The impact of a previous Kasai procedure on liver transplantation for biliary atresia.

The usual treatment for biliary atresia is a Kasai procedure followed by liver transplantation when indicated. Although primary transplantation for biliary atresia without a previous Kasai procedure is occasionally advocated, it is rarely performed. This review was undertaken to evaluate the impact of a Kasai procedure on the morbidity and mortality of patients who went on to need a liver transplant. Sixty-three patients with biliary atresia were included in this review. Fifty seven patients underwent transplantation: eight patients had a liver transplant only (group 1), and 49 patients underwent a Kasai procedure before transplantation (group 2). Six patients died before receiving a transplant. Time spent on the waiting list for liver transplant was longer in group 2 than in group 1 (170.3 +/- 24.6 days versus 63.3 +/- 7.1 days, P < .05). The patients in group 1 were younger (0.7 +/- 0.2 versus 2.3 +/- 0.4 years) and smaller (6.9 +/- 0.4 kg versus 11.6 +/- 1.2 kg) than the patients in group 2 (P = .07). There was no difference in pretransplant urgency status between the two groups. The mean duration of the transplant operation was shorter in group 1 patients (476.8 +/- 53.3 minutes) compared with group 2 (593.9 +/- 29.3 minutes, P = .06). Group 1 patients received 199.8 +/- 46.2 mL/kg blood transfusion intraoperatively, and group 2 patients had twice that amount, 466 +/- 122.5 mL/kg. No patients in group 1 experienced postoperative bowel perforations or required reoperation for bleeding. In group 2 however, 11 of 49 (22.4%) experienced bowel perforations and 7 of 49 (14.2%) required reoperation for bleeding. There was no difference in nonsurgical complications between the two groups. Long-term survival was equal in the 2 groups: six of eight patients (75%) in group 1 and 36 of 49 (74%) in group 2. The marked increase in complications noted in group 2 patients did not reach statistical significance because of the much smaller number of patients in group 1. These results suggest that patients with biliary atresia have fewer complications after transplantation if a Kasai procedure is not performed before the transplant, and that a more careful selection of surgical options available in treating patients with biliary atresia is required.