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Prof. Shilpa Sharma - Best of the Best in Pediatric Surgery 2024

Video Published 2024-02-26 Updated 2026-08-01

Timestops (14)

All right, so how do we get started here, Cecilia?

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 …

Surgery from the Department of Pediatric Surgery on All Indi…

Surgery from the Department of Pediatric Surgery on All India Institute of Medical Sciences, and she brought us today th…

Today I'll talk about exploring an alternative pathway of st…

Today I'll talk about exploring an alternative pathway of stem cell proliferation for hepatic regeneration by partial li…

Most infants succumb to hepatopulmonary syndrome

Most infants succumb to hepatopulmonary syndrome, oral hypertension, intraventricular hemorrhage, and even aspiration du…

When there is biliatresia

When there is biliatresia, the hepatic style cell comes into action and leads to the pro fibrogenetic pathway. Here the …

When there is hepatic resection

When there is hepatic resection, the hematopoietic stem cells come into play and lead to proliferation with the help of …

Here we can see the markings on the liver of segment 2 and 3…

Here we can see the markings on the liver of segment 2 and 3 in a non-attomical fashion. We proposed to examine whether …

And compared the preoperative day 7

And compared the preoperative day 7, 1st, 3rd, 6th, and 12th month bilirubin and APRI in both groups. Statistical analys…

The serum bilirubin levels were significantly different betw…

The serum bilirubin levels were significantly different between both the groups at a 1 month and 3 month postoperative p…

The jaundice-free percentage was 91% in the study group comp…

The jaundice-free percentage was 91% in the study group compared to only 25% in the control group. To conclude, resectio…

OK, so, unfortunately, Doctor uh Sharma is not here with us today, um, but I'm really grateful for her presentation, so …

I mean, these were drastic differences that the mortality was almost half. Yes, just by resecting a piece of the liver. …

We've seen in a long time.

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…

So that's why they decided.

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…

Topic Overview

A presentation by Dr. Shilpa Sharma from AIIMS India on a novel surgical approach for biliary atresia combining Kasai portoenterostomy with partial hepatic resection (segments 2 and 3). The study compared outcomes between patients receiving Kasai plus resection versus Kasai alone, reporting substantially lower mortality (56% vs 93%) and higher jaundice-free rates (91% vs 25%) in the resection group. The hypothesis is that hepatic resection triggers hematopoietic stem cell proliferation pathways that may counteract the pro-fibrogenic pathways active in biliary atresia.

Key Takeaways

Kasai plus partial hepatectomy (segments 2&3) reduced mortality to 56% vs 93% for Kasai alone in late-presenting biliary atresia. (3:41)
Jaundice clearance was 91% with Kasai+resection vs 25% with Kasai alone, with significant bilirubin differences at 1 and 3 months. (3:26)
Hepatic resection may trigger hematopoietic stem cell proliferation pathways (HGF, EGF receptors) countering pro-fibrogenic pathways. (2:09)
Study cohort presented late (median 89-96 days), a population with historically poor outcomes in resource-limited settings. (1:10)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Cecilia — host
Dr. Shilpa Sharma — guest

Chapters

0:00Introduction and Speaker Presentation — Session moderator introduces Dr. Shilpa Sharma, professor of pediatric surgery at AIIMS, who will present on stem cell proliferation pathways in biliary atresia treatment.
0:52Background on Biliary Atresia and Regeneration Pathways — Dr. Sharma describes biliary atresia pathophysiology, complications in delayed presentation, and contrasts pro-fibrogenic pathways (hepatic stellate cells) versus proliferative pathways (hematopoietic stem cells) triggered by hepatic resection.
2:39Study Design and Results — Presentation of study comparing Kasai alone versus Kasai plus segment 2-3 resection, showing significantly improved bilirubin clearance, lower mortality, and higher jaundice-free survival in the resection group.
4:16Discussion and Questions — Moderators discuss the dramatic mortality difference and raise questions about patient selection, randomization, and extent of resection, noting the presenter is not available for live questions.

Key claims

1:06Biliary atresia is a progressive cholangiopathy that leads to morbidity and end stage cirrhosis — Dr. Shilpa Sharma
1:10In developing countries with delayed presentation, most infants with biliary atresia succumb to hepatopulmonary syndrome, portal hypertension, intraventricular hemorrhage, and aspiration due to massive ascites — Dr. Shilpa Sharma
1:33The liver may regenerate after physiological insults and resection — Dr. Shilpa Sharma
1:37Hepatic resection acts as a trigger for liver regeneration — Dr. Shilpa Sharma
1:41The liver can regenerate only to a size that is proportional to its original size — Dr. Shilpa Sharma
1:53In biliary atresia, hepatic stellate cells lead to the pro-fibrogenetic pathway involving transforming growth factor, platelet derived growth factor, and interleukins — Dr. Shilpa Sharma
2:09With hepatic resection, hematopoietic stem cells lead to proliferation via hepatocyte growth factor receptor, epidermal growth factor receptor, and cytokines like tumor necrosis factor — Dr. Shilpa Sharma
2:26In 2015 the team started resecting segments 2 and 3 of the liver in a non-anatomical fashion to stimulate an alternative pathway of stem cell proliferation for hepatic regeneration — Dr. Shilpa Sharma
3:16The median age at presentation was 96 days in one group and 89 days in the other — Dr. Shilpa Sharma
3:26Serum bilirubin levels were significantly different between both groups at 1 month and 3 month postoperative period — Dr. Shilpa Sharma
3:35APRI was significantly different between groups on day 7 — Dr. Shilpa Sharma
3:41Mortality was 56% in the study group (Kasai plus resection) compared to 93% in the control group (Kasai alone) — Dr. Shilpa Sharma
3:49Jaundice-free percentage was 91% in the study group compared to 25% in the control group — Dr. Shilpa Sharma
3:58Resection of a part of the liver may trigger an alternative path of stem cell proliferation for hepatic regeneration with reduced fibrosis and improved survival — Dr. Shilpa Sharma
5:08The study resected the left liver (segments 2 and 3) to leave enough liver to regenerate — Cecilia
5:32Patients in the study presented late, after 80 days of life — Cecilia

Open questions

How much liver should be resected to optimize regeneration while maintaining adequate hepatic function?
Were the two study groups truly randomized or were there selection differences that could explain the dramatic mortality difference?
Would the same resection approach be beneficial in younger patients who present earlier than 80 days of life?
Why has this approach not been widely adopted if the mortality benefit is as substantial as reported?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Hepatic Resection at Kasai: Mortality Halved in Late-Presenting Biliary Atresia

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

The Intervention

Dr. Shilpa Sharma's group in India added non-anatomical resection of segments 2 and 3 to the standard Kasai procedure in infants with biliary atresia presenting after 80 days of life 5:32. The rationale: hepatic resection activates hematopoietic stem cells that drive proliferation via HGF receptor, EGF receptor, and TNF, potentially counteracting the pro-fibrogenic pathway mediated by hepatic stellate cells through TGF, PDGF, and interleukins 1:53 2:09. The hypothesis was that removing diseased parenchyma might trigger regeneration of healthier tissue in livers already committed to cirrhosis 2:26 3:58.

The Results

Median age at presentation was 89-96 days in both groups 3:16. Mortality was 56% in the resection group versus 93% in the Kasai-alone group 3:41. Jaundice clearance was achieved in 91% of resection patients compared to 25% of controls 3:49. Serum bilirubin differed significantly at 1 and 3 months postoperatively 3:26, and APRI was significantly different by day 7 3:35.

What This Means

The mortality difference is striking, but the study raises immediate questions about patient selection, randomization, and whether both groups had equivalent disease severity at baseline. The biological premise—that resection shifts the balance from fibrogenesis to regeneration—is plausible given the dual stem cell pathways involved 1:53 2:09, but the liver regenerates only to a size proportional to its original mass 1:41, which complicates the interpretation in infants with advanced cirrhosis.

For surgeons managing late-presenting biliary atresia in resource-limited settings, this approach offers a potential strategy when transplantation is unavailable and outcomes with Kasai alone are dismal 1:10. The critical unknowns: optimal timing, volume of resection, applicability to earlier presentations, and whether the benefit persists beyond the reported follow-up period. The mechanism remains speculative until validated in controlled trials with matched cohorts.

Takeaways from this story

Adding segments 2-3 resection to Kasai reduced mortality from 93% to 56% in late-presenting biliary atresia (median age 89-96 days).
Jaundice clearance was 91% with resection versus 25% with Kasai alone, with significant bilirubin differences at 1 and 3 months.
Resection may shift hepatic stellate cell fibrogenesis toward hematopoietic stem cell proliferation via HGF/EGF/TNF pathways.
Liver regenerates only to size proportional to original mass, limiting applicability in advanced cirrhosis with small remnant.

Partial Hepatectomy with Kasai for Late-Presenting Biliary Atresia

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Core brief · AI-written, human-reviewed

The Intervention

Dr. Shilpa Sharma's team in India added non-anatomical resection of liver segments 2 and 3 to the standard Kasai portoenterostomy in infants with biliary atresia presenting after 80 days of life 5:32. The hypothesis: removing diseased liver tissue would shift the balance from fibrosis-driving hepatic stellate cells toward regeneration-promoting hematopoietic stem cells 1:53 2:09.

The Results

In the study group receiving Kasai plus resection, mortality was 56% compared to 93% in the Kasai-alone control group 3:41. Jaundice clearance was achieved in 91% of resection patients versus 25% of controls 3:49. Serum bilirubin differed significantly between groups at one and three months postoperatively 3:26, and APRI scores diverged by day seven 3:35. Both groups presented at similar ages — median 96 and 89 days 3:16.

The Mechanism

In biliary atresia, hepatic stellate cells drive pro-fibrogenic pathways involving transforming growth factor, platelet-derived growth factor, and interleukins 1:53. Hepatic resection activates hematopoietic stem cells that promote proliferation via hepatocyte growth factor receptor, epidermal growth factor receptor, and tumor necrosis factor 2:09. The team began this approach in 2015, resecting segments 2 and 3 to "stimulate an alternative pathway of stem cell proliferation for hepatic regeneration" 2:26.

What This Means

The mortality difference is striking, but critical questions remain unanswered. The presentation does not specify whether group assignment was randomized or how baseline disease severity compared between cohorts. The choice to resect segments 2 and 3 appears pragmatic — leaving sufficient liver mass to regenerate 5:08 — but the rationale for that specific volume is not detailed. The liver regenerates only to a size proportional to its original mass 1:41, so the margin between therapeutic resection and insufficient remnant is narrow.

For the late-presenting biliary atresia population common in resource-limited settings 1:10, where most infants die of hepatopulmonary syndrome, portal hypertension, or complications of massive ascites 1:10, this approach may represent a meaningful advance. Whether it applies to earlier presentations or different practice contexts is unknown.

Takeaways from this story

Adding segments 2-3 resection to Kasai reduced mortality from 93% to 56% in late-presenting biliary atresia patients.
Hepatic resection may shift stem cell balance from fibrosis (stellate cells) to regeneration (hematopoietic cells).
Jaundice clearance was 91% with resection versus 25% with Kasai alone in this late-presenting cohort.
The liver regenerates only to a size proportional to its original mass, limiting how much can be safely resected.

Keywords

biliary atresia extrahepatic biliary atresia cholangiopathy cirrhosis hepatic failure hepatopulmonary syndrome portal hypertension intraventricular hemorrhage ascites fibrosis Kasai procedure Kasai portoenterostomy partial liver resection hepatic resection segmentectomy

Hashtags

#BiliaryAtresia #HepaticRegeneration #StemCellResearch #LiverSurgery #Cholangiopathy #Cirrhosis #HepaticFailure #PediatricSurgery #SurgicalInnovation #LiverResection #Cytokines #KasaiProcedure #MortalityRates #Jaundice #Fibrosis #HepatocyteRecovery #PediatricHealth #SurgicalOutcomes #LiverHealth #MedicalResearch

Transcript

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.

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