From a review of 71 cases and an evaluation of frozen-section examinations of liver biopsies, the authors propose the following method of management of infants with prolonged obstructive jaundice.
All patients are carefully selected on the basis of history, clinical findings and appropriate laboratory investigation. Laboratory studies found to aid in the differential diagnosis are: serial determinations of bilirubin (conjugated and unconjugated) in the serum, zinc sulfate turbidity test, cholesterol and cholesterol esters in serum, estimation of bile pigment in urine and stool, studies of the maternal and infant blood factors and erythrocyte fragility. Determinations that have not been useful in the differential diagnosis are: cholesterol esterase, alkaline phosphatase and cephalin fiocculation.19 The activity of transaminases in the serum may prove helpful and are currently under study. The measurement of the prothrombin time should be included in the preoperative studies.
If the diagnosis is impossible by the age of 7 weeks, then surgical exploration is carried out. This consists of exposing the liver, taking a biopsy for frozen-section examination and performing a cholangiogram, if possible. With increasing experience, confidence has been acquired in interpretation of the frozen-section of the liver biopsy at this age. The authors are convinced of its value in helping the surgeon establish the diagnosis before proceeding with further exploration of the bile ducts.
By this method of management, surgical exploration need not be delayed beyond 7 weeks of age. Thus a patient with congenital atresia of the bile ducts, who may be fortunate enough to have a correctable lesion, will not be deprived of the only possible chance of cure. At this age it is unlikely that biliary cirrhosis will have progressed to a severe degree. Admittedly, it would be preferable to explore such a case earlier, but more experience is needed in diagnosis by frozen-section examination at an earlier age.
It does not appear that any patient with hepatitis or other non-surgical condition has been harmed either by the anesthesia or surgical trauma attendant on this limited procedure. One of the greatest advantages of the frozen-section examination has been the information provided to the surgeon at a crucial time during the exploration. With this information the surgeon should be able to avoid unnecessary exploration of the bile ducts and possible injury to patent ducts, as well as unnecessary biliary-intestinal anastomoses which have been performed in the past because of mistaken diagnoses.
THE PATHOGENESIS OF EARLY OBSTRUCTIVE JAUNDICE
