Effects of the Infant Stool Color Card Screening

Program on 5-Year Outcome of Biliary

Atresia in Taiwan
Tien-Hau Lien,1 Mei-Hwei Chang,1 Jia-Feng Wu,1 Huey-Ling Chen,1 Hung-Chang Lee,2 An-Chyi Chen,3
Mao-Meng Tiao,4 Tzee-Chung Wu,5 Yao-Jong Yang,6 Chieh-Chung Lin,7 Ming-Wei Lai,8 Hong-Yuan Hsu,1
Yen-Hsuan Ni,1 and the Taiwan Infant Stool Color Card Study Group*

In Taiwan, a screening system using an infant stool color card to promote the early diagno-
sis of biliary atresia (BA) was established in 2002. This study aimed to investigate the
5-year outcome of BA before and after using the screening program. BA patients were
divided into three cohorts according to their birth dates. The patients in cohort A (n 5 89)
were born before the stool card screening program (1990-2000); those in cohort B (n 5
28) were screened by the stool card regional screening program (2002-2003); and those in
cohort C (n 5 74) were screened by the stool card universal screening program (2004-
2005). The relative odds ratios were computed using logistic regression to compare the dif-
ferent factors affecting survival time. The rate of age at Kasai operation <60 days was
49.4% and 65.7% in cohorts A and B1C, respectively (P 5 0.02). The jaundice-free (total se-
rum bilirubin <2.0 mg/dL) rate 3 months after surgery was 34.8% and 60.8% in cohorts A
and B1C, respectively (P < 0.001). The 3-year jaundice-free survival rate with native liver was
31.5% in cohort A and 56.9% in cohort B1C (P < 0.001), whereas the 3-year overall survival
rates were 64.0% and 89.2%, respectively (P < 0.001). The 5-year jaundice-free survival rate
with native liver was 27.3% in cohort A and 64.3% in cohort B (P < 0.001), and the 5-year
overall survival rates were 55.7% and 89.3%, respectively (P < 0.001). Conclusion: The stool
color card screening program for BA allows for earlier Kasai operation, which increases the
jaundice-free rate at 3 months postsurgery. With higher surgical success rates, the 3- and 5-year
outcome of BA patients in Taiwan improves remarkably. (HEPATOLOGY 2011;53:202-208)

B
iliary atresia (BA) is an inflammatory, progres-
sive fibro-sclerosing cholangiopathy of infancy
that variably affects both the extrahepatic and
intrahepatic bile ducts,1,2 resulting in the destruction
and obstruction of the biliary tract.2-4 If untreated, BA
progresses to cirrhosis with portal hypertension and
liver failure leading to death within 2 to 3 years. Since
the Kasai operation was first used for BA in 1959,
there have been encouraging results in treating this dis-
ease such that it has become the first-line treatment. The
Kasai operation can restore bile flow through a recon-
structed hepatic portoenterostomy to a jejunal loop.
Once the cholestasis progresses and/or complications of
liver cirrhosis occur, liver transplantation remains the
salvage way for BA. Although ongoing cholestasis, which
further aggravates liver cirrhosis, is present in most BA
children,5 a successful Kasai operation may still delay or
even decrease the need for liver transplantation.

Abbreviations: BA, biliary atresia; CI, confidence interval; OR, odds ratio.
From the 1Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; the 2Department of Pediatrics, Mackay Memorial Hospital, Taipei,
Taiwan; the 3Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan; the 4Department of Pediatrics, Chang Gung Memorial Hospital-
Kaohsiung Medical Center, Kaohsiung, Taiwan; the 5Department of Pediatrics, Taipei Veterans General Hospital & National Yang Ming University, Taipei, Taiwan;
the 6Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan; the 7Department of Pediatrics, Taichung Veterans General Hospital,
Taichung, Taiwan; and the 8Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Received May 4, 2010; accepted September 22, 2010.
Supported by grants of the Bureau of Health Promotion of the Department of Health, Taiwan (Project No. 9804004A).
The members of the Taiwan Infant Stool Color Card Study Group are: Wan-Hsin Wen (Cardinal Tien Hospital), Chun-Hsien Yu (Taipei City Hospital,
Branch for Women and Children), I-Hsien Lee (Changhua Christian Hospital), Lung-Huang Lin (Cathay General Hospital), Wen-Terng Lin (En Chu Kong
Hospital), Hsiang-Hung Shih (Kaohsiung Medical University), Pi-Feng Chang (Far Eastern Memorial Hospital), Ching-Feng Huang (Tri-Service General
Hospital), I-Fei Huang (Kaohsiung Veterans General Hospital), Chun-Yan Yeung (Mackay Memorial Hospital, Tamshui Branch), Shan-Ming Chen (Chung Shan
Medical University Hospital), and Te-Kuei Hsieh (Hsin Chu General Hospital, Department of Health, Executive Yuan).

202
HEPATOLOGY, Vol. 53, No. 1, 2011
It is generally accepted that the Kasai operation is
more successful in children when performed earlier
than 60 days of age.6,7 The reported successful bile
flow rates were 91%, 56%, 38%, and 17% in
patients receiving an operation before 60 days of age,
at 61-70 days of age, at 71-90 days of age, and
beyond 90 days of age, respectively.8 However, early
identification and timely surgery, which are crucial
for better prognosis, remain challenging.
In Taiwan, a pilot regional study using the infant
stool color card to increase the efficacy of early identifi-
cation of BA was started in 2002. Universal screening
for BA using the infant stool color card was launched
in 2004. This is the first nationwide screening program
for BA using an infant stool color card. The present
study aimed to compare the outcome of the BA patients
after Kasai operation before versus after the launch of
the infant stool color card screening program.
Patients and Methods
Infant Stool Color Card. An infant stool color card
was designed with six photographs of different colored
stool samples from Taiwanese infants. Three colors on
this card were labeled abnormal (clay-colored, pale yel-
lowish, and light yellowish), whereas the other three
were labeled normal (yellowish, brown, and greenish).
Telephone and fax numbers for consultation were also
printed on this card, and parents, guardians, and med-
ical personnel were instructed to inform the stool card
registry center if abnormal stool colors were noticed.
There are professional personnel in the stool card cen-
ter who respond to every related phone call or fax
within 24 hours. Instructions and follow-up were given
to every reported case. In 2002, 47,180 newborns
from 49 hospitals and clinics in northern and central
Taiwan were enrolled. In 2003, the range of coopera-
tion extended to southern and eastern Taiwan, and
72,793 newborns from 96 hospitals were enrolled. In
2004, the universal stool color screening program was
launched, and the stool color card was integrated into
the child health booklet. All neonates born in Taiwan
participated in the screening program since then.
Patients. All of the patients had a diagnosis of BA
made using clinical data, biochemical data, imaging
data, surgical findings, and liver histology. The patients
Address reprint requests to: Mei-Hwei Chang, M.D., Department of Pediatrics, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd., Taipei, 100,
Taiwan. E-mail: changmh@ntu.edu.tw; Fax: (886)-2-23114592.
Copyright VC 2010 by the American Association for the Study of Liver Diseases.
View this article online at wileyonlinelibrary.com.
DOI 10.1002/hep.24023
Potential conflict of interest: Nothing to report.
Additional Supporting Information may be found in the online version of this article.
LIEN ET AL. 203
were divided into three cohorts by their birth date.
The historical control cohort was derived from the 96
cases diagnosed as BA at the National Taiwan Univer-
sity Hospital from January 1990 to December 2000.
Five patients who did not receive Kasai operation and
two patients who underwent Kasai operation but were
not followed up for at least 3 years postoperatively
were excluded. The remaining 89 patients became
cohort A. All of these patients were followed up for at
least 5 years, except one patient who was followed up
for only 3 years postoperatively. Cohort A represented
patients born before the stool card screening program.
There were 29 BA patients born between 2002 and
2003. One patient who did not receive Kasai opera-
tion was excluded. The other 28 patients who were
followed up for at least 5 years postoperatively were
enrolled in cohort B, which represented the period of
the regional pilot study of the stool card screening pro-
gram in Taiwan.
Seventy-five BA patients were born between 2004
and 2005. After excluding one patient without Kasai
operation, the 74 patients who were followed up for at
least 3 years postoperatively were enrolled in cohort C, which
represented the nationwide screening data in Taiwan. Cohort
BþC was the merged data of cohorts B and C and repre-
sented the era of the stool color card screening program.
Statistical Methods and Data Analysis. Statistical
analyses were performed using Stata software (Stata-
Corp LP, College Station, TX). A chi-square test was
used to compare categorical variables, including age at
Kasai operation <60 days, jaundice-free rates at 3
months after Kasai operation, 3- and 5-year survival rates
with native liver, 3- and 5-year jaundice-free survival rates
with native liver, and 3-year and 5-year overall survival
rates between different cohorts. Overall survival included
those patients who survived with either their native liver
or a transplanted liver. Jaundice-free was defined as total
serum bilirubin <2.0 mg/dL (34 lmol/L).
Quality outcome was defined as jaundice-free sur-
vival with native liver. All survival time was calculated
after the date of the Kasai operation. Relative odds
ratios were computed using logistic regression models
to compare the different factors affecting survival time.
The Kaplan-Meier method and a log-rank test were
also used to assess factors affecting survival. P < 0.05
was considered statistically significant.
204 LIEN ET AL. HEPATOLOGY, January 2011

From 1990 until now, there was no systemic change Table 1. General Characteristics and Outcomes in Cohort A
in post-Kasai operation care except for the concept of versus Cohort B1C
prophylactic antibiotics use in Taiwan. Since 1997, Cohort A Cohort B1C
most patients have been prescribed with prophylactic (n 5 89)* (n 5 28 1 74)y P Value

antibiotics after operation. The data of the use of pro- Male sex 38 (42.7) 56 (54.9) 0.09
phylactic antibiotics are collected by chart review, and Age
60 days at 44 (49.4) 67 (65.7) 0.02
Kasai operation
this possible confounding factor is taken into consider- Jaundice-free‡ 31 (34.8) 62 (60.8) <0.001
ation for analyses. The regimen of prophylactic antibi- 3 months after
otics is trimethoprim-sulfamethoxazole (TMP-SMZ, 7 Kasai operation
Survival
days per week) or neomycin (4 days per week). Our 3-year SNL 46 (51.7) 63 (61.8) 0.16
previous study reveals the superior effect of using pro- 3-year JFSNL 28 (31.5) 58 (56.9) <0.001
phylactic antibiotic versus not using it, and the equal 3-year OS 57 (64.0) 91 (89.2) <0.001
5-year SNL 33 (37.5)§ 18 (64.3)|| 0.01
effect for the prophylaxis of cholangitis between the
5-year JFSNL 24 (27.3)§ 18 (64.3)|| <0.001
two antibiotic regimens.9 5-year OS 49 (55.7)§ 25 (89.3)|| <0.001

Data are expressed as No. (%).

Results
Comparisons of Cohort A versus Cohort
(B1C). There was no significant difference in the sex
distribution between cohort A and cohort (BþC). The
rates of Kasai operation performed before 60 days of
age were 49.4% in cohort A and 65.7% in cohort
BþC (P ¼ 0.02). At 3 months after Kasai operation,
the jaundice-free rate was significantly higher in cohort
BþC than in cohort A (60.8% versus 34.8%; P <
0.001). The 3-year survival rates with native liver in
cohort A and cohort BþC were 51.7% and 61.8%,
respectively. The 3-year jaundice-free survival rate with
native liver was significantly higher in cohort BþC
than in cohort A (56.9% versus 31.5%; P < 0.001).
The 3-year overall survival rate was 64.0% in cohort A
and 89.2% in cohort BþC (P < 0.001).
The 5-year follow-up was not yet finished in cohort
C; therefore, only cohort B was compared with cohort
A in the analyses of 5-year survival time. The 5-year
survival rates with native liver in cohorts A and B were
37.5% and 64.3%, respectively (P ¼ 0.01). The
5-year jaundice-free survival rate with native liver was
significantly higher in cohort B than in cohort A
(64.3% versus 27.3%; P < 0.001) and the 5-year
overall survival rates were 89.3% and 55.7%, respec-
tively (P < 0.001).
However, 15 cases in cohort BþC, despite their
birth after the launch of the stool card screening pro-
gram, were not successfully screened using the stool
card. In order to clearly demonstrate the effect of the
stool card screening program, we further analyzed the
outcome by redividing our total cases from 1990 to
2005 into two groups for comparison: one group rep-
resenting BA children without the screening program
or not screened out by the stool card, the other group
representing BA children who benefited from stool
Abbreviations: JFSNL, jaundice-free survival with native liver, OS, overall sur-
vival; SNL, survival with native liver.
*Includes patients born before the institution of the stool color card screen-
ing program (1990-2000).
†The data of cohort B and cohort C were merged to represent the outcomes
in the era of the stool color card screening program. Cohort B (n ¼ 28)
includes patients born during the regional study of the stool color card screen-
ing program (2002-2003). Cohort C (n ¼ 74) includes patients born after the
launch of the nationwide study of the stool color card screening program
(2004-2005).
‡Total serum bilirubin <2.0 mg/dL.
§One patient was lost to follow-up. Only 88 patients completed the 5-year
follow-up.
||
Only cohort B (n ¼ 28) was followed up for more than 5 years and
calculated in this data.
card screening (Supplement Table 1). The results are
similar to the comparisons of cohort A and cohort
BþC (Table 1).
Jaundice-Free at 3 Months After Kasai Opera-
tion. Logistic regression analyses revealed that patients
who underwent Kasai operation before 60 days of age
had a higher jaundice-free rate at 3 months after sur-
gery compared with those who underwent surgery after
60 days of age (odds ratio [OR] 2.62; P ¼ 0.001)
(Table 2). Patients born in the stool card screening era
(cohort BþC) had a significantly higher jaundice-free
rate at 3 months postsurgery than patients born before
the screening era (cohort A) (OR 2.90; P < 0.001).
Survival with Native Liver The 3-year survival
rates with native liver in patients who received Kasai
operation before 60 days of age and after 60 days of
age were 64.9% and 46.3%, respectively (OR 2.15;
95% confidence interval [CI] 1.19-3.86; P ¼ 0.01).
The 5-year survival rates with native liver in patients
who underwent surgery before 60 days old and after
60 days old were 55.0% and 32.1%, respectively (OR
2.58; 95% CI 1.21-5.50; P ¼ 0.01). The 3-year sur-
vival rates with native liver in patients who were and
were not jaundice-free at 3 months after Kasai
HEPATOLOGY, Vol. 53, No. 1, 2011 LIEN ET AL. 205

Table 2. Factors Affecting Jaundice-Free Status 3 Months liver than patients who received an operation after 60
After Kasai Operation in Patients with BA days of age (OR 3.25, P < 0.001 and OR 2.63, P ¼
Jaundice-Free* 3 Months 0.02, respectively). Patients who had used prophylactic
After Kasai Operation OR (95% CI) P Value antibiotics had better 3- and 5-year jaundice-free sur-
Age at Kasai operation 0.001 vival with native liver than patients who had not (OR

60 days 65/111 (58.6%) 2.62 (1.45-4.76) 3.03, P ¼ 0.009 and OR 2.79, P ¼ 0.01, respectively).
>60 days 28/80 (35%) 1.00
Stool card program <0.001 Moreover, patients who were jaundice-free at 3 months
Cohort BþC† 62/102 (60.8%) 2.90 (1.61-5.23) postsurgery had better 3- and 5-year jaundice-free sur-
Cohort A ‡ 31/89 (34.8%) 1.00 vival with native liver than those who were not jaun-
*Total serum bilirubin <2.0 mg/dL. dice-free (OR 39.34, 95% CI 17.00-97.06, P < 0.001
†The data of cohort B and cohort C were merged to represent the outcomes and OR 21.43, 95% CI 7.90-58.16, P < 0.001, respec-
in the era of the stool color card screening program. Cohort B (n ¼ 28)
includes patients born during the regional study of the stool color card screen-
tively). Sex did not affect outcome. Intervention by the
ing program (2002-2003). Cohort C (n ¼ 74) includes patients born after the stool card screening program, Kasai operation before 60
launch of the nationwide study of the stool color card screening program days of age, the use of prophylactic antibiotics, and
(2004-2005). jaundice-free at 3 months postsurgery were the predic-
‡Cohort A (n ¼ 89) includes patients born before the institution of the stool
color card screening program (1990-2000). tors of quality outcome for BA patients.
Overall Survival. Cohort BþC had better 3- and
5-year overall survival rates than cohort A (OR 4.64,
operation were 84.9% and 30.6%, respectively (OR P < 0.001 and OR 6.63, P ¼ 0.003, respectively)
12.79; 95% CI 6.27-26.08; P < 0.001). The 5-year (Figs. 1 and 2; Table 4). Patients who had used pro-
survival rates with native liver in patients who were phylactic antibiotics had better 3- and 5-year overall
and were not jaundice-free at 3 months postsurgery survival rates than those who did not (OR 5.33, P <
were 77.6% and 19.4%, respectively (OR 14.35; 95% 0.001 and OR 6.31, P < 0.001, respectively). Those
CI 5.81-35.43; P < 0.001). who were jaundice-free at 3 months after Kasai oper-
Jaundice-Free Survival with Native Liver. Jaun- ation had better 3- and 5-year overall survival rates
dice-free survival with native liver was considered as than those who were not jaundice-free (OR 11.15, P
quality outcome. Cohort BþC had higher rates of < 0.001 and OR 10.85, P < 0.001, respectively).
3- and 5-year jaundice-free survival with native liver
than cohort A (OR 2.87, P ¼ 0.001, and OR 4.80,
P ¼ 0.001, respectively) (Table 3). Patients who
Discussion
received Kasai operation before 60 days of age had Biliary atresia (BA) is an obliterative cholangiopathy
better 3- and 5-year jaundice-free survival with native of unknown etiology. It is the most common cause of

Table 3. Jaundice-Free Survival with Native Liver in Patients with BA

3-Year Jaundice-Free* 5-Year Jaundice-Free
Survival with Native Liver OR (95% CI) P Value Survival with Native Liver OR (95% CI) P Value

Age at Kasai operation <0.001 0.02

60 days 63/111 (56.8%) 3.25 (1.76-6.00) 28/60 (46.7%) 2.63 (1.19-5.78)
>60 days 23/80 (28.8%) 1.00 14/56 (25%) 1.00
Stool card program 0.001 0.001
Cohort BþC† 58/102 (56.9%) 2.87 (1.58-5.21) 18/28 (64.3%) 4.80 (1.94-11.86)
Cohort A‡ 28/89 (31.5%) 1.00 24/88 (27.3%) 1.00
Prophylactic antibiotics 0.009 0.01
Used 70/132 (53.0%) 3.03 (1.56-5.88) 30/65 (46.2%) 2.79 (1.25-6.20)
No use 16/59 (27.1%) 1.00 12/51 (23.5%) 1.00
Sex 0.44 0.58
Male 45/94 (47.9%) 1.25 (0.71-2.22) 21/54 (38.9%) 1.24 (0.58-2.65)
Female 41/97 (42.3%) 1.00 21/62 (33.9%) 1.00

*Total serum bilirubin <2.0 mg/dL.

†The data of cohort B and cohort C were merged to represent the outcomes in the era of the stool color card screening program. Cohort B (n ¼ 28) includes
patients born during the regional study of the stool color card screening program (2002-2003). Cohort C (n ¼ 74) includes patients born after the launch of the
nationwide study of the stool color card screening program (2004-2005).
‡Cohort A (n ¼ 89) includes patients born before the institution of the stool color card screening program (1990-2000). Only 88 patients completed the 5-year
follow-up.
206 LIEN ET AL. HEPATOLOGY, January 2011

Fig. 1. The 5-year overall survival rates in cohort B (dotted line), which Fig. 2. The 5-year overall survival rates in subjects who were jaun-
represents the era of stool color card screening program, and in cohort A dice-free (dotted line) versus those who were not jaundice-free (solid
(solid line), which represents the era before the stool color card screening line) at 3 months after Kasai operation was 89.8% and 44.8%,
program, were 89.3% and 55.7%, respectively (P ¼ 0.002). respectively (P < 0.001).

end-stage liver disease in children, with an incidence of
0.51 per 10,000 in France,10 0.60 per 10,000 in the
United Kingdom,11 0.70 per 10,000 in Sweden,12 and
0.85 per 10,000 in North America.12 There is a higher
incidence in Asia, including 1.04 per 10,000 in
Japan13,14 and 1.78 per 10,000 in Taiwan.7 Taiwan is
one of the areas with the highest incidence in the world.
Kasai operation is the primary surgical therapy for
BA, even in the era of liver transplantation.15 Survival
of BA patients with their native liver relies mainly on
the success of the Kasai operation,16 which is correlated
with age at surgery.13 In the Swiss national study,12 4-
year survival with native liver is 75% in patients who
receive the Kasai operation before 46 days, 33% in
patients receiving the operation between 46 and 75
days, and 11% in patients receiving the operation after
75 days (P ¼ 0.02). In long-term follow-up, the 20-
year survival with native liver is significantly better in
patients who receive the operation before the age of 90
days than in those who receive it after 90 days (28%
versus 13%; P ¼ 0.006).5 In the current study, patients
who underwent Kasai operation before the age of 60
days had significantly better survival with native liver
than those receiving the operation after 60 days of age.
The earlier age at Kasai operation is indeed an im-
portant predictive factor of better long-term survival
with native liver. For early diagnosis of BA, the stool
card screening program was started in Taiwan in re-
gional areas in 2002 and extended nationwide in
2004. The rate of children with Kasai operation before
60 days of age significantly improved in the stool card
screening era.

Table 4. Overall Survival with or Without Liver Transplantation in Patients with BA

3-Year Overall Survival OR (95% CI) P Value 5-Year Overall Survival OR (95% CI) P Value

Age at Kasai operation 0.30 0.15

60 days 89/111 (80.2%) 1.44 (0.73-2.85) 42/60 (70%) 1.75 (0.81-3.76)
>60 days 59/80 (73.8%) 1.00 32/56 (57.1%) 1.00
Stool card program <0.001 0.003
Cohort BþC* 91/102 (89.2%) 4.64 (2.17-9.94) 25/28 (89.3%) 6.63 (1.86-23.60)
Cohort A† 57/89 (64.0%) 1.00 49/88 (55.7%) 1.00
Prophylactic antibiotics <0.001 <0.001
Used 115/132 (87.1%) 5.33 (2.60-10.92) 53/65 (81.5%) 6.31 (2.75-14.48)
No use 33/59 (55.9%) 1.00 21/51 (41.2%) 1.00
Sex 0.28 0.32
Male 76/94 (80.9%) 1.47 (0.74-2.91) 37/54 (68.5%) 1.47 (0.68-3.16)
Female 72/97 (74.2%) 1.00 37/62 (59.7%) 1.00

*The data of cohort B and cohort C were merged to represent the outcomes in the era of the stool color card screening program. Cohort B (n ¼ 28) includes
patients born during the regional study of the stool color card screening program (2002-2003). Cohort C (n ¼ 74) includes patients born after the launch of the
nationwide study of the stool color card screening program (2004-2005). Only cohort B was followed up longer than 5 years and calculated in 5-year survival
analyses.
†Cohort A (n ¼ 89) includes patients born before the institution of the stool color card screening program (1990-2000). Only 88 patients completed the 5-year
follow-up.
HEPATOLOGY, Vol. 53, No. 1, 2011
The 3-year survival rate with native liver in the era
before the stool card screening program was 51.7%,
which increased to 61.8% in the stool card screening
era (Table 1). Why is this improvement not as evident
as expected? Persistent and/or progressive jaundice is
usually the first alarm of impaired bile flow and pro-
gressive liver cirrhosis. In the years before the stool
card screening program, the skills and care involved in
liver transplantation were not as fully developed as
they are now. Moreover, the concept of a living-related
donor had not yet been accepted by the general popu-
lation. The requirement and timing of liver transplan-
tation was therefore more conservative and delayed.
Some patients, however, lived with their native liver
despite severe jaundice-related complications.
In the era of the stool card screening program, liver
transplantation has become more polished and has
gained more social acceptance. Pediatricians and sur-
geons in recent years have preferred to choose an
appropriate but earlier timed liver transplantation for
those patients with persistent jaundice, before many
complications occur. Hence, the 3-year survival rate
with native liver in the stool card screening era is only
slightly better than that of the era without screening.
As time goes by, fewer and fewer patients can survive
without transplantation if their jaundice is persistent.
In the analyses of 5-year survival with native liver,
those born in the stool card screening era already show
significantly better results.
We believe that jaundice-free survival rate with native
liver can reflect the true outcome of BA without the in-
terference of liver transplantation during time change.
Our study defined patients who had jaundice-free sur-
vival with native liver as a quality outcome. In our anal-
yses, we found that use of the stool card screening pro-
gram and Kasai operation before 60 days of age both
contribute to quality outcome in BA patients.
In the study by Shneider et al.,17 jaundice-free at 3
months after Kasai operation is an excellent predictor
of 2-year survival with native liver. In the current
study, patients who were jaundice-free at 3 months
postsurgery had significantly higher survival rates with
native liver and overall survival rates, as well as more
quality outcome in both the 3- and 5-year analyses.
Jaundice-free at 3 months after Kasai operation can be
an indicator for successful surgery and a valuable pre-
dictor of 5-year outcome. In the analyses here, jaun-
dice-free at 3 months after surgery is significantly cor-
related with the implementation of the stool card
screening program and earlier age at surgery.
Although the timing of abnormal stool presented is
different in each case of biliary atresia, the stool color
LIEN ET AL. 207
card alerts the parents, medical personnel, and guardi-
ans to find BA patients and send them for Kasai oper-
ation earlier when their hepatic damage is milder. Our
data indeed supports that BA patients born in the era
of stool card screening program have significantly bet-
ter quality outcome than those born before the era.
Overall survival is significantly better in the era of
the stool card screening program. Other studies show
that the better the results of the Kasai operation, the
better the overall survival.16,18 Although more devel-
oped transplantation techniques in the stool card
screening era partly contribute to survival, the need for
liver transplantation still adds risk to impair the prog-
nosis. Successful Kasai operation still provides patients
with the best chance of survival, and every effort
should be made to improve its results.16 The stool
card screening program is a step in this direction,
because it efficiently increases the success rate of Kasai
operation and contributes to better overall survival.
The 5-year survival rate with native liver and 5-year
overall survival rate in other studies range from 30.1%
to 59.7% and from 75.5% to 85%, respectively.13,19,20
In Taiwan, these rates are 64.3% and 89.3%, respec-
tively (Table 1). This corroborates the promising results
of intervention using the stool card screening program.
In conclusion, the stool card screening program for
BA enhances early Kasai operation and increases the
jaundice-free rate at 3 months postsurgery, which is a
valuable predictor of 5-year outcome. In Taiwan, the
infant stool color card screening program has markedly
improved the 5-year outcome of BA patients.
Acknowledgments: We appreciate the valuable con-
tribution of the members of the Taiwan Infant Stool
Color Card Study Group and thank Li-Chin Fan,
Cheng-Hui Hsiao, Yu-Ru Tseng, and Szu-Ta Chen for
assistance in preparing this article.
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