Biliary atresia: Potential for a new decade

Biliary atresia is characterised as an obliterative cholangiopathy of both extra-and intra-hepatic bile ducts. There is marked aetiological heterogeneity with a number of different variants, some syndromic and others perhaps virally-mediated. Current research aims to try and define possible mechanisms and pathogenesis though an actual breakthrough remains elusive. There has been little in the way of surgical advances beyond subtle variations in the Kasai portoenterostomy and laparoscopic equivalents have no declared advantage and have yet to prove equivalence in measures of outcome. The next target has been to maximise potential with better adjuvant therapy, though the evidence base for most currently available therapies such as steroids and ursodeoxycholic acid remains limited. Still high-dose steroid use is widespread, certainly in Europe and the Far East. Clearance of jaundice can be achieved in 50-60% of those subjected to portoenterostomy at <70 days and should be an achievable benchmark. Transplantation is a widely available "rescue" therapy though whether it should be an alternative as a primary procedure is arguable but becoming increasingly heard. The aim of clinical practice remains to get these infants for surgery as early as is possible though this can be difficult to accomplish in practice, and "low-cost" screening projects using stool colour charts have been limited outside of Taiwan and Japan. Centralisation of resources (medical and surgical) is associated with a diminution of time to portoenterostomy but application has been limited by entrenched health delivery models or geographical constraints.