma was of the multiple type in five patients, and of the solitary type in one. This study also showed that 6 of the 16 (37.5%) patients with papilloma originating in the periphery had carcinomas, whereas none of the nine patients originating in the center did. This observation strongly suggests that the peripheral papilloma is highly susceptible to cancerous change.

Surgical limitation for biliary atresia: indication for liver transplantation

Of 245 patients undergoing corrective operations for biliary atresia, jaundice was cleared in 113. In January 1988, 84 of them were living and free of jaundice and the other 19 were alive with jaundice. A vast majority of long-term survivors showed normal growth and development, and were leading normal lives for their respective ages. Portal hypertension, a common late complication, improved spontaneously or after sclerotherapy in jaundice-free patients. Therefore, liver transplantation is not recommended for jaundice-free patients even with esophageal varices. Patients with persistent severe jaundice (serum bilirubin over 10 mg/dL) and those with moderate jaundice (serum bilirubin 5 to 10 mg/dL) and severe esophageal varices require liver transplantation. Patients with moderate jaundice having no or slight varices should be carefully followed. When varices become worse or serum bilirubin rises, liver transplantation is indicated. Patients with mild jaundice (serum bilirubin lower than 5 mg/dL) have a possibility of improvement in their condition before the age of 15 years, and are not recommended for liver transplantation. The high value of the lowest postoperative bilirubin level suggests the necessity of liver transplantation in early childhood. Liver transplantation as the primary treatment for biliary atresia may be indicated only for patients over 120 days of age with an enlarged and hard liver.

Portal hypertension after successful hepatic portoenterostomy in biliary atresia

From 1953 through 1984, we have operated on 225 cases of biliary atresia, and 95 patients are presently surviving. Portal hypertension with esophageal varices was endoscopically confirmed in 26 of 66 patients (39%) examined, 14 with and 52 without jaundice. All these patients except two had had frequent episodes of postoperative cholangitis. Eight patients have undergone treatment for portal hypertension. The treatment for variceal bleeding in jaundice-free infants with biliary atresia should be initiated conservatively, including endoscopic sclerotherapy. The results of our experience, however, justifies the employment of shunt procedures for patients older than 6 or 7 years of age.

Changes of portal vein pressure and intrahepatic blood vessels after surgery for biliary atresia

The portal vein pressure was measured and biopsies of the liver were taken during the corrective operation in 31 patients with biliary atresia and during relaparotomy in 16 patients free from jaundice 4 mo to 9 yr after a successful corrective operation. Because the portal vein pressure was higher than 200 mmH2O in about 70% of patients during the corrective operation, portal hypertension appears to have already developed in most of the patients with biliary atresia at 2-4 mo of age. In the patients who had had frequent episodes of postoperative cholangitis, the portal vein pressure was elevated and the amount of interstitial tissue in the liver was markedly increased at reoperation compared with those at the corrective operation. These results showed that postoperative cholangitis aggravated portal hypertension and fibrosis of the liver. On the contrary, the portal vein pressure declined in patients in whom active bile drainage had persisted and cholangitis had not been complicated after operation. An early corrective operation and prevention of postoperative cholangitis are of the greatest important for prevention of development of the portal hypertension and cirrhosis of the liver in long-term survivors after surgery for biliary atresia.

Advances in treatment of biliary atresia.

During 29 years from 1953 through 1981, 224 patients with congenital biliary atresia were treated and 200 of them underwent corrective operation at the Second Department of Surgery, Tohoku University Hospital. With the advance of surgical techniques and early diagnosis of biliary atresia, the rate of jaundice disappearance improved from the initial 15 per cent to Hre recent 69 per cent. Important factors contributing to the improvement of operative results included (1) an early operation, preferably within 60 days after birth, (2) a precise dissection and adequate transection of the porta hepatis, (3) prevention of post-operative cholangitis and (4) reoperation if indicated. Delayed operation and occurrence of post-operative results. Although, nearly all the patients with biliary atresia had portal hypertension at the time of surgery, the portal vein pressure decreased after successful operation, mainly due to improvement in portal venous circulation of the liver. It is considered from recent operative results that more than 80 per cent of patients with biliary atresia can be cured when an adequate corrective operation is carried out before 60 days of age and post-operative cholangitis is prevented.

Preoperative assessment of resectability for carcinoma of the thoracic esophagus. Part I. Esophagogram and azygogram.

The length and radiologic type of tumor, esophageal axis and azygogram were examined in 208 patients with carcinoma of the thoracic esophagus who underwent esophageal resection from 1965 to 1975. An histologic examination was performed on all resected specimens. These examinations were used as diagnostic aids to determine the resectability of esophageal carcinoma before surgery. Tumor length did not seem an adequate parameter on deciding resectability; nor did the radiologic type of tumor. Examination of the esophageal axis was in determining resectability. The azygogram gave the most accurate information about resectability of these 4 parameters. The probability of a correct diagnosis regarding differentiation of noncurative a3 lesions from other resectable lesions was 85.6%.

Rectal myotomy with colectomy: a new radical operation for Hirschsprung's disease.

Abstract A new radical operation for Hirschsprungs disease, i.e., rectal myotomy with colectomy, the aim of which is to minimize pelvic dissection and to preserve the rectal wall as much as possible, was performed in 11 cases of Hirschsprungs disease. It can be used on young infants, and rectal sensation is preserved. The result was satisfactory in all but one child.

Reoperation in patients with biliary atresia.

Twenty-seven reoperations were done on 23 patients among 100 infants with biliary atresia who have been treated at Tohoku University Hospital between 1971 and 1981. Nineteen patients had a single reoperation and 4 patients had 2 reoperations. We present the results and the role of reoperation in biliary atresia patients in our institution. Excellent bile drainage after reoperation was obtained in 13 of 15 patients with good bile flow after the initial operation. On the contrary, good bile drainage was not obtained by reoperation in 8 of 12 cases without active bile flow after the initial operation. Cessation of bile flow after successful initial operation is an absolute indication for reoperation. Aggressive reoperations under proper indications improve the surgical results in biliary atresia patients.