Long-term Results With the Kasai Operation for Biliary Atresia

We read with considerable interest the article by Karrer et al¹ in the May 1996 issue of the Archives. However, we were disappointed that the authors failed to provide any recommendations regarding strategies to identify patients who would most likely benefit from a portoenterostomy (other than those infants younger than 90 days of age). Nor do the authors discuss the risks of a failed portoenterostomy. Clearly, with the advances in perinatal noninvasive (or minimally invasive) tests, we can identify infants with biliary atresia who already have advanced cirrhosis. Should these children undergo the stress and risks of a laparotomy and a biliary enteric anastomosis, or even a laparotomy alone? The 100% mortality in the 6 patients who underwent laparotomy alone in their current series suggests that laparotomy may be harmful in cases of advanced cirrhosis. We have also encountered children who have developed rapid and severe decompensation of their