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2009 pediatrics late results kasai

  1. 1. Impact of Age at Kasai Operation on Its Results in Late Childhood and Adolescence: A Rational Basis for Biliary Atresia ScreeningMarie-Odile Serinet, Barbara E. Wildhaber, Pierre Broué, Alain Lachaux, Jacques Sarles, Emmanuel Jacquemin, Frédéric Gauthier and Christophe Chardot Pediatrics 2009;123;1280-1286 DOI: 10.1542/peds.2008-1949The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/123/5/1280PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  2. 2. ARTICLEImpact of Age at Kasai Operation on Its Results inLate Childhood and Adolescence: A Rational Basisfor Biliary Atresia ScreeningMarie-Odile Serinet, MDa, Barbara E. Wildhaber, MD, PhDa,b, Pierre Broue, MDa, Alain Lachaux, MDa, Jacques Sarles, MDa, ´Emmanuel Jacquemin, MD, PhDa, Frederic Gauthier, MDa, Christophe Chardot, MD, PhDa,b ´ ´a French Observatory of Biliary Atresia, Le Kremlin, Bicetre, Paris, France; bPediatric Surgery Unit, University of Geneva Children’s Hospital, Geneva, Switzerland ˆThe authors have indicated they have no financial relationships relevant to this article to disclose. What’s Known on This Subject What This Study Adds Increased age at the time of Kasai operation for BA has a negative effect on its short-term Increased age at surgery has a continuous and sustained deleterious effect on the results results in infancy and early childhood. of the Kasai operation until adolescence. Our data represent a rational basis for BA screening to reduce the need for LTs in infancy and childhood.ABSTRACTBACKGROUND. Increased age at surgery has a negative impact on results of the Kasaioperation for biliary atresia in infancy and early childhood. It remained unclear if anage threshold exists and if this effect persists with extended follow-up. In this study www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1949we examined the relationship between increased age at surgery and its results inadolescence. doi:10.1542/peds.2008-1949 Key WordsMETHODS. All patients with biliary atresia who were living in France and born between biliary atresia, outcome, Kasai, screening1986 and 2002 were included. Median follow-up in survivors was 7 years. Abbreviations BA— biliary atresiaRESULTS. Included in the study were 743 patients with biliary atresia, 695 of whom LT—liver transplantationunderwent a Kasai operation; 2-, 5-, 10-, and 15-year survival rates with native liver SNL—survival with native liverwere 57.1%, 37.9%, 32.4%, and 28.5%, respectively. Median age at Kasai operation Accepted for publication Sep 10, 2008was 60 days and was stable over the study period. Whatever the follow-up (2, 5, 10, Address correspondence to Barbara E. Wildhaber, MD, Hopital des Enfants, Chirurgie ˆor 15 years), survival rates with native liver decreased when age at surgery increased Pediatrique, Rue Willy Donze 6, 1211 Geneve, ´ ´ `(Յ30, 31– 45, 46 – 60, 61–75, and 76 –90 days). Accordingly, we estimated that if Switzerland. E-mail: barbara.wildhaber@every patient with biliary atresia underwent the Kasai operation before 46 days of hcuge.ch.age, 5.7% of all liver transplantations performed annually in France in patients PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2009 by theyounger than 16 years could be spared. American Academy of PediatricsCONCLUSIONS. Increased age at surgery had a progressive and sustained deleteriouseffect on the results of the Kasai operation until adolescence. These findings indicate a rational basis for biliary atresiascreening to reduce the need for liver transplantations in infancy and childhood. Pediatrics 2009;123:1280–1286B ILIARY ATRESIA (BA) is a perinatal disease of unclear etiology, characterized by inflammation and obliteration of intrahepatic and extrahepatic bile ducts, leading to cholestasis and cirrhosis.1 The currently recommendedtreatment is sequential: in the first weeks of life, the Kasai operation aims to bypass the obstructed extrahepatic bileducts and to restore the biliary flow.2 When this procedure fails to clear jaundice and/or complications associated withbiliary cirrhosis appear, secondary liver transplantation (LT) is needed.3 Altogether, ϳ20% of the patients can reachthe age of 20 years with their native liver, and 10% can reach the age of 30 years.4,5 Several prognostic factors of the Kasai operation have been related to the short-term results of this procedure.Among them are many that can not be altered, such as anatomy of the biliary remnant,6 histology of the liver,7–9portal pressure at the time of Kasai operation,10 or association of BA with polysplenia (BA splenic malformationsyndrome).11–13 Other prognostic factors of BA are related to the organization of care to these patients, and thereforeare improvable: age at Kasai operation, accessibility to LT, experience of the center in the management of patientswith BA.11,14 Although some discordant results have been published regarding the impact of age at surgery (Table 1),large series concordantly show that short-term results of the Kasai operation are better when surgery is performedearly in life. Whether an age threshold exists remains unclear, with published series often being divided at 45 or 60days for statistical purposes. Furthermore, the follow-up of the series is often limited, and whether the age effectpersists in later childhood and adolescence is uncertain. Therefore, the possible benefits of a neonatal screening policyare difficult to evaluate. On the basis of the analysis of the series of all patients with BA born in France between 1986 and 2002, this study1280 SERINET et al Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  3. 3. TABLE 1 Variations of Outcome According to Age at Kasai Operation in Reported Series Age Threshold, Effect Follow-up and End No. of Origin of Study Year Study Points PatientsϽ30 d, unfavorable Age at LT 92 St Louis Children’s Hospital (US) 2001 17Ͻ30 d, favorable 4-y SNL 349 Multicenter study (Canada) 2007 16Ͻ46 d, favorable 10-y SNL and 10-y OS 164 University Hospital Kremlin-Bicetre, Paris (France) ˆ 1997 32 5-and 10-y SNL 472 Multicenter study (France) 1999 6 5-y and 10-y OS 4-y SNL 252 Multicenter study (France) 2006 11Ͻ8 wk, favorable Clearance of jaundice 159 Chulalongkorn University, Bangkok (Thailand) 2005 33 Clearance of jaundice 50 King’s College, London (United Kingdom) 1989 34Ͻ60 d, favorable 5-y and 10-y SNL 141 National Taiwan University Hospital, Taipei (Taiwan) 2006 35 5-y OS (ϭSNL) 904 Multicenter study (US) 1990 13 Actuarial OS 21 University of Oslo (Norway) 1993 36 Clearance of jaundice 62 Prince of Songkla University, Songkhla (Thailand) 2003 37 Clearance of jaundice 200 Tohoku University Hospital, Sendai (Japan) 1983 38 Bile flow 41 Childrens Hospital of Los Angeles (US) 1989 39Ͻ2 mo, favorable 3-y OS (ϭSNL) 21 University of Colorado, Denver (US) 1980 40 10-y SNL 122 University Hospital Kremlin-Bicetre, Paris (France) ˆ 1990 41Ͻ7 wk, favorable 2-y SNL 36 University Hospital Munich (Germany) 2000 42Ͻ10 wk, favorable SNL 266 University of Colorado, Denver (US) 1997 43Ͻ10.5 wk, favorable 4-y SNL University of Colorado, Denver (US) 1979 44Ͻ12 wk, favorable Clearance of jaundice 93 University of Hong Kong (Hong Kong) 1997 45Ͻ90 d, favorable 20-y SNL 63 University Hospital Kremlin-Bicetre, Paris (France) ˆ 2005 5 Clearance of jaundice 66 Indiana University School of Medicine, Indianapolis (US) 1989 46Related (no defined 5-y SNL 1381 Multicenter study (Japan) 2003 47 threshold, younger age at Clearance of jaundice 108 University of Tubingen (Germany) 1998 9 surgery was observed in Actual SNL 47 Hospital of Porto Alegre (Brazil) 2002 48 groups with successful Actual SNL 49 Booth Hall Children’s Hospital, Blackley, Manchester (United Kingdom) 2000 49 Kasai operation) Clearance of jaundice 29 University of Alberta (Canada) 1996 50No significant effect of age at 1-y SNL 75 Chulalongkorn University, Bangkok (Thailand) 2006 51 Kasai operation 2-y SNL 104 Multicenter study (US) 2007 12 5-y SNL 93 Multicenter study (United Kingdom) 2000 52 1-, 5-, 10-, and 20-y SNL 92 Hospital Infantil La Paz, Madrid (Spain) 2000 53 5-y OS 30 University of Bochum (Germany) 2005 54 5-y SNL 338 King’s College, London (United Kingdom) 1997 55 5-y OS (ϭSNL) 117 Juntendo University (Tokyo) 1993 56 3-y SNL 27 Ege University, Izmir (Turkey) 2004 57 OS (ϭSNL) 34 University of Michigan, Ann Arbor (US) 1991 58 Clearance of jaundice 81 University of Michigan, Ann Arbor (US) 2002 59 Clearance of jaundice 31 Emory University, Atlanta (US) 2001 60 Clearance of jaundice 35 Juntendo University, Tokyo (Japan) 1985 61OS indicates overall survival.examined: (1) the impact of age at Kasai operation on included. The diagnosis of BA was critically reassessed bysurvival with native liver (SNL) in later childhood and the investigators of the study by consultation of theadolescence; and (2) the expected benefits if the Kasai charts of every patient before inclusion in the study.operation was performed earlier in every patient because Results of histologic examination of the biliary remnantsof a BA screening. were available in 584 (78%) patients. The median fol- low-up in survivors was 7 years (range: 0.2–18.1 years).PATIENTS AND METHODSThe charts of all children with BA or suspected BA Ethical Approvaltreated in France since LT became available were re- This study received the agreement of French authoritiesviewed by the investigators of the study, who visited the (Commission Nationale de l’Informatique et des Lib-participating centers and analyzed the charts locally. All ertes, authorization 997085). The registry was strictly ´45 pediatric centers (including medical, surgical, and LT confidential. Each family received an information letterunits) involved in the management of patients with BA indicating the aims and methods of the study and hadin France contributed to this survey; therefore, data the possibility to check or correct the data recorded forcollection was exhaustive. their child. Inclusion criteria and registered data have been de-scribed extensively for the French national outcome Statistical Analysisstudy.11 In summary, all patients with BA who were Survival rates were estimated according to the Kaplanliving in France and born between 1986 and 2002 were Meier method. SNL ends at LT or at death (in patients PEDIATRICS Volume 123, Number 5, May 2009 1281 Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  4. 4. 200 180 160 Median age (minimum–maximum), d 140 120 100 80 60 40 20 0 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 YearFIGURE 1Age at Kasai operation from 1986 to 2002. No significant variation of age at Kasai operation was observed during the 17 years of the study.who had not received a transplant). Results were ex- As described in the French national outcome study,pressed as value with the SE of the mean. All statistical increased age at Kasai operation was independently, fromanalyses were performed with StatView 5.0 (SAS Insti- other prognostic factors (such as polysplenia syndrome ortute, Inc, Cary, NC). unfavorable anatomic patterns of the extrahepatic biliary remnant), associated with a worse SNL outcome.11RESULTS The comparison between patients who underwentA total of 743 children were included. The detailed med- the Kasai operation before the age of 46 days versusical history of the patients has been reported in the patients who underwent the Kasai operation later andFrench national outcome study.11 Briefly, a total of 695 patients without contraindications to surgery who did(93.5%) children with BA underwent the Kasai opera- not undergo the Kasai operation (the main reason beingtion or a derived procedure, 48 (6.5%) children with BA delayed diagnosis in most of them), showed a 12.1%did not undergo the Kasai operation. Median age at difference of 15-year SNL between the 2 groups (Fig 3).Kasai operation was 60 days (range:12–180 days). No Consequently, the estimation of the possible benefits ofsignificant variation of the age at Kasai operation was early Kasai operation (performed before 46 days of life inobserved during the 17 years of the study (Fig 1). SNL all patients with BA) was calculated according to theafter the Kasai operation was 57.1% at 2 years of age following data: A ϭ number of new BA cases per year:(SE: 1.9%; 363 patients alive with native liver), 37.9% 743/17 years ϭ 43.7 /year; B ϭ 15-year SNL for patientsat 5 years of age (SE: 2.0%; 177 patients alive with operated before 46 days of life: 34.9%; C ϭ 15-year SNLnative liver), 32.4% at 10 years of age (SE: 2.0%; 86 for patients operated after 45 days of life or patientspatients alive with native liver), and 28.5% at 15 years without contraindications to surgery who did not un-of age (SE: 2.3%; 22 patients alive with native liver). dergo the Kasai operation: 22.8%; D ϭ ratio of patients SNL decreased when age at Kasai operation increased with BA operated after 45 days of life or patients without(P Ͻ .001) (Fig 2). The best results were obtained if the contraindications to surgery who did not undergo theKasai operation was performed before the age of 30 days, Kasai operation: 72.6%; E ϭ number of liver grafts perand then decreased regularly with increased age at opera- patient who had received a transplant: 456 grafts in 386tion. Nevertheless, patients operated after the age of 90 patients who received a transplant ϭ 1.18 graft perdays still had a 13% chance of surviving with their native patient who received a transplant.liver until adolescence. The effect of age at Kasai operation The estimated savings of liver grafts in infancy andlasted in late childhood and adolescence (Fig 2). childhood, if every patient with BA underwent the Kasai1282 SERINET et al Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  5. 5. FIGURE 2Variations of 2-, 5-, 10- and 15-year SNL according to age at Kasai operation. SNL significantly decreased when age at Kasai operation increased (P Ͻ .0001). a In this subgroup, the patientwith the longest follow-up underwent LT at the age of 14 years; therefore, the curve drops to zero without any consequence, however, to statistical results.operation before 46 days of life, are 4.5 liver grafts per 2005: 476 pediatric LTs ϭ 79 LTs per year. Source:year [ϭ A ϫ D ϫ (BϪC) ϫ E], which represents 5.7% of Agence de la Biomedecine, Paris, France). ´all pediatric LTs performed annually in France (2000 – DISCUSSION Although numerous reports have shown that late per- formance of the Kasai operation worsens its results (Ta- 1.0 ble 1), the real impact of age at the time of Kasai oper- 0.8 ation has remained controversial.15 To establish the potential benefits of mass screening for BA, 2 main 0.6 issues remained unclear: (1) does the prognosis of the Kasai operation progressively decrease when age at sur- SNL 0.4 gery increases, and what happens to children operated in 12.1% the first month of life? and (2) Does the better short- 0.2 term prognosis observed after early Kasai operations persist or fade in late childhood and adolescence? 0.0 In the present large series, we found that the earlier the Kasai operation, the better its results. Especially in 0.0 2.5 5.0 7.5 10.0 12.5 15.0 17.5 20.0 Age, y the subgroup of 59 patients operated on in the first month of life, the outcome was better than in the chil-FIGURE 3Comparison of the 15-year SNL between patients with BA having undergone a Kasai dren operated on later in life. These findings correlateoperation before and after 45 days of life. The comparison of the 2 groups showed a with data from the Canadian national study, in which 2112.1% difference of the 15-year SNL. patients with BA operated on before the age of 1 month PEDIATRICS Volume 123, Number 5, May 2009 1283 Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  6. 6. had a better SNL than 291 patients operated on when transplant are not well known but are undoubtedly lessolder.16 These results contrast with a previous study fo- than those of a transplanted child. In a scenario wherecusing on the results of the Kasai operation performed in the annual charges of a patient with BA who has notthe first month of life17: the outcome seemed worse in received a transplant would be 10 000 Euros, the totalthe 9 of 92 patients who underwent the Kasai operation savings for the 4.5 yearly economized pediatric LTs inin the first month of life, suggesting that early diagnosis France would amount to ϳ500 000 Euros per year. Inmight have been related to a different pathogenesis of the United States, the same savings of 5.7% of all pedi-the disease, associated with a worse prognosis. Notewor- atric LTs would represent 32.7 LTs per year (4016 pedi-thy, in the detailed analysis of prognostic factors of Kasai atric LTs were performed in the United States betweenoperation in the French series, classical factors of poor 2000 and 2006 [ie, 574 pediatric LTs per year (www.prognosis such as polysplenia syndrome, or unfavorable unos.org)]). The estimated first-year charge for a LT isanatomy of the extrahepatic biliary remnant, were ϳ450 000 dollars, and the estimated annual follow-upfound to be independent of age at surgery by multivar- charges are ϳ30 000 dollars.24 In a scenario where theiate analysis.6,11 charges of a patient with BA who has not received a Whether the benefit of an early Kasai operation transplant would be 15 000 dollars, the total financialwould last in late childhood and adolescence remained savings would amount to ϳ18 million dollars per year.uncertain. It has been shown that most of the patients Therefore, BA screening programs seem to be a cost-with BA alive with their native livers at the ages of 10 effective investment for society.years and 20 years5 had undergone the Kasai operation Despite repeated attempts to sensitize medical staff tobefore the age of 90 days. The recent national Canadian check the color of stools in the first month of life, the agestudy showed that the benefit of an early Kasai opera- at Kasai operation did not decrease in France during thetion, in the first month of life, is maintained until late 17 years of the study, with a stable median age at Kasaichildhood and adolescence.16 Our data confirm these operation of 60 days. Recently, a special mention hasfindings in a larger series, and show that whatever the been added in the French individual health booklet offollow-up in childhood, survival rate with native liver each infant, to inform the parents to check the color ofincreased when age at surgery decreased (Fig 2). To the stools of their infants, and another information cam-evaluate the potential benefits of a realistic mass screen- paign to parents and health professionals is currentlying, we compared the children operated before 46 days underway.25 It is too early to evaluate the benefits ofto the rest of the patients without contraindications to these actions. In other countries, several screeningsurgery. The threshold of 45 days was chosen, because in methods have been proposed.15 Currently, the most sim-many countries the first visit with the pediatrician is at ple and effective method seems to be the stool color card,the end of the first month of life, and in case of suspected introduced by Matsui and Dodoriki26 in Japan, and alsocholestasis, the diagnosis of BA seems realistic in the used in Argentina27 and Taiwan.28 Systematic checkingnext 2 weeks. This comparison showed a 12.1% differ- of stool color before the end of the first month of life isence of 15-year SNL (34.9% vs 22.8%) between the 2 a sensitive method to detect cholestasis. The costs of suchgroups. From our data, a rough estimation showed that a screening program are limited, and are most likelyif the Kasai operation was performed before 46 days in inferior to the savings obtained by the spared LTs; thisevery patient, 4.5 pediatric LTs could be spared each was evaluated in Switzerland by a financial simulationyear, representing 5.7% of all pediatric LTs performed within a project for the executive MBA in managementannually in France. of technology at the Swiss Federal Institute of Technol- What would be the impact of such a pediatric LT- ogy, Lausanne and the University of Lausanne, Switzer-saving policy? Reducing the need for scarce pediatric land (P. Minder, MBA Launch plan for BA screeningliver grafts would shorten the transplantation waiting card, unpublished data, November 2007). A nationallist and reduce the need for living related donors, whose pilot study of such BA screening is under way in Swit-risks cannot be neglected (the morbidity rate of left zerland.lobectomy is estimated at 10%).18,19 The very long-term At the other end of the spectrum, our data also showadverse effects of prolonged immunosuppression are that late Kasai operations (performed after the age of 3still incompletely known, but impaired renal function months) still can help avoid some LTs in infancy and(that may lead to chronic renal failure), dyslipidemia, childhood: 15-year SNL was 13.4% in this subgroup ofdiabetes, and increased risk of malignancy are cer- patients. Therefore, as already emphasized by othertain.20 Delaying transplantation after infancy and avoid- studies, the Kasai operation should not be systematicallying Epstein-Barr virus primary infection in an immuno- denied after 3 months.29–31 Nevertheless, a precise pre-suppressed child might reduce the risk of posttransplant operative checkup is necessary to detect patients withlymphoproliferative disease.21 Today, the results of LT in advanced liver disease (presenting with signs such asadults are close to those in pediatric patients,22 especially ascites, impaired synthetic functions, reversed portalwith diseases that do not recur after LT, such as BA. flow and/or arterial diastolic flow) and orient them to Reducing pediatric LTs would also lead to significant primary LT.financial savings. In France, the estimated first-year costfor LT is 100 000 Euros, and the estimated annual fol- CONCLUSIONSlow-up charges are 20 000 Euros.23 The costs of fol- Increased age at surgery had a progressive and sustainedlow-up of a patient with BA who has not received a deleterious effect on the results of the Kasai operation1284 SERINET et al Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  7. 7. until adolescence. These findings indicate a rational basis 5. Lykavieris P, Chardot C, Sokhn M, Gauthier F, Valayer J,for BA screening to reduce the need for LT in childhood. Bernard O. Outcome in adulthood of biliary atresia: a study of 63 patients who survived for over 20 years with their native liver. Hepatology. 2005;41(2):366 –371ACKNOWLEDGMENTS 6. Chardot C, Carton M, Spire-Bendelac N, Le Pommelet C, Gol-This study was supported by PHRC National 2002 grant mard JL, Auvert B. Prognosis of biliary atresia in the era of liverAOM 02007. The study sponsor had no influence on the transplantation: French national study from 1986 to 1996.study design; the collection, analysis, or interpretation of Hepatology. 1999;30(3):606 – 611 7. Wildhaber B, Coran AG, Drongowski RA, et al. The Kasaidata; the writing of the report; or the decision to submit portoenterostomy for biliary atresia: a review of 27-yearthe article for publication. experience with 81 patients. J Pediatr Surg. 2003;38(10): We thank the pediatricians and surgeons of the 45 1480 –1485centers who participated in our study: Amiens: C. Lena- 8. Shteyer E, Ramm GA, Xu C, White FV, Shepherd RW. Out-erts and J. P. Canarelli; Angers: J. L. Ginies and L. Cou- come after portoenterostomy in biliary atresia: pivotal role ofpris; Besancon: E. Plouvier and D. Aubert; Bondy: J. ¸ degree of liver fibrosis and intensity of stellate cell activation.Gaudelus and C. Grapin; Bordeaux: T. Lamireau and P. J Pediatr Gastroenterol Nutr. 2006;42(1):93–99Vergnes; Brest: L. de Parscau and B. Fenoll; Caen: J. F. 9. Schweizer P, Lunzmann K. Extrahepatic bile duct atresia: howDuhamel and T. Petit; Clermont-Ferrand: M. Meyer and efficient is the hepatoporto-enterostomy? Eur J Pediatr Surg.T. Scheye; Colmar: D. Meyer Gast and S. Geiss; Dijon: 1998;8(3):150 –154F. Huet and E. Sapin; Grenoble: J. P. Chouraqui and J. F. 10. Duche M, Fabre M, Kretzschmar B, Serinet MO, Gauthier F, ´Dyon; Le Havre: B. 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Sequential treat- The example of liver transplantation. Rev Epidemiol Sante Pub- ment of biliary atresia with Kasai portoenterostomy and liver lique. 2001;49(3):259 –272 transplantation: a review. Hepatology. 1994;20(1 pt 2):S41–S48 24. UNOS; UNfOS. Financing Transplantation: What Every Patient 4. Howard ER, MacLean G, Nio M, Donaldson N, Singer J, Ohi R. Needs to Know. Available at: www.transplantliving.org/ Survival patterns in biliary atresia and comparison of quality of sharedcontentdocuments/WEPNTK2008.pdf. Accessed March life of long-term survivors in Japan and England. J Pediatr Surg. 18, 2009 2001;36(6):892– 897 25. Jacquemin E. Screening for biliary atresia and stool colour: PEDIATRICS Volume 123, Number 5, May 2009 1285 Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  8. 8. method of colorimetric scale [in French]. Arch Pediatr. 2007; 29. Davenport M, Puricelli V, Farrant P, et al. The outcome of the 14(3):303–305 older (Ն100 days) infant with biliary atresia. J Pediatr Surg.26. Matsui A, Dodoriki M. Screening for biliary atresia. Lancet. 2004;39(4):575–581 1995;345(8958):1181 30. Azarow KS, Phillips MJ, Sandler AD, Hagerstrand I, Superina27. Ramonet M. Stool Color Cards for Screening for Biliary Atresia. BA RA. Biliary atresia: should all patients undergo a portoenter- Single Topic Conference. Bethesda, MD: National Institutes of ostomy? J Pediatr Surg. 1997;32(2):168 –172 Health; September 12–13, 2006 31. Chardot C, Carton M, Spire-Bendelac N, et al. Is the Kasai28. Chen SM, Chang MH, Du JC, et al. Screening for biliary atresia operation still indicated in children older than 3 months by infant stool color card in Taiwan. Pediatrics. 2006;117(4): diagnosed with biliary atresia? J Pediatr. 2001;138(2): 1147–1154 224 –228 OUR PIGS, OUR FOOD, OUR HEALTH “The late Tom Anderson, the family doctor in this little farm town in north- western Indiana, at first was puzzled, then frightened. MRSA (methicillin- resistant Staphylococcus aureus) sometimes arouses terrifying headlines as a ‘superbug’ or ‘flesh-eating bacteria.’ The best-known strain is found in hos- pitals, where it has been seen regularly since the 1990s, but more recently different strains also have been passed among high school and college ath- letes. The federal Centers for Disease Control and Prevention reported that by 2005, MRSA was killing more than 18 000 Americans a year, more than AIDS. Dr Anderson at first couldn’t figure out why he was seeing patient after patient with MRSA in a small Indiana town. And then he began to wonder about all the hog farms outside of town. Could the pigs be incubating and spreading the disease? One of the first clues that pigs could infect people with MRSA came in the Netherlands in 2004, when a young woman tested positive for a new strain of MRSA, called ST398. The family lived on a farm, so public health authorities swept in—and found that 3 family members, 3 co-workers and 8 of 10 pigs tested all carried MRSA. Since then, that strain of MRSA has spread rapidly through the Netherlands— especially in swine- producing areas. A small Dutch study found pig farmers there were 760 times more likely than the general population to carry MRSA (without necessarily showing symptoms), and Scientific American reports that this strain of MRSA has turned up in 12% of Dutch retail pork samples. Now this same strain of MRSA has also been found in the United States. A new study by Tara Smith, a University of Iowa epidemiologist, found that 45% of pig farmers she sampled carried MRSA, as did 49% of the hogs tested. The study was small, and much more investigation is necessary.” Kristof ND. New York Times. March 12, 2009 Noted by JFL, MD1286 SERINET et al Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011
  9. 9. Impact of Age at Kasai Operation on Its Results in Late Childhood and Adolescence: A Rational Basis for Biliary Atresia Screening Marie-Odile Serinet, Barbara E. Wildhaber, Pierre Broué, Alain Lachaux, Jacques Sarles, Emmanuel Jacquemin, Frédéric Gauthier and Christophe Chardot Pediatrics 2009;123;1280-1286 DOI: 10.1542/peds.2008-1949Updated Information including high-resolution figures, can be found at:& Services http://www.pediatrics.org/cgi/content/full/123/5/1280References This article cites 28 articles, 1 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/123/5/1280#BIBLCitations This article has been cited by 3 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/123/5/1280#otherartic lesSubspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Surgery http://www.pediatrics.org/cgi/collection/surgeryPermissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtmlReprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org. Provided by APHP on February 5, 2011