OK, can we move on to the next presentations? OK, Doctor Sam Min Lee. Oh, OK. Is my slide visible on the screen? Yes, OK, I'll start the presentation. Uh, hello, my name is Sung Min Lee, and I'm a clinical fellow in pediatric surgery at Severn Children's Hospital. It's an honor to speak in this place. Uh, today, I will be presenting about we do casaiporanstomy. Let me provide you some brief information. The patient was female, born at a gestational age of 36 weeks and 1 day via cesarean section and was born as a twin. Uh, she was immediately admitted to the neonatal ICU due to being underweight. Uh, from day 3, the patient began to test cholic stools and blood tests showed an elevation in bilirubin and gamma gluta transferase. On day 6, an abdominal ultrasound was performed, revealing signs of biliary atrasa. The patient was subsequently transferred to another hospital and underwent Kasai operation on day 9. So according to the surgical records from the other hospital, conventional casipo to enterostomy was done. After the surgery, the patient began feeding on the day 4 post-operation and started taking prednisone from day 7. And until the 14th day, until the 14th day of operation, Breste's tools were observed, but thereafter, a colics tools were noticed. On the twenty-sixth day, an ultrasound was performed for follow up, revealing that triangular cord thickness was still noted. Additionally, SDLT, bilirubin, and gamma glutaransferase levels continued to rise persistently, leading to the patient being transferred to Severn Children's Hospital. So the, the radiologic imaging test was done upon admission to our hospital. Uh, this is an ultrasound image, and you can see the presence of the triangular chord sign. Uh, this is an MRI image, and similarly, findings confirming the presence of biliary atrasia were observed. Despite undergoing Kasai operation at the previous hospital, the findings still indicate the presence of biliary atresia. So we determined that an incomplete or inappropriate surgery was performed. And therefore we continuedch treatment while completing the necessary examinations, and then we proceeded with a redo Kasai operation. This is a picture taken during the surgery. Uh I'm sorry for the blur. Uh, you can see this area here is where the previous portoentostomy was located. When we, uh, when the previous Psumi site was separated, bile was observed to be partially accumulated, indicating that it was not completely obstructed. Uh, you can see here the remaining portal masts here. Uh, you can, you may understand the picture better by looking at this diagram. So we removed the remaining portal mass and performed port portoenterostomy to cover this whole area. Postoperatively, AST and ALT levels rose sharply on the day of surgery and then steadily decreased. On the day 23. When the, when they rose again, cholangitis was suspected, and antibiotic antibiotics were administered for treatment. Bilirubin levels increased from the 1st 2 days post-surgery and then steadily decreased thereafter, and stool color improved as well. The patient was treated well and was discharged on the 29th day of post-surgery. So through this presentation, I wanted to share our experiences of deciding when we do casa operation. And if so, is the, when is the optimal timing to do it? Uh, this is the end of the slide, and thank you for listening. Thank you, Sam Ming. Thank you so much. So can we get the pole? Yeah, this is the first poll. If the jaundice persist. After initial kasa, would you do the redo or liver transplantation? It's gonna be 50% and 50%. It looks like 50% and 50%. Actually, personally I'm a, you know. Redo Kasai believer. I believe Rido Kasai should have been done more, especially even once Jaundice 3 could be obtained after initial Kasai. They should be done more occasionally, so. Do we have a second pause? So if jaundice recur within a year after initial kai. Would you do a they do or a liver transplant? It's still 50 to 50, 50% and 50%. So Satoshi, do you have any comments about this Vikasai? Yes, uh, uh, Doctor, uh, thank you for the, the informative presentation for the, uh, Casa brought to me. The, what is, uh, the main reason for the, uh, this case for the, uh, we do, uh, requirement to incomplete, uh, fibrous resection or after initial CASA, uh. Regenerate the uh fibrous tissue for the Photo uh photo hepatitis. What is the main reason of the uh Requirements of the customer. Uh, this is my cases, so, and I, I have to explain about this. Uh, as shown in the photo, this patient have portal vein branching variations. So, unfortunately, the previous CASI operation in at the hospital, they do not proceed the radiological examination, uh, only Only in, uh, depends on the ultrasound graphic find found. And after first CAA, the, the radiologist in the, that hospital also noted that the remnant uh photo mass. So we also checked the by MRCP as you can see on the slide, we found the remnant put a mass, but as shown in the photo, uh, the main putal mass, remnant putter mass was hidden behind the right anterior portal vein and our left. Uh, between the left portal vein, but, uh, the main portal mass was behind the right anterior perturbin branch. So, uh, at this, as seen in the case presentation, this case involved the remnant cord identified. Uh, identified in imaging after first KSI operation. Uh, so I, as a result, there is an incomplete dissection. Uh, so, I learned the two lessons from these cases, uh, after being transferred to our institution, um, The, uh, in the such a, in such a potter bin variation, we, the surgeon need to, uh, uh, exactly identify the branching anomaly and to check the remnant potamus. So, also, in our hospital's experiences and combined these cases, uh, maybe, uh, the first, the first surgery was done. Uh, maybe the hepaticojalostomy on their operation record. So, uh, in, in our hospital, type 1C, uh, previous surgery was, uh, hepatico jelostomy, but remnant hepatico became a fibrating mass after some days from, uh, the first class site. So also read cases was noted. So we, we think that The remnant potamus can be transformed to fibrotic thickened mass, resulting in persistent jaundice. So I don't know two kinds of. lessons from these cases. Thanks so much. So, for, so, uh, how about the protocol was the straight administration of the post-operative, uh, KASai, uh, tra steroid protocol in Korea. And after, uh, in our center, uh, in our services from nationwide survey from our, from Korea, though we do not, uh, all, uh, almost all Korean surgeons do not adapt to routine, uh, course, but, uh, In our center, we selected the, uh, selected the strategy for strategy, uh, steroid therapy, uh, based on the status of jaundice clearance. If the surgery was, has no complication after one week, but the, uh, the succola was to stay, uh, green, uh stay acholic, uh, with steroid first after one week after C operation and Or during 4 to 6 weeks after surgery. It depends on the uh presence of surgical complications such as wound infection or other leakage and it depends on also the status of jaundice clearance. Thanks so much. I have a question. You hear, you, here you got imaging showing, you know, a cord, but how often, how aggressive you guys are? A go you mentioned a year. I mean, we tend, you know, uh, if, if, if you have sometimes you have cholangitis, other things, but they tend to be more aggressive for transplant here, uh, instead of, especially after a year. So my question is, how, you know, when do you call it, you know, you know, we're gonna re-explore, is it an early failure that you go for or you, or based on age? If it's a 4 month old, I mean, if you have cirrhosis, is it worth, you know, sometimes they'll ask us to do a casai on a kid and just to give him time. But how do you measure the cirrhosis and, and age and timing on the radio? I think, I think that's the most difficult point to answer, but, uh, basically, uh, uh, even once the, the patients get the jaundice free, I think there is a chance for us to try to do the recay. But I cannot clear answer that how long we can wait. I mean, the, if the patient is 2 years old or 3 years old, that, that's uh, uh, uh, that's no chance for us to do the reduced site. But at least 6 months or 8 months, 10 months, within a year, I think we can have a chance to do the reduced site. What, what about the other recommendations? I go and Satoshi. hello, um, so this case is not a typical redo that we see because, uh, as somebody have mentioned, it seemed to be some technique either a technical issue where the, the first kind was because I was incomplete or that there's a very, uh, early fibrosis from the, the, the code. Um, so typically, um, if, if a jaundice occurs within a few weeks. Um, I would think it's a surgical issue. That I will, I will redo. If it occurs much longer after 4 or 6 months, it probably the underlying liver problem. And, and I, I wouldn't do a, a redo. I would think that the child will need a transplantation, and, and it would depend on how you support them. So, this case is not a typical redo we consider because, uh, uh, I agree with the redo because, uh, because it's so early after the first operation. Right? But, uh, the typical cases are not like that. They occur maybe 4 or 6 months later with jaundice, then you have difficulties deciding whether your transplant team can perform the transplantation as soon as they can, uh, or you think, uh, a redo will help. But I think, I think after 4 or 6 months of the surgery, a redo doesn't help very much. I also had one comment. Uh, uh, in this case is very early cases, uh, but from our census or other various, uh, published articles revealed that Uh, age at CASA operation is a very important factor for the long-term nativity of survivor. But from our center's, uh, data, the, this patient like this only neonatal CAI surgery cases is, uh, has a low, uh, native survival than the aged Kasai from 30 days to 60 days. Based on our experiences, that there was a, uh, I think, uh, some. In this case, like these cases, the, the very early CAI surgery cases, the bile duct maturation was less formed than the for uh more early, uh more aged uh patients. So, Observation that patients who underwent CASA after 30 days and within 60 days at a higher rates of jaundice currence compared to the neonatal cases, such as that very early CASA operation may not always be beneficial for the pedia surgeon to perform exact dissection of maturation of potamus. So I think also the, this, in this cases, the previous surgeon has a cut operation but missed the last maturation of a posterior otamus. That is why we do cutsite operation, uh, Uh. The, the very early cancer operation is not always beneficial for the patients. This is my uh hypothesis. Well, there's a couple of questions on the chat real quick. Samir, uh, Panda asked about an algorithm. I think you guys kind of mentioned some who goes, how do you do, redo instead of transplants. I think we're in the West, I think we're pushing more for transplant. I don't know if it's availability of organs, uh, but if somebody can, uh, answer that. I, I, we saw, uh, Cor already said he, he will, you know, he goes for transplant when they're older, uh, but that's one of the questions there. Yeah, that's a, uh, the, the difficult question is that, you know, what is the age limit to do the, decide to do the, uh, uh, you know, the side instead of the liver transplantation. So probably from the Yeah, from probably the 6 months to the 8 or 8 or 10 months around, but we don't have clear answers, but And also Do you guys have any, you know, the, uh, this is also the question from the chat. So, is there any criteria that we go for to the, the straight 3 liver transplantation or doing the uh lead a side? Probably that's the most tough, tough question though. Among the commentators, do you guys have any Clear criteria. I'm Zhong Tabo, yeah. Usually the rea is, is much, much easier than liver transplant. Liver transplantation, isn't it? You, you guys doing. The liver transplantation by your team by yourselves and usually we in common sense little kasai when you perform the little kassai you just explore the putter area and uh we we do anastomo photoentostomy just so it's, I think it's much easier than liver transplantation. Yeah actually mhm. Yeah, one of the, the most famous Japanese liver transplanting surgeon, Dr. Kasahara, he always told us that uh You know, everything you have to do. To prevent the liver transplantation, that's his recommendation. It's always, he always told us that you, you have to do everything. You have to try to do everything before doing the liver transplantation. Yeah, I totally, uh, so I think that visa is not so difficult procedure, I think. So people liver transplantation, we, uh, uh. For the uh selected case we can do uh we do casa operation I think. I think um you have to look at your uh Joos free rate after, after your Redukite. I mean, if somebody come up with a 20%, Success rate after redo Kassel, CI, then there's no, not much point in doing a uh uh a redo. If you have a high success rate of doing a redo, depends on the, the reason, then, then, and if you can get a jaundice-free, then, of course, uh, if you get more than 50% chance of success, then, um, you can consider doing that. Otherwise, I would suggest, uh, uh, uh early transplantation rather than a reduced site. Success success rate to uh the little carsa, I think it depends on the food upon the first operation. So I think the, uh, this case has suggests the post-operative imaging, the MRI. MRI clearly visualize the, uh, residual fibrous tissue for this case. The, uh, imaging, uh, it's post-operative, post cai, uh, operation is important for the decision for the next step for the transplantation or, uh, redocai, I think. Thank you.
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