Improvement in bile drainage after Kasai portoenterostomy with a tailored steroid protocol

Abstract Objectives Postoperative steroids after Kasai portoenterostomy (KPE) for biliary atresia (BA) patients remains controversial. We established a postoperative protocol with selective corticosteroid usage depending on postoperative stool color assessment. Herein, we report outcomes in KPE before and after implementation of our tailored steroid protocol. Methods At our institution, 28 infants underwent KPE between 2015 and 2025. Group A had 16 infants managed without steroids between 2015 and 2021, while Group B included 12 infants managed under the new tailored steroid protocol between 2021 and 2025. Under the new protocol, infants with postoperative stool color ≤3 based on Japanese Tochigi Stool card received corticosteroids and antibiotics for 5 weeks if they were ≤45 days old or >45 days old with acute inflammation on liver biopsy obtained during operation. Postoperative total bilirubin (TB) levels at 3 months, 2‐year native liver survival (NLS), length of stay (LOS) of surgical admission, postoperative reoperations, readmissions, and complications were compared between groups. Results Preoperative liver function tests were similar between groups. The 3‐month post‐KPE TB levels were significantly lower in Group B compared to Group A (0.9 [0.3, 1.9] mg/dL vs. 6.5 [0.6, 10.4] mg/dL, p = 0.036). The 2‐year NLS was also significantly higher in Group B (72.9% vs. 37.5%, p = 0.046). LOS, readmissions, reoperations, and complications in the 90‐day postoperative period were not different between both groups. Conclusions Infants with BA managed with a tailored steroid protocol based on postoperative stool colors and histologic evidence of inflammation had significantly lower 3‐month TB levels and better 2‐year NLS.