Anatomy of the porta hepatis (PH) as rational basis for the hepatoporto-enterostomy (HPE)

Purpose: In a prospective study it was investigated whether and to what deg ree the morphology of the porta hepatis has a bearing on the early prognosi s of children with EHBA, The results will point to consequences of surgery and to the formulation of a rational understanding of the successes and fai lures of HPE. Methods: The macroscopy and the microscopy of the liver was studied on nati ve specimen and corrosion preparations of deceased adults, children and emb ryos. The area potentially draining the bile was determined in excised PH s pecimen of children with EHBA, The histologically and planimetrically measu red areas were correlated to clinical follow-up studies. In order to be abl e to study exclusively the influence of the PH morphology, the conditions o f the intrahepatical structural changes (level of fibrosis, metric and morp hic changes of biliary ductules in the Glisson's triads) had to be equal. U nder these conditions 61 excised PH specimen were evaluated. The level of f ibrosis was determined according to the definition of Schweizer/Muller 1984 (9). Results: 1) Biliary ductules of the PH end in three definable zones according to a r egular pattern. 2) Biliary ductules of the PH run in a narrow and immediate relation to the vascular structures. 3) Biliary ductules of the PH are often hidden between the vascular structu res of the PH and are not always accessible to preparatory exposure for the anastomosis. 4) The quantity of the bile flow is a significant function of the total are a of the biliary ductules secured in the excised PH specimen. 5) Incised biliary ductules at the excision edge may be obstructed again in the scarring of the anastomosis, leading to an early interruption of bile flow. 6) The opening-up of the biliary ductules in the central zone alone i s not enough to guarantee a permanent bile flow. Only if intact biliary duc tules of the two lateral hepatical lobes are secured, can a positive progno sis be made.