title: Assessment of latent manganese toxicity as a prognostic factor following surgery for biliary atresia.
abstract: OBJECTIVE
  The aim of this study was to investigate latent manganese toxicity in patients with biliary atresia and to use this tool to predict the prognosis of biliary atresia patients after Kasai's portoenterostomy.
  
  
  METHODS
  14 patients who underwent Kasai's portoenterostomy between 1993 and 2005 were included in the study. Whole blood manganese assays were performed using atomic adsorption spectroscopy (Philips PU 9200, Cambridge, UK) and verified by repeat analysis; these were done at the time of surgery and 6 months later. All blood samples were collected in an identical manner, blinded and then assayed by technicians. Whole blood manganese levels were correlated with the development of manganese deposits in the globus pallidus on T1-weighted images on magnetic resonance imaging (MRI) of the brain. Serum bilirubin of all 14 patients were noted both at the time of surgery and 6 months later. A hepatobiliary (HIDA) scan was done in all patients 6 months after Kasai's portoenterostomy.
  
  
  RESULTS
  The bilirubin declined in all except 2 patients after surgery. Both these patients developed ascites and severe jaundice and 1 expired one year after surgery. HIDA scan was excretory in all 14 patients. Whole blood manganese ranged from 1.26 - 27.58 microg/dl (mean 4.63 +/- 7.00) at the time of surgery; the levels were normal in 11 patients and elevated in 3. The postoperative assay at 6 months after surgery demonstrated values from 1.08 - 74.46 microg/dl (mean 13.55 +/- 24.17); 4 patients showed an increase from the previous value. Globus pallidus hyperintensity on T1-weighted images was noted in 1 patient on MRI; this patient had a sharp rise in the postoperative manganese level. All other MRI examinations were normal. All 14 patients were neurologically intact.
  
  
  CONCLUSIONS
  Although the study size is small, it shows that there is a risk of latent manganese toxicity in patients with biliary atresia who have undergone Kasai's portoenterostomy. Whole blood manganese assay in conjunction with brain MRI can be used to serially monitor these patients for early detection of these complications. This tool can be used for prognosis after Kasai's portoenterostomy and can also be extremely useful in selecting patients who will need a liver transplant on a priority basis.
authors.affiliation: Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: G S
authors.initials: GS
authors.lastname: Agarwal
authors.forename: R
authors.initials: R
authors.lastname: Sharma
authors.forename: V
authors.initials: V
authors.lastname: Bhatnagar
mesh_terms: D001656:Biliary Atresia / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D005917:Globus Pallidus / Q000737:chemistry; D006801:Humans; D007231:Infant, Newborn; D008107:Liver Diseases / Q000175:diagnosis; D008279:Magnetic Resonance Imaging; D008345:Manganese / Q000032:analysis / Q000097:blood*; D020149:Manganese Poisoning / Q000097:blood* / Q000175:diagnosis / Q000209:etiology*; D011171:Portoenterostomy, Hepatic / Q000009:adverse effects*; D011379:Prognosis; D013997:Time Factors
chemical_list: D015415:Biomarkers; D008345:Manganese