Is the Kasai operation still indicated in children older than 3 months diagnosed with biliary atresia?

Objectives: The prognosis of hepatoportoenterostomy (the Kasai operation) f or biliary atresia worsens when the age at surgery increases. This study ex amines whether the Kasai operation remains justified after 3 months of life . Study design: Records for all patients with biliary atresia living in Franc e and born in the years 1986 to 1996 were reviewed, and patients were class ified into 3 groups: group 1 (n = 30), no contraindication to the Kasai ope ration, but orientation to de novo transplantation; group 2 (n = 380), age at Kasai operation <90 days; and group 3 (n = 60), age at Kasai operation < greater than or equal to>90 days. Survival with native liver, survival afte r liver transplantation, and overall survival (Kaplan-Meier method) were co mpared by using the log-rank test. Results: Five-year (10-year) survival with native liver was 35% (30%) in gr oup 2 and 25% (22%) in group 3 (P =.03). Five-year overall survival was 57% , 74%, and 55% in groups 1, 2, and 3, respectively (P =.003). Poor results in groups 1 and 3 were mainly due to increased pre-transplantation mortalit y, but survival after transplantation was not significantly different in th e 3 groups. Conclusions: Performance of the Kasai operation after 3 months of age is ju stified in selected cases, because it may obviate liver transplantation. Pr eoperative evaluation should exclude patients with advanced liver disease f or whom liver transplantation should not be delayed.