Prof. Shilpa Sharma - Best of the Best in Pediatric Surgery 2024
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- Partial hepatectomy (segments 2-3) combined with Kasai may trigger hematopoietic stem cell proliferation, offering alternative regeneration pathway in biliary atresia
- Study group showed 91% jaundice-free rate vs 25% in Kasai-only controls, with mortality reduced from 93% to 56%
- Hepatic resection may shift from profibrogenic (hepatic stellate cell) to regenerative (hematopoietic stem cell) pathway in late-presenting BA cases
- Significant bilirubin reduction at 1 and 3 months post-op and improved APRI scores at day 7 in resection group vs controls
- Approach targets late-presenting BA cases (median age ~90 days) with advanced cirrhosis in resource-limited settings where transplant unavailable
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All right, so how do we get started here, Cecilia? OK, so, uh, first we are going to start with the first, um, kit, and we have, uh, WAPs, that is the World Federation of Associations of Pediatric Surgeons. We have also IPEC, the International Pediatric and the Surgery Group, and the Iber Americana Society of Pedediatric Surgeons. So for the first presenter of the day, we have Doctor Shilpa Sharma. She's a professor in pediatric. Surgery from the Department of Pediatric Surgery on All India Institute of Medical Sciences, and she brought us today the exploring alternative pathways of stem cell proliforation for hepatic regeneration by partial liver resection in extrahepatic biliary attricia. So let's hear it. Greetings from India. Today I'll talk about exploring an alternative pathway of stem cell proliferation for hepatic regeneration by partial liver resection in extrahepatic bilia resita. Biliary atresia is a dreadful disease with no definite cure. We all know there is progressive cholangiopathy that leads to morbidity and also end stage cirrhosis in a developing country like ours with delayed presentation, advanced cirrhosis, and hepatic failure. Most infants succumb to hepatopulmonary syndrome, oral hypertension, intraventricular hemorrhage, and even aspiration due to massive ascitis. The liver may regenerate after physiological insults and resection. Hepatic resection acts as a trigger for this regeneration. The liver, however, can regenerate only to a size that is proportional to its original size. Hepatocyte recovery is affected by many factors. When there is biliatresia, the hepatic style cell comes into action and leads to the pro fibrogenetic pathway. Here the involved cytokines include transforming growth factor, platelet derived growth factor, and interleukins. When there is hepatic resection, the hematopoietic stem cells come into play and lead to proliferation with the help of hepatocyte growth factor receptor, epidermal growth factor receptor, and several cytokines like tumor necrosis factor. In 2015 we started resecting a part of the liver, segment 2 and 3, to stimulate an alternative pathway of stem cell proliferation for hepatic regeneration. Here we can see the markings on the liver of segment 2 and 3 in a non-attomical fashion. We proposed to examine whether this segmentectomy could curtail or reverse the ongoing damage when combined with a routine Kasai procedure and compare the results with those cases in which only Kasai had been done. After ethical permission, we divided the cases into two groups. And compared the preoperative day 7, 1st, 3rd, 6th, and 12th month bilirubin and APRI in both groups. Statistical analysis was done. The median age at presentation was similar in both the groups, being 96 and 89. We had more number of females in Group A. The serum bilirubin levels were significantly different between both the groups at a 1 month and 3 month postoperative period. The APRI was significantly different on day 7. The mortality was lower in the study group compared to the control group, that is, 56% to 93%. The jaundice-free percentage was 91% in the study group compared to only 25% in the control group. To conclude, resection of a part of the liver may trigger an alternative path of stem cell proliferation for hepatic regeneration with reduced fibrosis and improved survival. Thank you for patient listening. OK, so, unfortunately, Doctor uh Sharma is not here with us today, um, but I'm really grateful for her presentation, so we get to move to the second one. Wait, I just, I just, can I just wait, can I ask a question now or do I have to wait till later, Cecilia? I know there's no one to answer it. I just wanna. I just want to make sure I'm getting this right. I mean, these were drastic differences that the mortality was almost half. Yes, just by resecting a piece of the liver. I don't know if the two groups were exactly the same, or did the, I mean, was it totally randomized because that's a drastic difference in mortality. And how did they know how much liver to resect? I just, I mean, this seems to me like there's something I'm not getting cause this seems like one of the most groundbreaking discoveries. We've seen in a long time. So there's probably something about this of why it's not all over everywhere now. Um, I think like, yeah, they resected, uh, they decided to resect, I think, um, Like, it's mandatory that part cause they study to resect the uh left liver so that they can leave um enough to regenerate and um they did this because they got patients like really late after 80 days of life. So that's why they decided. I was hoping she could answer like, if, if it is younger, um, what do, should we do the same thing, but yeah, the, the results are drastic. All right. Thank you.