Microsurgery in Japan

Many babies are "jaundiced" in the first few days of life, but usually the yellow discoloration of the skin and eyes disappears quickly as the liver adjusts to its new metabolic work load. William Lewis, born last Oct. 10 in New York City, was a rare example of a far more serious condition. His complexion remained abnormal. Even more frightening, his stools and urine indicated that he suffered from an inborn defect, biliary atresia--the absence or severe underdevelopment of tiny bile ducts emerging from the liver. William's case proved to be unusual in another respect: he was flown to Japan in the search for lifesaving corrective surgery.

Nature designed the ducts to carry bile on its way from the liver, where it is made, to the duodenum, where it aids in digestion. Among the estimated 200 occurrences each year of biliary atresia in the U.S., there are a few in which ducts outside the liver are large enough for corrective surgery. But not in William's case.

The bile backing up in his liver would soon cause irreparable damage to that vital organ and affect others. The prognosis, at one of Manhattan's most famed university hospitals, was grim. Although operations for biliary atresia are performed in the U.S., the experts concluded that William's condition could not be corrected by surgery and that he probably would live no longer than nine months.

But his parents, Mina and Brian Lewis, refused to accept the sentence of death. They consulted Dr. Orvar Swenson, a noted pediatric surgeon at Children's Memorial Hospital in Chicago. He, too, was pessimistic. He recalled, without recommending it, a modified operation devised by a Japanese surgeon, Dr. Keijiro Suruga, who reported that it had succeeded in some cases. Mina Lewis did some research of her own and found a new article by Suruga in the Journal of Pediatric Surgery. Then, using her experience as a travel agent, she quickly arranged a family trip to Tokyo in early January.

At Juntendo University, Suruga, 52, explained his special interest in biliary atresia: for reasons unknown it is far more common in Asia than in Western countries. Suruga's early techniques for correcting the condition proved to be only palliative, not curative. In 1968 he hit upon a method that he has since used in 40 cases, with 30 children now surviving. It was a variation of this technique that he used for William.

The child had one thing in his favor: he was less than 90 days old and his liver so far had suffered relatively little damage. As Suruga explained, after three months the backed-up bile is likely to cause irremediable cirrhosis of the liver. Another factor was most unfavorable: the bile ducts in the liver were the tiniest imaginable--averaging only one five-hundredth of an inch in diameter. Suruga is not hopeful unless they are twice that size, but he nevertheless decided to make the attempt.

U Curve. The surgery lasted ten hours. Almost 3/2 hours were spent dissecting the adhesions of scar tissue left by an earlier operation in New York to correct an intestinal blockage. Only then was Suruga able to snip out an eight-inch section of jejunum (the upper part of the small intestine) and to fashion it into the shape of a U (see diagram). Next he trained his surgical microscope, working at 20-to 40-power magnification, on the minuscule bile ducts. He exposed them, and with incredibly fine needlework sewed one branch of the U over them like a funnel. He sutured the other branch of the U into the upper part of the duodenum, about where nature intended bile to go.

As a temporary precaution, Suruga led the bend of the U to the abdominal wall and made an opening there; with hair-thin nylon threads running to it from inside the bile ducts to make sure that they stay open, this "window" can be used to draw off fluid or to instill medication. In a few months, if all goes well, the base of the U and the abdominal opening can be closed.

William was crying and kicking two hours after surgery. The next day, he was not producing enough bile, so a medication which enhances bile flow, cholestyramine, was flown from the U.S. to Tokyo for him. The output of the baby's digestive tract by late January showed that he was producing bile and that it was being used in the metabolism of the special formula that he was receiving in addition to mother's milk. Last week he was strong enough to make the long trip home.

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