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Khayat A, Alamri AM, Saadah OI. Outcomes of late Kasai portoenterostomy in biliary atresia: a single-center experience. J Int Med Res 2021; 49:3000605211012596. [PMID: 33947263 PMCID: PMC8113946 DOI: 10.1177/03000605211012596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To describe the clinical, histopathologic, and outcomes data for a cohort of patients with biliary atresia (BA), and to identify the factors affecting survival. METHODS This was a cross-sectional study of all BA patients diagnosed between 1999 and 2017. Clinical, biochemical, imaging, and histopathologic data were analyzed, and Kaplan-Meier survival rates were compared to identify potential prognostic factors. RESULTS We evaluated 23 patients. The median age at the Kasai procedure was 77 ± 34 days, and the median overall survival was 12.5 ± 65 months. Thirteen (56%) patients survived with their native livers, 3 (13%) received a transplant, and 6 died (26%) while awaiting a transplant. Cholangitis and the use of ursodeoxycholic acid were associated with longer survival, while impaired synthetic function was associated with shorter survival. CONCLUSIONS Most patients presented late for the Kasai procedure. The survival rate with the native liver was comparable to other cohorts. Therefore, clinicians are encouraged to refer for the Kasai procedure even with late presentation (between 60 and 90 days), provided there is no hepatic decompensation.
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Affiliation(s)
- Ammar Khayat
- Department of Pediatrics, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia.,Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Aisha M Alamri
- Department of Pediatrics, East Jeddah General Hospital, Jeddah, Saudi Arabia
| | - Omar I Saadah
- Pediatric Gastroenterology Unit, Department of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.,Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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The rate of hepatic artery complications is higher in pediatric liver transplant recipients with metabolic liver diseases than with biliary atresia. J Pediatr Surg 2018; 53:1516-1522. [PMID: 29861326 DOI: 10.1016/j.jpedsurg.2018.04.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/31/2018] [Accepted: 04/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA. BASIC PROCEDURES Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed. MAIN FINDINGS Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P < 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014). PRINCIPAL CONCLUSION Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications. TYPE OF SUBMISSION Original article, Case control study, Retrospective. EVIDENCE LEVEL III.
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Surgical modifications, additions, and alternatives to Kasai hepato-portoenterostomy to improve the outcome in biliary atresia. Pediatr Surg Int 2017; 33:1275-1282. [PMID: 28980051 DOI: 10.1007/s00383-017-4162-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Abstract
Kasai hepato-portoenterostomy (HPE) is the most widely used surgical technique to restore bile flow in biliary atresia (BA). We aimed to review literature on HPE substitutes and additions to Kasai especially in advanced BA (ABA). A PubMed search was done for surgical procedures apart from or along with Kasai HPE for BA. Additional procedures to prevent cholangitis were also reviewed. Procedures and outcome were analysed. Alternative procedures done by the authors have also been described briefly. Results have been compiled in this review article. In ABA, with portal hypertension and liver cirrhosis, Kasai HPE is associated with poor outcome, increased morbidity, and even mortality. Most require liver transplant (LT). Some alternatives to HPE include exploration at porta hepatis to assess the bile flow yet avoid the major surgery (HPE) as a bridge to LT. Conduit diversion may help to combat cholangitis resistant to steroid therapy. Stoma formation is not preferred in cases listed for LT due to high risk of bleeding. Hepatocyte infusion, stem cell therapy, and synthetic liver are the future options to meet the challenges in BA. Various alternative procedures may become handy in the future especially in ABA.
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Song Z, Dong R, Shen Z, Chen G, Yang Y, Zheng S. Surgical outcome and etiologic heterogeneity of infants with biliary atresia who received Kasai operation less than 60 days after birth: A retrospective study. Medicine (Baltimore) 2017; 96:e7267. [PMID: 28658122 PMCID: PMC5500044 DOI: 10.1097/md.0000000000007267] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This study aimed to analyze the impact of etiologic heterogeneity and operation age on prognosis of infants with biliary atresia (BA) who received Kasai operation prior to 60 days of age.From 2004 to 2010, 158 infants received Kasai operation before turning 60 days old. According to Davenport 2012 classifications, 4 groups of BA were defined: cystic BA, syndrome BA, and associated malformation, cytomegalovirus (CMV)-associated BA, and isolated BA. Native (autologous) liver survival rates and incidence of cholangitis 2 years after operation, as well as jaundice clearance rates 3 months after operation, were recorded.Although infants who received the operation between 51 and 60 days of age had a better jaundice clearance 3 months after operation and lower incidence of cholangitis as compared with those under 40 or between 41 and 50 days of age, there was no significant difference in survival rates. Among types of BA, infants with cystic BA had the best prognosis. In the syndrome BA and associated malformations group, as well as CMV-associated group, infants who received the operation early (<40 days of age) had a worse outcome as compared with those who received the operation between 41 and 50 days or 51 and 60 days of age.Both clinical etiologic heterogeneity and operation age may influence BA prognosis.
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5
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Fn14 hepatic progenitor cells are associated with liver fibrosis in biliary atresia. Pediatr Surg Int 2017; 33:593-599. [PMID: 28180936 DOI: 10.1007/s00383-017-4068-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE The liver in biliary atresia (BA) is characterized by progressing fibrosis which is promoted by unclear reasons. We aimed to understand the factors influencing liver fibrosis. This study hypothesized that HPCs (hepatic progenitor cells) are activated and associated with liver fibrosis in biliary atresia. METHODS Liver samples from biliary atresia patients are as BA group, and the normal liver derived from hepatoblastoma infants during operation are control group. The extent of fibrosis in liver samples was blindly evaluated by two experienced pathologists depending on Ishak system. The BA liver samples were divided into mild liver fibrosis group (grade I-IV, BAa) and severe liver fibrosis group (grade V-VI, BAb) to detect Fn14 protein expression. RESULTS In mRNA level, Fn14 expression was 21.23 ± 8.3 vs. 1.00 ± 0.17, p = 0.023 < 0.05 and CD133 expression was 6.02 ± 2.16 vs. 1.14 ± 0.75, p = 0.008 < 0.01 between BA group and control group. Fn14 cells co-expressed the progenitor marker CD133 in liver, and activated in BA. Fn14 andα-SMA were co-location in fibrous area in liver. Compared to the control group, Fn14, CD133, and α-SMA protein expression were 2.10 ± 0.53 vs. 0.97 ± 0.2, p = 0.001, 2.23 ± 0.57 vs. 1.00 ± 0.03, p = 0.000, 4.96 ± 2.4 vs. 1.00 ± 0.22, p = 0.001. The Fn14 protein expression was 2.60 ± 0.35 vs. 1.86 ± 0.42, p = 0.012, between BAb and BAa group. CONCLUSION Fn14 cells, which co-express the progenitor marker CD133 in liver, are HPCs and activated in BA. Fn14 + HPCs are associated with liver fibrosis in BA.
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Early type I collagen deposition is associated with prognosis in biliary atresia. J Pediatr Surg 2016; 51:379-85. [PMID: 26452701 DOI: 10.1016/j.jpedsurg.2015.08.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/13/2015] [Accepted: 08/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a cholestatic liver disease of children that progresses to hepatic fibrosis. BA is the main indication of pediatric liver transplantation (LTx). Histopathological markers in liver biopsies could be useful for predicting progression to end-stage disease. OBJECTIVE To establish histopathological or immunohistochemical markers in liver biopsies of BA patients and correlate those markers with prognosis. METHOD Histological analysis of biliary alterations and morphometric assessment of liver fibrosis were performed, in addition to indirect immunofluorescence assays (IF) for type I, III, IV and V collagens in initial and final liver biopsies of 36 patients with BA who underwent Kasai hepatoportoenterostomy (KPE) and LTx in the last 20years at a single center. RESULTS Histopathological markers had no correlation with evolutive time until LTx. The perisinusoidal deposition of type III and V collagens was more prominent in the initial biopsies (p<0.01), whereas deposition of type I and IV collagens indicated progression (p<0.01). Patients with large amounts of perisinusoidal type I collagen in the initial biopsies had worse progression time curves until LTx (p=0.04). CONCLUSION Morphometric assessment of perisinusoidal deposition of type I collagen by IF in the initial biopsy can correlate with progression time to LTx in post-surgical BA.
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Keyzer-Dekker CMG, Lind RC, Kuebler JF, Offerhaus GJA, Ten Kate FJW, Morsink FHM, Verkade HJ, Petersen C, Hulscher JBF. Liver fibrosis during the development of biliary atresia: Proof of principle in the murine model. J Pediatr Surg 2015; 50:1304-9. [PMID: 25783404 DOI: 10.1016/j.jpedsurg.2014.12.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/16/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The murine model of biliary atresia (BA) is used for examining the pathogenesis of BA. The aim of the study was description of the morphological features and illustrating the detailed development of fibrosis using the Biliary Atresia Research Consortium (BARC) system. METHODS Neonatal mice were injected intraperitoneally with rhesus rotavirus (RRV) strain (N=17). Healthy mice were the control group (N=29). All mice were sacrificed at 7 or 14days after birth. Two pathologists examined the morphological features using the BARC system; CK19, αSMA and collagen type I were assessed by immunohistochemistry. RESULTS In RRV mice, portal fibrous expansion with focal bile duct proliferation and strong portal cellular infiltrate was found in contrast to healthy mice. In RRV mice, CK19 bile duct staining was significantly less or absent (p<0.01), with stronger portal staining of collagen type I (p=0.02). Expansion of staining for αSMA was more in RRV mice (p<0.01), but αSMA portal staining was stronger in healthy mice (p=0.02). CONCLUSIONS The morphological features observed in the murine model of BA correspond with the BA characteristics according to the BARC criteria. Fibrosis is an important feature of the model. Therefore, this murine model is useful for investigating the pathogenesis of BA.
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Affiliation(s)
- Claudia M G Keyzer-Dekker
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert Cornelis Lind
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - J F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - G J A Offerhaus
- Department of Pathology, University Medical Centre Utrecht, The Netherlands
| | - F J W Ten Kate
- Department of Pathology, University Medical Centre Utrecht, The Netherlands
| | - F H M Morsink
- Department of Pathology, University Medical Centre Utrecht, The Netherlands
| | - H J Verkade
- Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - C Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - J B F Hulscher
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, The Netherlands.
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Mazariegos G, Shneider B, Burton B, Fox IJ, Hadzic N, Kishnani P, Morton DH, McIntire S, Sokol RJ, Summar M, White D, Chavanon V, Vockley J. Liver transplantation for pediatric metabolic disease. Mol Genet Metab 2014; 111:418-27. [PMID: 24495602 DOI: 10.1016/j.ymgme.2014.01.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/12/2014] [Accepted: 01/12/2014] [Indexed: 12/22/2022]
Abstract
Liver transplantation (LTx) was initially developed as a therapy for liver diseases known to be associated with a high risk of near-term mortality but is based upon a different set of paradigms for inborn metabolic diseases. As overall outcomes for the procedure have improved, LTx has evolved into an attractive approach for a growing number of metabolic diseases in a variety of clinical situations. No longer simply life-saving, the procedure can lead to a better quality of life even if not all symptoms of the primary disorder are eliminated. Juggling the risk-benefit ratio thus has become more complicated as the list of potential disorders amenable to treatment with LTx has increased. This review summarizes presentations from a recent conference on metabolic liver transplantation held at the Children's Hospital of Pittsburgh of UPMC on the role of liver or hepatocyte transplantation in the treatment of metabolic liver disease.
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Affiliation(s)
- George Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Faculty Pavilion, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh School of Medicine/UPMC Department of Surgery, Thomas E. Starzl Transplantation Institute, E1540 Biomedical Science Tower (BST), 200 Lothrop Street, Pittsburgh, PA 15261, USA.
| | - Benjamin Shneider
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Rangos Research Center, 4401 Penn Avenue, 7th Floor, Pittsburgh, PA 15224, USA.
| | - Barbara Burton
- Department of Pediatrics, Northwestern University Feinberg School of Medicine/Ann & Robert H. Lurie Children's Hospital of Chicago, Box MC 59, 225 E Chicago Avenue, Chicago, IL 60611, USA.
| | - Ira J Fox
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Faculty Pavilion, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh School of Medicine/UPMC Department of Surgery, Thomas E. Starzl Transplantation Institute, E1540 Biomedical Science Tower (BST), 200 Lothrop Street, Pittsburgh, PA 15261, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Nedim Hadzic
- King's College Hospital, Paediatric Liver Center, London, UK.
| | - Priya Kishnani
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, DUMC 103856, 595 Lasalle Street, GSRB 1, 4th Floor, Room 4010, Durham, NC 27710, USA.
| | - D Holmes Morton
- Franklin and Marshall College, Clinic for Special Children, 535 Bunker Hill Road, Strasburg, PA 17579, USA.
| | - Sara McIntire
- Department of Pediatrics, Paul C. Gaffney Diagnostic Referral Service, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Suite Floor 3, Pittsburgh, PA 15224, USA.
| | - Ronald J Sokol
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Section of Gastroenterology, Hepatology and Nutrition, 13123 E. 16th Avenue, B290, Aurora, CO 80045-7106, USA.
| | - Marshall Summar
- Division of Genetics and Metabolism, George Washington University, Children's National Medical Center, Center for Genetic Medicine Research (CGMR), 111 Michigan Avenue, NW, Washington, DC 20010-2970, USA.
| | - Desiree White
- Department of Psychology, Washington University, Psychology Building, Room 221, Campus Box 1125, St. Louis, MO 63130-4899, USA.
| | - Vincent Chavanon
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, 5 East 98th Street, 15th Floor, New York, NY 10029, USA.
| | - Jerry Vockley
- Department of Pediatrics, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA 15261, USA; Division of Medical Genetics, Children's Hospital of Pittsburgh of UPMC, Rangos Research Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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Urahashi T, Ihara Y, Sanada Y, Wakiya T, Yamada N, Okada N, Mizuta K. Effect of repeat Kasai hepatic portoenterostomy on pediatric live-donor liver graft for biliary atresia. EXP CLIN TRANSPLANT 2013; 11:259-63. [PMID: 23530849 DOI: 10.6002/ect.2012.0188] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Treatment for patients with biliary atresia is a Kasai hepatic portoenterostomy; however, the efficacy of repeat Kasai hepatic portoenterostomy is unclear. This study sought to examine the effect of a prior Kasai hepatic portoenterostomy, especially a repeat Kasai hepatic portoenterostomy, on the outcomes of living-donor liver transplant. MATERIALS AND METHODS One hundred twenty-six of 170 children that underwent a living-donor liver transplant between May 2001, and March 2010, received a living-donor liver transplant for biliary atresia. These patients were divided into 2 groups according to the number of previous portoenterostomies: 1 (group A, n=100) or 2 or more Kasai hepatic portoenterostomies (group B, n=26). Portoenterostomy was performed twice in 24 patients in group B, 3 times in 1, and 4 times in 1. Preoperative, operative factors, mortality, morbidity, and survival rates were examined and compared between groups. RESULTS The surgical factors such as operative time, blood loss per weight, cold ischemia time, and weight of the native liver were significantly greater in group B than they were in group A. The patient survival rates were comparable in the 2 groups (94.5% in group A and 93.3% in group B), and the difference was not statistically significant. No statistically significant difference was observed between the groups with regard to vascular complications, biliary complications, and other factors including postoperative variables. Bowel perforation requiring surgical repair was more frequent in group B than it was in group A. CONCLUSIONS Repeat Kasai hepatic portoenterostomy might have a negative effect on patients who undergo living-donor liver transplant for biliary atresia patients with potential lethal complications such as bowel perforation. More biliary atresia patients could have a liver transplant, with improved survival and better life expectancy, if they have inadequate biliary drainage after the initial Kasai hepatic portoenterostomy.
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Affiliation(s)
- Taizen Urahashi
- Department of Transplant Surgery, Jichi Medical University, Yakushiji, Shimotsuke-shi, Tochigi, Japan.
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Wildhaber BE. Biliary atresia: 50 years after the first kasai. ISRN SURGERY 2012; 2012:132089. [PMID: 23304557 PMCID: PMC3523408 DOI: 10.5402/2012/132089] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/30/2012] [Indexed: 12/20/2022]
Abstract
Biliary atresia is a rare neonatal disease of unknown etiology, where obstruction of the biliary tree causes severe cholestasis, leading to biliary cirrhosis and death in the first years of life, if the condition is left untreated. Biliary atresia is the most frequent surgical cause of cholestatic jaundice in neonates and should be evoked whenever this clinical sign is associated with pale stools and hepatomegaly. The treatment of biliary atresia is surgical and currently recommended as a sequence of, eventually, two interventions. During the first months of life a hepatoportoenterostomy (a "Kasai," modifications of which are discussed in this paper) should be performed, in order to restore the biliary flow to the intestine and lessen further damage to the liver. If this fails and/or the disease progresses towards biliary cirrhosis and life-threatening complications, then liver transplantation is indicated, for which biliary atresia represents the most frequent pediatric indication. Of importance, the earlier the Kasai is performed, the later a liver transplantation is usually needed. This warrants a great degree of awareness of biliary atresia, and the implementation of systematic screening for this life-threatening pathology.
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Affiliation(s)
- Barbara E Wildhaber
- Division of Pediatric Surgery, Department of Pediatrics, University Hospital of Geneva, 1211 Geneva, Switzerland
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Andrade WDC, Silva LFFD, Coelho MCDM, Tannuri ACA, Alves VAF, Tannuri U. Effects of the administration of pentoxifylline and prednisolone on the evolution of portal fibrogenesis secondary to biliary obstruction in growing animals: immunohistochemical analysis of the expression of TGF-β and VEGF. Clinics (Sao Paulo) 2012; 67:1455-61. [PMID: 23295601 PMCID: PMC3521810 DOI: 10.6061/clinics/2012(12)17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/15/2012] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE During the neonatal and infancy periods, some chronic liver diseases may lead to progressive hepatic fibrosis, which is a condition that can ultimately result in the loss of organ function and severe portal hypertension necessitating hepatic transplantation. In a previous report, pharmacological interventions were demonstrated to modulate hepatic fibrosis induced by bile duct ligation in young rats. The administration of pentoxifylline or prednisolone, or the combination of both, resulted in reduced fibrogenesis in portal spaces. The objectives of the present study were to evaluate the expression of transforming growth factor β and vascular endothelial growth factor after bile duct ligation in young rats and to assess the effect of those same drugs on cytokine expression. METHODS In this experimental study, 80 young rats (21 or 22 days old) were submitted either to laparotomy and common bile duct ligation or to sham surgery. The animals were allocated into four groups according to surgical procedure, and the following treatments were administered: (1) common bile duct ligation + distilled water, (2) sham surgery + distilled water, (3) common bile duct ligation + pentoxifylline, or (4) common bile duct ligation + prednisolone. After 30 days, a hepatic fragment was collected from each animal for immunohistochemical analysis using monoclonal antibodies against transforming growth factor β and vascular endothelial growth factor. Digital morphometric and statistical analyses were performed. RESULTS The administration of pentoxifylline reduced the transforming growth factor β-marked area and the amount of transforming growth factor β expressed in liver tissue. This effect was not observed after the administration of prednisolone. There was a significant reduction in vascular endothelial growth factor expression after the administration of either drug compared with the non-treatment group. CONCLUSIONS The administration of pentoxifylline to cholestatic young rats resulted in the diminished expression of transforming growth factor β and vascular endothelial growth factor in liver tissue. The administration of steroids resulted in the diminished expression of vascular endothelial growth factor only. These pathways may be involved in hepatic fibrogenesis in young rats submitted to bile duct ligation and exposed to pentoxifylline or prednisolone.
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Affiliation(s)
- Wagner de Castro Andrade
- Faculdade de Medicina da Universidade de São Paulo, Pediatric Surgery Division, Laboratory of Pediatric Surgery (LIM-30) and Laboratory of Hepatic Pathology (LIM-14), São Paulo/SP, Brazil.
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Lee MJ, Kim MJ, Yoon CS, Chung YE, Han SJ, Koh H. Gadopentetate dimeglumine-enhanced MR cholangiopancreatography in infants with cholestasis. Pediatr Radiol 2011; 41:488-94. [PMID: 21127853 DOI: 10.1007/s00247-010-1911-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 10/07/2010] [Accepted: 10/13/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a progressive, obliterative cholangiopathy that occurs in neonates with hepatic portoenterostomy the treatment of choice, but early surgery is important for optimum outcomes. MRI, including MR cholangiopancreatography (MRCP) may be a diagnostically useful alternative to US, but the heavily T2-weighted sequences used include not only bile duct signals, but also other heterogeneously high signal intensities from surrounding structures. OBJECTIVE To evaluate the effects of gadolinium when used to decrease background signal intensity on T2-weighted MR cholangiopancreatography (MRCP) in infants and to evaluate the qualitative improvement of the depiction of the common bile duct (CBD) for evaluating neonatal cholestasis. MATERIALS AND METHODS Our Institutional Review Board approved this prospective study. MRCP was performed with gadopentetate dimeglumine injection using a 1.5-T scanner. Pre- and postcontrast MRCP images were compared. Forty-nine infants (male:female = 21:28; age 0-12 months, mean 2.3) were included. The final diagnoses were biliary atresia (BA) in 28 cases and non-BA in 21. Quantitative analysis was conducted using region-of-interest measurements of mean signal intensities of the liver, pancreatic head and gallbladder (if defined). Qualitative analysis was performed by four radiologists who subjectively scored image confidence in the presence of CBD on a 4-point scale (0 for definitely absent, 1 for probably absent, 2 for probably present, and 3 for definitely present). RESULTS The signal-to-noise ratios were significantly decreased in the liver and pancreatic head after contrast medium enhancement (mean 5.7→4.0 in liver and mean 44.9→12.7 in the pancreatic head; P < 0.0001), and this finding was constant in both the BA and the non-BA group. The mean confidence score in the presence of CBD decreased in the BA group (0.9→0.5; P < 0.0001), but did not change significantly in the non-BA group (2.0→2.1; P = 0.459) after contrast medium enhancement. Both intra- and interobserver agreement was higher after contrast medium enhancement (P = 0.046). CONCLUSION Gadopentetate dimeglumine-enhanced MRCP increased the diagnostic confidence of absence of the CBD in cholestatic infants with increased intra- and interobserver agreement.
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Affiliation(s)
- Mi-Jung Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Children's Hospital, Yonsei University, College of Medicine, 250 Seongsanno (134 Sinchon-dong), Seodaemun-gu, Seoul, 120-752, South Korea
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Andrade WDC, Tannuri U, da Silva LFF, Alves VAF. Effects of the administration of pentoxifylline and prednisolone on the evolution of portal fibrogenesis secondary to biliary obstruction-an experimental study in growing animals. J Pediatr Surg 2009; 44:2071-7. [PMID: 19944210 DOI: 10.1016/j.jpedsurg.2009.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 05/10/2009] [Accepted: 05/11/2009] [Indexed: 01/21/2023]
Abstract
BACKGROUND Many chronic liver diseases lead to progressive hepatic fibrosis, a condition that can ultimately result in loss of organ function and severe portal hypertension necessitating hepatic transplantation. Within the last few decades, studies have been conducted to demonstrate the possibility of drug modulation of hepatic fibrogenesis. Regarding biliary obstruction, it has been suggested that administration of corticosteroids could promote better late outcomes for children with biliary atresia submitted to Kasai's portoenterostomy. Models used to test potential antifibrogenic drugs such as pentoxifylline (PTX) have not included growing animals. METHODS In this experimental study, 119 young rats (21st or 22nd days) were submitted to laparotomy and common bile duct ligation (CBDL) or to sham surgery (SHAM). Animals were allocated into 5 groups, according to surgical procedure, and administered the following solutions: (1) CBDL + distilled water, (2) SHAM + distilled water, (3) CBDL + PTX, (4) CBDL + prednisolone (PRED), and (5) CBDL + PTX + PRED (PTX + PRED). Each group was further divided into 2 subgroups according to the length of the experiment (15 or 30 days). At the end of the defined period, animals were weighed, and a hepatic fragment was collected from each one for analyses. RESULTS The PTX animals exhibited increased weight gain compared to animals in the PRED or PTX + PRED groups. Animals from the 3 therapeutic groups (PTX, PRED, and PTX + PRED) showed diminished collagen-filled area in portal spaces. Total portal space area was increased in the PTX group. CONCLUSIONS Hepatic fibrosis induced by bile duct ligation in young rats could be modulated by pharmacologic interventions. Administration of PTX or PRED, or the combination of both, resulted in diminished collagen-filled areas in portal spaces.
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Affiliation(s)
- Wagner de Castro Andrade
- Pediatric Surgery Division, Laboratory of Pediatric Surgery, University of Sao Paulo Medical School, CEP 01246-903 Sao Paulo, Brazil
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14
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Pape L, Olsson K, Petersen C, von Wasilewski R, Melter M. Prognostic value of computerized quantification of liver fibrosis in children with biliary atresia. Liver Transpl 2009; 15:876-82. [PMID: 19642116 DOI: 10.1002/lt.21711] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Biliary atresia (BA) is the leading indication for liver transplantation (LTx) during childhood. Predictive markers for progression are lacking. We investigated the correlation between quantified fibrosis of the liver at the time of Kasai hepatic portoenterostomy (KPE) and the clinical course. Liver tissue was obtained at the time of KPE in 53 children and stained with Picrosirius red. The mean volume of fibrosis per number of periportal fields (Vfib) and the Ishak score were calculated. Vfib was 3.9%. Transplant-free survival was significantly higher in those patients with Vfib < 2.5% (P < 0.05, Kaplan-Meier analysis). Vfib < 2.5% predicted transplant-free survival with a sensitivity of 100% and a specificity of 48% (positive predictive value: 100%, negative predictive value: 17%). Vfib was correlated with bilirubin 6 months after KPE (Bili6m). The negative predictive value could be enhanced to 23% if Vfib < 2.5% was combined with Bili6m < 20 micromol/L. The Ishak score showed no correlation with transplant-free survival or Vfib. Detection of Vfib at the time of KPE is a valid marker in predicting transplant-free survival in children with BA. This method should be considered an integral part of scoring systems predicting the indication for LTx. Liver Transpl 15:876-882, 2009. (c) 2009 AASLD.
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Affiliation(s)
- Lars Pape
- Department of Pediatric Nephrology, Hepatology, and Metabolic Disorders, Hannover Medical School, Hannover, Germany.
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Abstract
The etiology of liver disease in childhood varies significantly from its etiology in the adult population. More children with complex diseases are surviving into adulthood, providing challenges to the primary care provider. Adults with pediatric liver disease differ in management, treatment, complications, and extrahepatic considerations. To provide these patients with an optimal transition into the adult health care system, the provider needs a comprehensive knowledge of the common causes of childhood liver disease and their implications and must understand the differences in caring for these patients. This review addresses some of the most common childhood liver diseases, their causes, presentation, evaluation, management, complications, and additional concerns.
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Affiliation(s)
- Michelle Rook
- Pediatric Gastroenterology, Hepatology and Nutrition, University of California San Francisco, 500 Parnassus Avenue, MU4E, Box 0136, San Francisco, CA 94143, USA
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Sookpotarom P, Vejchapipat P, Chittmittrapap S, Sookpotarom P, Vejchapipat P, Chittmittrapap S, Chongsrisawat V, Chandrakamol B, Poovorawan Y. Short-term results of Kasai operation for biliary atresia: experience from one institution. Asian J Surg 2006; 29:188-92. [PMID: 16877223 DOI: 10.1016/s1015-9584(09)60085-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The purpose of this study is to review the short-term outcome of patients with biliary atresia (BA) treated by the Kasai operation at our institution. METHODS Ninety-two BA patients treated by the Kasai operation between January 1996 and December 2002 were reviewed. The diagnosis of BA was confirmed by intraoperative cholangiography. The outcome of treatment was categorized into two groups: jaundice-free (total bilirubin < 2 mg%) and persistent jaundice (>or= 2 mg%). The outcome of Kasai operation was evaluated 1 year after surgery. Data are expressed as mean +/- SD. RESULTS Average age at the time of surgery was 90.26 +/- 36.44 days. Only 22.8% (21/92) of patients had Kasai operation before 60 days of age. Histologically, 49 patients (54.4%) had liver fibrosis at the time of surgery. Of 92 patients, 17 were not included in outcome evaluation as they were less than 1-year postsurgery. Therefore, 75 patients could be evaluated for the outcome. Thirty-eight patients (50.67%) were jaundice-free 1 year after surgery. Liver histology and age at the time of the Kasai operation did not influence early outcome. The most common complication was ascending cholangitis. CONCLUSION Half of our BA patients who underwent Kasai operation were jaundice-free 1 year after surgery. The lack of impact of age and liver pathology on outcome is presumably due to the briefness of the follow-up. In general, our patients underwent Kasai procedure too late. It is therefore important for us to conduct a campaign to highlight the plight of these patients and the urgency of referral for neonates with jaundice.
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Affiliation(s)
- Paiboon Sookpotarom
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Ryeom HK, Choe BH, Kim JY, Kwon S, Ko CW, Kim HM, Lee SB, Kang DS. Biliary Atresia: Feasibility of Mangafodipir Trisodium–enhanced MR Cholangiography for Evaluation. Radiology 2005; 235:250-8. [PMID: 15749972 DOI: 10.1148/radiol.2343040028] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The study was approved by the institutional review board, and informed consent was obtained from the patients' parents. Twenty-three consecutive infants suspected of having biliary atresia (BA) were prospectively examined by using mangafodipir trisodium (Mn-DPDP)-enhanced magnetic resonance (MR) cholangiography. Sequential T1-weighted spoiled gradient-echo MR cholangiograms were obtained 1, 2, and 3 hours after intravenous administration of Mn-DPDP. The possibility of BA was excluded if bowel excretion of contrast material was noted at contrast material-enhanced MR cholangiography. The diagnostic specificity and accuracy of contrast-enhanced MR cholangiography were compared with those of conventional MR cholangiography, technetium 99m Tc ((99m)Tc)-disofenin (DISIDA) scintigraphy, and the triangular cord sign at ultrasonography (US). MR cholangiography was used to accurately distinguish four cases of BA from 19 cases of other cholestatic liver diseases, without false-positive results. Conventional MR cholangiography, (99m)Tc-DISIDA scintigraphy, and the triangular cord sign at US respectively yielded false-positive results of 42% (eight of 19 infants), 35% (six of 17 infants), and 11% (two of 19 infants) in patients without BA. Mn-DPDP-enhanced MR cholangiography appears to be a promising modality for early diagnosis of BA as the cause of neonatal cholestasis.
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Affiliation(s)
- Hun Kyu Ryeom
- Department of Radiology, Kyungpook National University School of Medicine, Samduk 2Ga, Jung-Gu, Daegu 700-721, Republic of Korea
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Visser BC, Suh I, Hirose S, Rosenthal P, Lee H, Roberts JP, Hirose R. The influence of portoenterostomy on transplantation for biliary atresia. Liver Transpl 2004; 10:1279-86. [PMID: 15376306 DOI: 10.1002/lt.20234] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
After portoenterostomy (PE) for biliary atresia (BA), many patients suffer progressive deterioration of liver function and ultimately require liver transplantation. We retrospectively reviewed a single center's experience with pediatric liver transplantation for BA from 1988 to 2002. Sixty-six patients underwent 69 liver transplants for BA. Forty-two (63%) patients had previously undergone Kasai PE, 11 (17%) biliary appendicoduodenostomy (BAD), and 13 (20%) had no prior biliary drainage (NBD). The BAD procedure offered only short-term biliary drainage--the mean interval between PE and transplant was more than twice that for Kasai patients than for BAD patients (132 versus 49 weeks). The transplants included 11 cadaveric partial, 27 cadaveric whole, and 31 living related transplants. Three patients required retransplant. Prior PE did not increase the incidence of major perioperative complications or unplanned reexploration. After transplant, the 1-, 5-, and 10-year actuarial graft survival rates were 87%, 86%, and 80%, respectively. The 1-, 5-, and 10-year actuarial patient survival rates were 91%, 89%, and 83%. PE remains an important bridge to transplant. In conclusion, transplantation for BA offers excellent long-term graft and patient survival.
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Taat F, Bosman DK, Aronson DC. Hepatoblastoma in a girl with biliary atresia: coincidence or co-incidence. Pediatr Blood Cancer 2004; 43:603-5. [PMID: 15382280 DOI: 10.1002/pbc.20115] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hepatoblastoma (HB) and biliary atresia (BA) are both rare conditions that occurred in the patient described. This is the second such case in the literature. An explanation for this apparent coincidence could possibly be found in the existance of pluripotent liver stem cells. In humans, small epithelial cells (SEC) behave as pluripotent stem cells. These are cells that can develop as biliary epithelial cells or as liver parenchymal cells, and are thought to be the precursor cell of HB. They are present in a much higher concentration in the livers of patients with BA, which may make them prone to develop HB.
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Affiliation(s)
- F Taat
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital, AMC, Academic Medical Center, Amsterdam, The Netherlands
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Hadzić N, Davenport M, Tizzard S, Singer J, Howard ER, Mieli-Vergani G. Long-term survival following Kasai portoenterostomy: is chronic liver disease inevitable? J Pediatr Gastroenterol Nutr 2003; 37:430-3. [PMID: 14508212 DOI: 10.1097/00005176-200310000-00006] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Extrahepatic biliary atresia (EHBA) is the most common indication for liver transplantation in childhood. Most children who do not undergo transplant are reported to have chronic liver disease and its complications. The aim of this single-center study was to identify children with normal laboratory indices and no clinical evidence of chronic liver disease 10 or more years after Kasai portoenterostomy (KP). METHODS A retrospective analysis of the medical notes of all children surgically treated at the authors' center between 1979 and 1991 was undertaken. Criteria for inclusion were absence of surgical complications, unremarkable clinical examination, and normal bilirubin, aspartate aminotransferase, albumin, international normalized prothrombin ratio, and platelet count. RESULTS Of 244 children surgically treated during the observation period, the authors identified 28 (11%) adolescents (14 male) who fulfilled the entry criteria. Their median age was 13.4 years (range, 10.2-22.2 years). Twenty-six with type 3 EHBA had conventional KP, whereas 2 underwent modified operations. The corrective surgery was performed at a median age of 58 days (range, 20-99 days). Median time of complete clearance of jaundice from the date of KP was 75 days (range, 21-339 days). Twelve (43%) patients had history of cholangitis at a median age of 3.4 years. The liver histologic findings were suggestive of mild to moderate fibrosis in 54.2% and cirrhosis in 40.7% of the patients who underwent biopsy. No child had gastrointestinal bleeding during follow-up. Thirteen (46%) patients had an elective esophagogastroduodenoscopy, which was normal in all. Twenty-six (93%) patients were in mainstream education, whereas the remaining two (7%) attended special school because of reasons unrelated to liver disease. CONCLUSIONS A sizable proportion of children with EHBA avoid significant chronic liver disease and its complications 10 years or more after conventional surgical correction and have an excellent quality of life. Their good outcome is not hampered by isolated episodes of ascending cholangitis. Whether or not the residual histologic damage will become symptomatic during their lifetime remains to be established.
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Affiliation(s)
- Nedim Hadzić
- Department of Child Health, King's College Hospital, Denmark Hill, London, United Kingdom.
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Diem HVT, Evrard V, Vinh HT, Sokal EM, Janssen M, Otte JB, Reding R. Pediatric liver transplantation for biliary atresia: results of primary grafts in 328 recipients. Transplantation 2003; 75:1692-7. [PMID: 12777858 DOI: 10.1097/01.tp.0000062570.83203.a3] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study was to assess the overall results of recipients undergoing transplantation for biliary atresia (BA), according to age, surgical techniques, and transplant eras, and to identify the prognostic factors affecting outcome. METHODS Between 1984 and 2000, 328 pediatric recipients with BA who underwent orthotopic liver transplantation (OLT) were reviewed. Median age at OLT was 1.5 years (range, 0.4-14.5 years). Kasai hepatoportoenterostomy (KHPE) had been previously performed in 285 (87%) children. Regarding surgical techniques, 125 (38%) children received a whole-liver graft, 128 (39%) received a reduced-size graft, 16 (5%) received a split-liver graft, and 59 (18%) received a living-related (LR) donor graft. RESULTS Overall actuarial patient survivals were 87%, 83%, and 81% at 1, 5, and 10 years, respectively. One-year patient survivals in children undergoing transplantation at the different age ranges were 85% (under 1 year), 86% (1-3 years), 83% (3-6 years), 100% (6-10 years), and 100% (beyond 10 years) (not significant). One-year patient survivals for the different transplant eras were 75% (1984-1988), 85% (1989-1992), 93% (1993-1996), and 98% (1997-2000) (P=0.0001). Multivariate analysis demonstrated that pretransplant recipient weight (P=0.004), indication for OLT (P=0.083), and age at OLT (P=0.024) predicted patient survival. The type of baseline calcineurin inhibitor (tacrolimus) and the age at OLT (beyond 6 years) were significantly associated with a better graft survival. CONCLUSIONS Best results in children undergoing transplantation beyond 6 years indicate the importance of performing a KHPE as the first therapeutic step in BA; innovative surgical techniques, particularly LR donor graft, allowed successful transplantation in infants with early failure of KHPE.
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Affiliation(s)
- H Vo Thi Diem
- Pediatric Liver Transplant Program, Saint-Luc University Clinics, Université catholique de Louvain, Brussels, Belgium
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Kuroda T, Saeki M, Nakano M, Morikawa N. Biliary atresia, the next generation: a review of liver function, social activity, and sexual development in the late postoperative period. J Pediatr Surg 2002; 37:1709-12. [PMID: 12483637 DOI: 10.1053/jpsu.2002.36702] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The current study aimed to establish the management for biliary atresia (BA) patients in the late postoperative period. METHODS Of 165 BA patients operated on in the authors' department, 44 patients (16 boys, 28 girls) with a follow-up period of more than 15 years were reviewed retrospectively. RESULTS Forty-one of 44 patients (93.2%) currently are employed or highly educated, 7 are married, whereas 2 (4.5%) died, and 10 (22.7%) required liver transplantation after puberty. Four babies have been born from BA parents without congenital anomalies. Four girls conceived 5 times and delivered 3 newborns weighing 2,330 to 2,474 g including one delivered after transplantation. Maternal portal hypertension uniformly deteriorated during pregnancy, and one pregnancy was terminated. Menstrual disorder correlated significantly with the biochemical data related to liver function at puberty such as serum choline esterase (266 +/- 70.4 in 19 normal patients v 159 +/- 34.3 IU/L in 9 abnormal patients, P =.00057), asparate aminotransferase (42 +/- 30.8 v 96.0 +/- 63.6 IU/L; P =.0031), and serum albumin (4.6 +/- 0.4 v 3.9 +/- 0.6 g/dL; P =.013). CONCLUSIONS The long-term survivors of Kasai's operation, with or without liver transplantation, have reached the next generation. Transgenerational follow-up and management including conception and perinatal care should be required for BA patients.
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Affiliation(s)
- Tatsuo Kuroda
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan
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Abstract
Although the prognosis of biliary atresia has been improved in recent years, particularly in the era of liver transplantation, hepatic portoenterostomy, e.g., the Kasai operation, is still the first line of surgical treatment. Successful hepatic portoenterostomy depends on early diagnosis and operation, adequate operative technique, prevention of postoperative cholangitis, and precise postoperative management. The pathophysiology of the liver and of the intrahepatic bile ducts in this disease is still controversial.
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Affiliation(s)
- R Ohi
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan.
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