# Jaundice — GCMD Library living collection

Everything in the library about jaundice — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 34 cited statements

## Episodes
### Evidence & Research
- [Clinical Characteristics and Prognosis of Biliary Atresia with Low Serum Matrix Metalloproteinase-7 Levels](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911) — video · 0:55 · [machine version](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911.md)

### Case-Based Learning
- [Biliary Atresia-Case Presentation and Panel Discussion: Update Course 2014](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909) — video · 23:47 · [machine version](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909.md)

### In-Depth Reviews
- [Hepatoblastoma: Update Course 2014](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882) — video · [machine version](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882.md)

## Chapters
- [0:00](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=0) PRETEXT Staging System and Case Presentation (Ep 1)
- [3:52](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=232) Management Strategies and Chemotherapy Response (Ep 1)
- [12:08](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=728) Transplant Versus Extended Resection (Ep 1)
- [18:56](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1136) Surgical Decision-Making and Biopsy Practices (Ep 1)
- [24:49](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1489) Pulmonary Metastases and Future Research (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=0) Case presentation and optimal age for Kasai procedure (Ep 2)
- [3:46](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=226) Age versus duration of symptoms and contraindications to Kasai (Ep 2)
- [7:01](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=421) Contraindications and redo procedures (Ep 2)
- [13:11](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=791) Diagnostic workup: HIDA scans and phenobarbital (Ep 2)
- [17:13](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1033) Role of preoperative liver biopsy and percutaneous cholangiography (Ep 2)
- [20:30](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1230) Prenatal ultrasound, postoperative steroids, and Japanese surgical technique (Ep 2)
- [0:00](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=0) MMP-7 as a Prognostic Marker in Biliary Atresia (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- PRETEXT staging stands for pretreatment extent of disease and is based on segmental liver anatomy prior to chemotherapy (clinical) [Ep 1 · 1:41](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=101)
- PRETEXT staging has a tendency to overstage because it is based purely on imaging and bulky tumors make it hard to assess true vascular invasion versus mass effect (clinical) [Ep 1 · 1:41](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=101)
- POSTTEXT refers to extensive disease after neoadjuvant chemotherapy has been given (clinical) [Ep 1 · 1:41](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=101)
- Key staging annotations include involvement of the retrohepatic cava or hepatic veins and the portal vein bifurcation (clinical) [Ep 1 · 3:52](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=232)
- COG recommendations state that PRETEXT stage 2 tumors with no vascular involvement and achievable 1 cm margin can be resected upfront without neoadjuvant chemotherapy (guideline) [Ep 1 · 7:30](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=450)
- COG feels that PRETEXT stage 1 and 2 tumors do not necessarily need referral to centers with liver resection expertise if the local surgeon feels competent (guideline) [Ep 1 · 7:55](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=475)
- Most tumor shrinkage from chemotherapy occurs within the first two cycles (clinical) [Ep 1 · 10:26](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=626)
- Current recommendations are that after two cycles of chemotherapy, if the tumor has not shrunk to a resectable point, the patient should be evaluated for transplant (guideline) [Ep 1 · 10:26](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=626)
- As hepatoblastoma tumors shrink with chemotherapy, they do not shrink away from the vascular supply, so chemotherapy does not improve vascular margins (clinical) [Ep 1 · 10:26](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=626)
- The goal surgical margin for hepatoblastoma resection is 1 cm (clinical) [Ep 1 · 12:08](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=728)
- Survival in patients undergoing extended or heroic resections (tumor liver explants with back table resection and reimplant, portal vein reconstructions, hepatic vein reconstructions) is not as good as transplant survival (clinical) [Ep 1 · 12:33](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=753)
- There has been a move away from heroic resections for hepatoblastoma (opinion) [Ep 1 · 12:33](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=753)
- Patients who undergo failed resection followed by rescue transplant have worse survival than patients who undergo planned transplant upfront (clinical) [Ep 1 · 14:52](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=892)
- Patients should be referred to a transplant center early even if they may not ultimately need transplant, to have pre-transplant evaluation completed and be plugged into the system (guideline) [Ep 1 · 15:48](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=948)
- Primary transplant patients with hepatoblastoma do surprisingly well despite immunosuppression against rejection in the setting of cancer (clinical) [Ep 1 · 16:38](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=998)
- For non-transplant center surgeons, criteria for proceeding with resection include feeling 95% confident of success and ability to perform an anatomic resection with good margin (opinion) [Ep 1 · 18:56](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1136)
- Disease close to hepatic veins, disease extending across the liver, or involvement of the portal vein should prompt referral to a transplant center (opinion) [Ep 1 · 19:54](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1194)
- The truth about resectability is determined at the time of operation despite all available imaging (opinion) [Ep 1 · 21:52](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1312)
- In Europe, all liver tumors receive chemotherapy upfront before surgery because it results in smaller, easier-to-resect tumors (clinical) [Ep 1 · 22:13](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1333)
- Core needle biopsy for hepatoblastoma typically requires about 10 passes through an area that includes normal parenchyma and tumor (clinical) [Ep 1 · 23:53](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1433)
- There are two camps regarding pulmonary metastasis treatment: one advocates resecting metastases upfront before hepatectomy, the other suggests waiting until after hepatectomy because liver regeneration growth factors may stimulate previously unrecognized lung sites (clinical) [Ep 1 · 24:49](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1489)
- There is no good data on either side of the pulmonary metastasis timing debate, with both approaches limited to a handful of patients (opinion) [Ep 1 · 24:49](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1489)
- Papers on stage IV hepatoblastoma with lung metastases are limited to cohorts of less than 20 patients, making it hard to draw good conclusions (epidemiological) [Ep 1 · 26:11](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1571)
- There may be reporting bias in transplant outcomes because successes are reported but not all failures (opinion) [Ep 1 · 26:11](https://origin-library.globalcastmd.com/watch/hepatoblastoma-update-course-2014-882?t=1571)
- In the first large Michigan series, children who had Kasai performed after 3 months had the best drainage and long-term outcomes. (epidemiological) [Ep 2 · 1:03](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=63)
- The critical factor determining outcome may be the degree of cirrhosis present in the liver at the time of Kasai, which does not always correlate directly with chronological age. (opinion) [Ep 2 · 3:24](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=204)
- Reversal of portal flow is a concerning contraindication to Kasai because patients can achieve good biliary drainage but continue to develop progressive portal hypertension requiring transplant. (clinical) [Ep 2 · 9:19](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=559)
- Even a failed Kasai can buy time by allowing the child to grow, expanding the donor pool and making transplantation technically easier with lower hepatic artery thrombosis risk. (clinical) [Ep 2 · 10:05](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=605)
- Hepatologists can manage children with biliary atresia medically (without Kasai or transplant) for up to a year, though nutritional status is compromised. (clinical) [Ep 2 · 10:41](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=641)
- In patients with profound portal fibrosis and reversal of portal flow, Kasai may not improve outcomes and the operative stress may worsen the patient's condition. (opinion) [Ep 2 · 10:56](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=656)
- Some biliary atresia patients show delayed clearance of bilirubin, with bilirubin dropping to normal at 5 months post-Kasai, suggesting a race between hepatocyte regeneration and fibrosis progression. (clinical) [Ep 2 · 12:20](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=740)
- Pathologists' understanding of biliary atresia histology has improved significantly compared to 20 years ago. (opinion) [Ep 2 · 18:01](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1081)
- Patent gallbladder is extremely rare in true biliary atresia, making percutaneous cholangiography rarely successful. (clinical) [Ep 2 · 18:41](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1121)
- Prenatal ultrasound diagnosis of biliary atresia based on absent gallbladder is unreliable and angle-dependent, with at least one reported case of normal outcome after consideration of abortion. (clinical) [Ep 2 · 20:44](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1244)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The study was a retrospective cohort study conducted in China — Cecilia Gigena summarizing a resource [Ep 3 · 0:11](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=11)
- The study included 329 patients with biliary atresia — Cecilia Gigena summarizing a resource [Ep 3 · 0:21](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=21)
- 40 of the 329 patients had low MMP-7 levels — Cecilia Gigena summarizing a resource [Ep 3 · 0:21](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=21)
- Patients with low MMP-7 had significantly lower 3-month jaundice clearance — Cecilia Gigena summarizing a resource [Ep 3 · 0:27](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=27)
- Patients with low MMP-7 had significantly lower 6-month jaundice clearance — Cecilia Gigena summarizing a resource [Ep 3 · 0:27](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=27)
- Patients with low MMP-7 had significantly lower 1-year native liver survival — Cecilia Gigena summarizing a resource [Ep 3 · 0:27](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=27)
- Measuring MMP-7 can help with prognosis in biliary atresia patients — Cecilia Gigena summarizing a resource [Ep 3 · 0:40](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=40)
- MMP-7 measurement may in the future help with treatment of biliary atresia patients — Cecilia Gigena summarizing a resource [Ep 3 · 0:40](https://origin-library.globalcastmd.com/watch/clinical-characteristics-and-prognosis-of-biliary-atresia-with-low-serum-matrix-8911?t=40)
- French registry data showed children who had Kasai at less than 1 month of age had nearly twice the 5- and 10-year native liver survival rate compared to those done after 90 days. — The host summarizing the discussion [Ep 2 · 2:32](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=152)
- Rich Ricketts' series showed not statistically significant better results with Kasai performed at 76 days or older compared to 0-75 days. — The host summarizing the discussion [Ep 2 · 4:03](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=243)
- Peter Altman from Columbia, who had the largest U.S. series, recommended performing Kasai between 60 and 75 days of age. — The host summarizing the discussion [Ep 2 · 5:57](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=357)
- A Children's National Medical Center study from 1990-2011 showed HIDA scan with phenobarbital has high sensitivity for biliary atresia diagnosis. — The host summarizing the discussion [Ep 2 · 15:21](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=921)
- An effective HIDA scan requires at least 5 days of phenobarbital with adequate serum levels, representing a significant time commitment. — The host summarizing the discussion [Ep 2 · 15:47](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=947)
- A recent paper in Gastroenterology showed that liver biopsy plus other clinical parameters in a scoring system could predict biliary atresia with almost 100% accuracy. — The host summarizing the discussion [Ep 2 · 17:35](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1055)
- Japanese surgeons still recommend postoperative steroids for biliary atresia, either routinely or when drainage decreases, based on their national registry experience. — The host summarizing the discussion [Ep 2 · 21:33](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1293)
- Yamataka's modified Kasai technique uses wider dissection than the classic Kasai, more superficial sutures to avoid damaging ductules, and avoids placing sutures at 10 o'clock and 3 o'clock positions where normal bile ducts bifurcate. — The host summarizing the discussion [Ep 2 · 22:15](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1335)
- Japanese surgeons claim their modified technique produces better results than classic Kasai, though the numbers are not statistically valid. — The host summarizing the discussion [Ep 2 · 23:01](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1381)
- Yamataka is attempting to refute IPEG's recommendation against laparoscopic Kasai by showing that laparoscopic results are as good as open procedures. — The host summarizing the discussion [Ep 2 · 23:08](https://origin-library.globalcastmd.com/watch/biliary-atresia-case-presentation-and-panel-discussion-update-course-2014-909?t=1388)

## Changelog
- Sep 7: 3 items added automatically

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