It gives me much pleasure to write a review article for the papers published in this issue (Dec 2019) of the JPS. In this current issue, as usual, there are several high-quality studies published on the topics of thoracic, gastrointestinal, hepatobiliary and urology conditions. A variety of studies have been included and some of which are prospective randomized study or meta-analysis that provide the highest level of evidence. Apart from clinical studies, a few paper focused on translational research works which have the potential to advance our knowledge in the clinical management paediatric cancer and several intestinal diseases. Among all these studies, there are two paper (1, 2) from Japan that I would like to recommend for reading. They are entitled ‘The outcome of real-time evaluation of biliary flow using near-infrared fluorescence cholangiography with Indocyanine green in biliary atresia surgery’ Both studies addressed on biliary atresia. One (1) of them questioned the traditional wisdom of performing liver biopsy on suspected biliary atresia while another paper proposed a novel technology to assist the level of porta transection during the Kasai operation Indocyanide Green technology. Both issues are linked to the survival and prognosis of biliary atresia patients and are therefore highly relevant to our clinical practice.

Ultrasound image and liver biopsy have been widely accepted as part of the diagnostic protocol for anyone with cholestasis and suspected biliary atresia. In an ideal situation, when the ultrasound examination shows a distended gallbladder and liver histology is unremarkable, patients could be excluded from having biliary atresia. This would help to avoid unnecessary laparotomy which is a major trauma to a young infant. However, not uncommonly, the findings from ultrasound and liver biopsy are equivocal and the baby still need to undergo a major laparotomy which may turn out to be negative. In the era of laparoscopy, the authors of this paper questioned this practice and evaluated the value of liver biopsy. In their paper, the diagnostic accuracy of laparoscopy was 100% and patients received immediate Kasai operation. In my opinion, this paper has pointed out an important change brought about by laparoscopy since the 21^st century, that is --- direct access to organs with minimal surgical trauma only. Although the risk of liver biopsy resulted in life-threatening event is low, major bleeding could still happen from time to time and in this regard, the risk of bleeding maybe even lower in laparoscopy. In addition, with the advances in paediatric anesthesia, the anesthetic risk of laparoscopy is comparable to the sedation risk of performing liver biopsy. And another major advantage of performing laparoscopy directly is the shortening of the waiting time. Nonetheless, I believe that liver biopsy under the same session of laparoscopy is still warranted as a mean to assess the underlying liver damage in biliary atresia cases (before proceeding to Kasai operation) or for making the diagnosis in case biliary atresia is excluded after laparoscopic assessment.

Another paper (2) from this issue, also coming from Japan, reported their experience of using Indocyanine green (ICG) fluorescence to assist the diagnosis of biliary atresia during laparoscopy. ICG is hydrosoluble molecule and has been used for the evaluation of hepatic function before liver resection. The clinical application of its fluorescent properties during HCC resection was first reported in 2009. Since then, more major studies have proven its usefulness during liver tumor resection. After intravenous injection, ICG will become protein-bounded and emit fluorescence under infrared light. In the liver, ICG will be taken up by the normal hepatocytes and excreted in bile after 4 to 6 hours. Therefore, it is particular suitable for the examination of bile flow intra-operatively. Adverse reaction to ICG is rare. Biliary atresia is a disease characterized by inflammatory sclerosing cholangiopathy resulting in biliary tract fibrosis. Under ICG fluorescence, bile will appear green. What is the optimal level of porta transection is always the questions of the operating surgeon and traditionally, there is a lack of effective assessment tool and mostly depend on direct inspection of bile flow. However, it is sometimes not difficult to detect bile flow or it may be confused with lymphatic drainage. The authors of this paper reported their experience of this technology on 10 patients and compared the result with historical control. Their results showed that ICG fluorescence visualized the hilar micro-bile ducts, and the incidence of positive fluorescence was 80%. The ratio of postoperative normalization of hyperbilirubinemia was significantly higher than historical control. The authors concluded that the application of ICG fluorescence could provide important objectifiable information about the biliary structures in surgery of biliary atresia. In fact, ICG fluorescence has a much extensive application that bile duct surgery and is widely used in other forms of surgery like esophageal, colorectal and breast surgery. Although it is still not available in China, it is good for us to know the latest practice of other country to keep ourselves up-to-dated about the latest technology.

These two papers have highlighted two important issues in the management of biliary atresia and I would recommend these to clinicians who are interested in biliary atresia