The United Kingdom restricts surgery for biliary atresia.

Abstract

Surgical treatment for biliary atresia was developed in Japan by Professor M. Kasai in 1968. The success of this palliative operation, the Kasai procedure, is dependent on many factors, including age at surgery and experience of the surgeon. A British survey (BMJ 1985;290:347-7), reported that the Kasai procedure took place in 16 centres in Britain between 1980 to 1982. They demonstrated that the initial success of this operation, as defined as normalisation of plasma bilirubin, was related not only to age at surgery but to surgical expertise. Their data demonstrated that only centres operating on more than five cases per year had success rates in excess of 50%. Following the publication of this study, the British Department of Health (DOH) advised that surgery for biliary atresia should only be performed at King's College Hospital, London, and The Children's Hospital, Birmingham, where there were established, centrally funded paediatric liver units. Unfortunately, this advice was not heeded and paediatric surgeons continued to carry out biliary atresia surgery locally, leading the DOH to reverse their decision in 1993. A prospective survey designed to evaluate the incidence and long-term outcome of biliary atresia in the British Isles between 1993 and 1995 (McKiernan et al., 1999; in press), found that 10 years later, surgery for biliary atresia was still performed at 15 centres throughout the British Isles. Furthermore, not only was the initial success of the procedure affected but overall survival with or without liver transplantation also was clearly related to the caseload and experience of the centre. Essentially, children who were operated on at more experienced hospitals were four times more likely to survive without liver transplantation than those who were in less-experienced centres. These data were made available to the DOH in 1997, which sought professional advice from the Royal Colleges of Medicine and Surgery. Regrettably these professional bodies, which included the British Association of Paediatric Surgeons, initially rejected the proposal to restrict the number of centres, preventing the DOH from reinstating designation of the Kasai procedure to specialised centres only. Following pressure from paediatric hepatologists, a Parents Support Group, The Children's Liver Disease Foundation, and a media campaign that highlighted the national variation in success rates, the DOH successfully achieved agreement among the relevant parties to restrict biliary atresia surgery to three centres as of April 1999. These centres include King's College Hospital and The Birmingham Children's Hospital as stated previously. A third centre, St. Jame's Hospital, Leeds, will be developed to provide biliary atresia surgery, specialised liver services, and liver transplantation in due course as it was thought important that all children with biliary atresia should have equal access to specialised care. This time the DOH proposal has the support not only of the Royal College of Surgeons but also of the British Association of Paediatric Surgeons, which has appointed Professor Lewis Spitz of Great Ormond Street Hospital to audit the outcome of the surgery carried out at the three centres. It is a sad reflection of today's world that the power of the media is needed to make sensible decisions about medical and surgical services, but let us hope that this enlightened approach will indeed improve survival for children with biliary atresia. Deirdre Kelly, MD, FRCP, FRCPI The Liver Unit; Birmingham Children's Hospital; Birmingham