Journal List > Korean J Pediatr Gastroenterol Nutr > v.14(1) > 1043532

Korean J Pediatr Gastroenterol Nutr. 2011 Mar;14(1):74-80. Korean.
Published online March 31, 2011.
Copyright © 2011 The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition
Tentative Proposal of Optimal Timing of Kasai Operation for Biliary Atresia Based on Fibroscan Results
Hwa Young Lee, M.D.,* Young A Park, M.D.,* Seok Joo Han, M.D.,, and Hong Koh, M.D.*,
*Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.
Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
Severance Pediatric Liver Disease Research Group, Seoul, Korea.

Corresponding author (Email: )
Received August 13, 2010; Revised September 10, 2010; Accepted September 10, 2010.



Based on previous research findings, it is well-known that the timing of surgery is generally considered the most important prognostic factor for a Kasai portoenterostomy, the primary treatment for biliary atresia. This research aimed to identify the optimal timing of a Kasai portoenterostomy and to verify if the proposed optimal timing corresponds to previous studies. All patients were classified by the timing of surgery, and pre- and post-operative fibrotic changes of the liver were measured with the elasticity value from fibroscans.


The stiffness scores of the pre- and post-operative fibroscans in 34 patients who were treated by Kasai portoenterostomy from October 2007 to September 2010 in Severance children's hospital were reviewed.


The earlier the patients were treated by Kasai portoenterostomy, the lower the fibroscan scores. When the patients were treated prior to the 8th week, the post-operative scores of the fibroscans were significantly better than those patients who were treated after the 8th week, and some even recovered partially. Moreover, when operated before the 8th week, the differences between each pre- and post-operative fibroscan score also showed statistical relevance (p=0.0002).


The earlier the patient was treated by Kasai portoenterostomy, the less liver fibrosis that developed, the lower the level of post-operative fibrosis, and the less the degree of fibrotic progress before and after the operation. Thus, this research proposal reconfirms once more that the 8th week is the optimal timing for a Kasai portoenterostomy.

Keywords: Biliary atresia; Liver fibrosis; Fibroscan


Table 1
Baseline Characteristics of Patients
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Table 2
Comparison with Pre- and Post-operative Stiffness Scores of Liver according to Each Age Group of Kasai Operation
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Table 3
Comparison of Stiffness Scores between Pre- and Post-operation according to Each Age Group of Kasai Operation
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1. Hartley JL, Davenport M, Kelly DA. Biliary atresia. Lancet 2009;374:1704–1713.
2. Hays DM, Snyder WH Jr. Life-span in untreated biliary atresia. Surgery 1963;54:373–375.
3. Kasai M, Suzuki S. A new operation for "non correctable" biliary atresia: hepatic portoenterostomy. Shujitsu 1959;13:733–739.
4. Karrer FM, Lilly JR, Stewart BA, Hall RJ. Biliary atresia registry, 1976 to 1989. J Pediatr Surg 1990;25:1076–1080.
discussion 81.
5. Houwen RH, Zwierstra RP, Severijnen RS, Bouquet J, Madern G, Vos A, et al. Prognosis of extrahepatic biliary atresia. Arch Dis Child 1989;64:214–218.
6. Ohi R, Nio M, Chiba T, Endo N, Goto M, Ibrahim M. Long-term follow-up after surgery for patients with biliary atresia. J Pediatr Surg 1990;25:442–445.
7. Ohi R. Biliary atresia. A surgical perspective. Clin Liver Dis 2000;4:779–804.
8. Castera L, Vergniol J, Foucher J, Le Bail B, Chanteloup E, Haaser M, et al. Prospective comparison of transient elastography, Fibrotest, APRI, and liver biopsy for the assessment of fibrosis in chronic hepatitis C. Gastroenterology 2005;128:343–350.
9. Fraquelli M, Rigamonti C, Casazza G, Conte D, Donato MF, Ronchi G, et al. Reproducibility of transient elastography in the evaluation of liver fibrosis in patients with chronic liver disease. Gut 2007;56:968.
10. Sandrin L, Fourquet B, Hasquenoph JM, Yon S, Fournier C, Mal F, et al. Transient elastography: a new noninvasive method for assessment of hepatic fibrosis. Ultrasound Med Biol 2003;29:1705–1713.
11. Marcellin P, Ziol M, Bedossa P, Douvin C, Poupon R, de Ledinghen V, et al. Non-invasive assessment of liver fibrosis by stiffness measurement in patients with chronic hepatitis B. Liver Int 2009;29:242–247.
12. Corpechot C, El Naggar A, Poujol-Robert A, Ziol M, Wendum D, Chazouilleres O, et al. Assessment of biliary fibrosis by transient elastography in patients with PBC and PSC. Hepatology 2006;43:1118–1124.
13. Gomez-Dominguez E, Mendoza J, Garcia-Buey L, Trapero M, Gisbert JP, Jones EA, et al. Transient elastography to assess hepatic fibrosis in primary biliary cirrhosis. Aliment Pharmacol Ther 2008;27:441–447.
14. Chang HK, Park YJ, Koh H, Kim SM, Chung KS, Oh JT, et al. Hepatic fibrosis scan for liver stiffness score measurement: a useful preendoscopic screening test for the detection of varices in postoperative patients with biliary atresia. J Pediatr Gastroenterol Nutr 2009;49:323–328.
15. McKiernan PJ. Neonatal cholestasis. Semin Neonatol 2002;7:153–165.
16. Sokol RJ, Shepherd RW, Superina R, Bezerra JA, Robuck P, Hoofnagle JH. Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop. Hepatology 2007;46:566–581.
17. Sokol RJ, Stall C. Anthropometric evaluation of children with chronic liver disease. Am J Clin Nutr 1990;52:203–208.
18. Davenport M, De Ville de Goyet J, Stringer MD, Mieli-Vergani G, Kelly DA, McClean P, et al. Seamless management of biliary atresia in England and Wales (1999-2002). Lancet 2004;363:1354–1357.
19. Jeong H, Choi BH, Hwang S, Kim KM, Kim SC, Park KM, et al. Factors influencing the early outcome following liver transplantation for biliary atresia. Korean J Gastroenterol 2000;35:212–218.
20. Altman RP, Lilly JR, Greenfeld J, Weinberg A, van Leeuwen K, Flanigan L. A multivariable risk factor analysis of the portoenterostomy (Kasai) procedure for biliary atresia: twenty-five years of experience from two centers. Ann Surg 1997;226:348–353.
discussion 53-5.
21. Chiba T. Indication of Kasai's operation for biliary atresia: for early decision of liver transplantation. Nippon Geka Hokan 1988;57:261–266.
22. Chardot C, Carton M, Spire-Bendelac N, Le Pommelet C, Golmard J, Reding R, et al. Is the Kasai operation still indicated in children older than 3 months diagnosed with biliary atresia? J Pediatr 2001;138:224–228.
23. A-Kader HH, Balisteri WF. Cholestasis. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson textbook of pediatrics. 17th ed. Philadelphia: Sunders; 2004. pp. 1314-1319.
24. Cadranel JF, Rufat P, Degos F. Practices of liver biopsy in France: results of a prospective nationwide survey. For the Group of Epidemiology of the French Association for the Study of the Liver (AFEF). Hepatology 2000;32:477–481.
25. Colloredo G, Guido M, Sonzogni A, Leandro G. Impact of liver biopsy size on histological evaluation of chronic viral hepatitis: the smaller the sample, the milder the disease. J Hepatol 2003;39:239–244.
26. Piccinino F, Sagnelli E, Pasquale G, Giusti G. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J Hepatol 1986;2:165–173.
27. Maharaj B, Maharaj RJ, Leary WP, Cooppan RM, Naran AD, Pirie D, et al. Sampling variability and its influence on the diagnostic yield of percutaneous needle biopsy of the liver. Lancet 1986;1:523–525.
28. Foucher J, Chanteloup E, Vergniol J, Castera L, Le Bail B, Adhoute X, et al. Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study. Gut 2006;55:403–408.
29. Vizzutti F, Arena U, Romanelli RG, Rega L, Foschi M, Colagrande S, et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology 2007;45:1290–1297.
30. de Ledinghen V, Vergniol J. Transient elastography (FibroScan). Gastroenterol Clin Biol 2008;32:58–67.
31. Kettaneh A, Marcellin P, Douvin C, Poupon R, Ziol M, Beaugrand M, et al. Features associated with success rate and performance of FibroScan measurements for the diagnosis of cirrhosis in HCV patients: a prospective study of 935 patients. J Hepatol 2007;46:628–634.
32. de Ledinghen V, Le Bail B, Rebouissoux L, Fournier C, Foucher J, Miette V, et al. Liver stiffness measurement in children using FibroScan: feasibility study and comparison with Fibrotest, aspartate transaminase to platelets ratio index, and liver biopsy. J Pediatr Gastroenterol Nutr 2007;45:443–450.
33. Lee H, Kang J, Kim KM, Jang JY, Jang SJ, Yu E. The Clinicopathological Parameters for Making the Differential Diagnosis of Neonatal Cholestasis. [Journal Article MH - Infant MH - Male MH - Female MH - Infant, Newborn MH - Humans]. Korean J Pathol 2009;43:43–47.
34. Kim SY, Seok JY, Han SJ, Koh H. Assessment of liver fibrosis and cirrhosis by aspartate aminotransferase-to-platelet ratio index in children with biliary atresia. J Pediatr Gastroenterol Nutr 2010;51:198–202.
35. Weerasooriya VS, White FV, Shepherd RW. Hepatic fibrosis and survival in biliary atresia. J Pediatr 2004;144:123–125.