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Selective Steroid Use After Kasai Portoenterostomy Improves Outcomes in Biliary Atresia

Selective Steroid Use After Kasai Portoenterostomy Improves Outcomes in Biliary Atresia 1024 683 Pam Georgiana

Postoperative protocol is associated with improved bile drainage and higher native liver survival without increased short-term risk.

A new study published in the Journal of Pediatric Gastroenterology and Nutrition provides evidence that a selective, marker-guided approach to postoperative steroid use improves outcomes for infants with biliary atresia following Kasai portoenterostomy. Led by Jaimie D. Nathan, MD, FACS, chief of Pediatric Abdominal Transplant and Hepatopancreatobiliary Surgery at Nationwide Children’s Hospital and professor of surgery at The Ohio State University College of Medicine, the research addresses a long-standing area of debate in pediatric hepatology and surgery.

Biliary atresia remains one of the most challenging neonatal liver diseases. Even with timely Kasai portoenterostomy, nearly half of affected infants require liver transplantation by age 2. Researchers have studied steroids as a strategy to improve bile drainage and preserve native liver function. However, findings have been inconsistent. As a result, postoperative steroid use varies widely, ranging from universal administration to complete avoidance.

“We wanted to determine whether a tailored approach to steroid use could improve outcomes after Kasai portoenterostomy without introducing additional risk,” Dr. Nathan says. “Because existing data do not support routine steroid use for every infant, we focused on identifying those most likely to benefit while avoiding unnecessary exposure.”

The retrospective cohort study included 28 infants who underwent Kasai portoenterostomy at Nationwide Children’s between 2015 and 2025. Sixteen infants treated between 2015 and 2021 served as a historical control group and did not receive steroids. In 2021, Dr. Nathan’s team implemented a selective postoperative steroid protocol guided by early markers of bile drainage and inflammation. Twelve infants received treatment from 2021 to 2025, making up the intervention group.

Dr. Nathan’s team used the Japanese Tochigi Stool Color Card to assess stool color during the first 5 days after surgery. They considered pale stools (score 3 or lower) indicative of poor bile drainage. The team administered steroids to infants with pale stool color if they were younger than 45 days of age at the time of Kasai operation. For infants older than 45 days, the team initiated steroid therapy only if pale stool color was accompanied by evidence of active inflammation on their intraoperative liver biopsy. Infants with stool color scores of 4 or higher did not receive steroids.

“It was important to tailor treatment to patient-specific physiologic indicators rather than apply steroids universally,” Dr. Nathan explains.

The study’s primary outcomes were total bilirubin levels at 3 months and native liver survival at 2 years. Secondary outcomes included length of stay, readmissions, reoperations and short-term complications. Preoperative disease characteristics were similar between the two groups.

Infants treated under the tailored protocol had significantly lower median total bilirubin levels at 3 months compared with the historical cohort (0.9 mg/dl versus 6.5 mg/dl). Two-year native liver survival was also significantly higher in the selective steroid group, at 72.9% versus 37.5%. Importantly, selective steroid use was not associated with increased length of stay, readmissions, reoperations or postoperative complications.

“These findings suggest that steroids can meaningfully improve bile drainage and native liver survival when used strategically,” Dr. Nathan says. “We did not see evidence of increased short-term harm.”

For pediatricians and referring providers, the study reinforces the importance of early diagnosis and referral for Kasai portoenterostomy, including the use of tools such as the Japanese Tochigi Stool Color Card.

“Age at operation remains critical for biliary atresia,” Dr. Nathan says. “Early intervention gives us the best opportunity to optimize bile drainage and avoid early liver transplantation.”

There are several limitations to this study, including the small sample size, retrospective design, and lack of data on growth outcomes. Longer-term follow-up and multi-center studies are needed. Still, these findings add to a growing body of evidence supporting targeted postoperative steroid use as a strategy to balance clinical benefit with potential risk.

 

Reference:

Colak MA, Joshi S, Heinzman C, et al. Improvement in bile drainage after Kasai portoenterostomy with a tailored steroid protocol. J Pediatr Gastroenterol Nutr. 2025; 1-8. doi:10.1002/jpn3.70292.

Credit Image: Adobe Stock

 

 

 

About the author

Pam Georgiana is a brand marketing professional and writer located in Bexley, Ohio. She believes that words bind us together as humans and that the best stories remind us of our humanity. She specialized in telling engaging stories for healthcare, B2B services, and nonprofits using classic storytelling techniques. Pam has earned an MBA in Marketing from Capital University in Columbus, Ohio.

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