Kasai Procedure - Surgery, Operation, Scar, Recovery & Care

Kasai Procedure

Treatment Duration

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3 Hours

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4 Hours

Treatment Cost

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2,00,000

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4,00,000

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Kasai Procedure

The Kasai procedure treats Biliary atresia, a birth defect (congenital disorder) that can lead to liver cirrhosis or failure. A 2019 study by Ramachandran et al. showed successful Kasai procedures among 44% of children under 3 months and 29% over 3 months. It significantly improves liver functioning and prevents immediate liver failure in infants.

Parents often get concerned about surgical factors like the Kasai procedure scar, surgery benefits, risks, and cost. Have concerns or seek guidance about the best treatment for a child? Then, continue reading to learn about the surgery, cost, benefits and risks to make an informed decision.

Procedure Name

Kasai Procedure

Alternative Name

Hepatoportoenterostomy, Kasai Portoenterostomy

Conditions Treated

Biliary Atresia (Type I, IIa, IIb, and III)

Benefits of Procedure

Improves Liver Function, Life Saving

Treated By

Surgical Gastroenterologist

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What is Kasai Procedure?

Biliary Atresia (BA) affects the bile ducts, leading to a blocked or absent bile flow from the liver to the gallbladder and small intestine. During the surgery, a surgeon creates a new pathway for bile drainage by connecting the liver directly to the small intestine.

This bypasses the blocked or missing bile ducts, allowing bile to flow more freely and improve liver function. The doctor replaces the damaged duct with a segment of the child's small intestine. This segment is joined to the liver. It acts as a new extrahepatic bile duct system.

What is Kasai procedure

Anatomy and Physiology of the Hepatobiliary System

The biliary system helps with digestion. It makes and stores bile, which breaks down fats. Bile has water, electrolytes, cholesterol, acids, and pigments.

The main organs of the hepatobiliary tract include:

  1. The Liver is the largest organ in the biliary system, producing bile to break down and absorb lipids in the small intestine. Hepatocytes break down red blood cells to produce bile.
  2. The gallbladder is a small, elongated, pear-shaped organ below the liver. It stores and concentrates bile, released into the small intestine when needed.
  3. Hepatic Ducts are responsible for collecting and storing bile. The right and left ducts combine to form the common hepatic duct for liver drainage.
  4. The Cystic Duct joins the common hepatic duct to the gallbladder, forming the common bile duct.
  5. Common Bile Duct transports bile from the liver and gallbladder to the small intestine.
  6. The Sphincter of Oddi controls the release of bile and pancreatic juices into the digestive tract.
  7. Pancreatic Duct carries digestive enzymes into the duodenum. It often shares an opening with the common bile duct called the Ampulla of Vater.
  8. The Duodenum is the beginning area of the small intestine where bile and pancreatic enzymes facilitate digestion and nutrient absorption, particularly fats. 
  9. The Small Intestine is where the released bile emulsifies fat and promotes absorption.

Anatomy of the Hepatobiliary System

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Signs Indicative of Biliary Atresia

Kasai operation is done for newborn babies. This procedure helps in managing biliary atresia among newborns. Usually, surgeons recommend the surgery if the baby is diagnosed with BA within 2-6 weeks after birth.

The common indications implying the need for treatment include:

  1. Persistent Jaundice: The first sign of the condition is excessive bile juice release, causing the baby's skin and nails to turn yellow. If this symptom worsens and cannot be managed, it may indicate BA.
  2. Pale/White Stools: Since the bilirubin release is impaired in the condition. The intestinal region gets minimal to no bilirubin. It leads to discolouration or changes in stool appearance among newborns.
  3. Dark-Coloured Urine: Excessive bilirubin in the bloodstream causes extensive urine yellowing. This is also an indication of worsening jaundice or BA.
  4. Swollen Belly: The reversed movement of bile to the liver instead of the abdomen causes digestive issues and stomach inflammation.
  5. Enlarged Liver: As the flow of bile acid is impaired in BA, it leads to the accumulation of the bile in the liver. Thus causing an extensive increase in its size (hepatomegaly) and facilitating liver diseases like cirrhosis.
  6. Enlarged Spleen: If the fluid pressure increases between the hepatic veins (portal hypertension), it increases spleen size (splenomegaly).

Signs indicative of biliary Atresia

Types of Biliary Atresia Treated with Kasai Procedure

The Kasai procedure done for BA is considered its primary treatment modality. As per the Japanese Association of Paediatric Surgery, the condition is classified into three grades:

  1. Type I: The common bile duct is damaged, causing bile flow obstruction.
  2. Type II a & b: The impairment can be restricted to the common hepatic duct (Type IIa). Obliteration can extend to the common bile duct, hepatic duct, and cystic duct (Type IIb).
  3. Type III: This is the most common type of BA. It extensively damages the common bile, hepatic, and cystic ducts, leaving no adjacent duct for linkage.

Sometimes, there are various complexities detected with biliary atresia. It includes polysplenia (multiple small spleens), asplenia (absence of spleen), malrotation (abnormal positioning of small intestine) and heart defects. If any or all of these conditions are present, the condition is known as biliary atresia-splenic malformation syndrome (BASM).

Kasai Procedure for Biliary Atresia

Benefits of Kasai Surgery

The operation focuses on improving the bile flow and enhancing liver function. Are you curious about the other advantages of the treatment? Here are the prominent benefits of the surgery.

  1. Improved Bile Flow: After the procedure, the bile gets transmitted to the abdomen by bypassing the baby's small intestine. This overcomes the issue of imbalanced biliary movement.
  2. Better Digestion: The technique allows appropriate metabolic movement and bile transfer, which promotes digestive activity.
  3. Enhanced Liver Function: Khayat et al., 2021 showed that among 23 patients in their study, 56% were able to survive with their native liver. This implies that the need for liver transplants was reduced after the surgery.
  4. Improved Quality of Life: Early treatment of biliary atresia can prevent impaired liver function and enhance the standard of living. The progression of this congenital disorder can become a reason for poor growth and fatal diseases like liver cirrhosis.
  5. Treatment Accuracy: Technological advancements have made the procedure more precise and effective. The laparoscopic technique is minimally invasive, reducing surgery complexities.

Benefits of Kasai Surgery

Expectations Before and On the Day of Kasai Procedure

Every patient carries certain doubts regarding what happens throughout the surgery. This section sheds light on the expected surgical preparation before and on the day of the surgery.

Before the Kasai Surgery

Before any surgical process, the healthcare team abides by a protocol to ensure the patient's overall safety.

Benefits of Kasai Procedure

On the day of the Kasai Procedure

On the day of surgery, the patient can be expected to undergo the following. Check the

How is Kasai Surgery Performed?

The purpose of the surgery is to create a passage to allow the bile to drain directly from the liver into the small intestine, bypassing the gallbladder and the various ducts. The doctor will:

  1. Patient Positioning: Generally, a dorsal decubitus (lying on the back) on an elevated surface. This allows improved accessibility to the surgical site.
  2. Incision: In an open surgery, the doctor makes a cut (2-3 cm in size) on the upper right abdominal region for bile system assessment. However, in laparoscopic surgery, the cuts are smaller (keyhole size).
  3. Cholangiogram: It is used for the diagnosis of biliary atresia. The doctor uses X-rays and medication to locate the bile ducts. It also detects if the ducts are blocked along with the gallbladder.
  4. Damaged Ducts Excision: Remove the damaged bile ducts and abnormal gallbladder outside the liver.
  5. Bypassing Through Small Intestine: The patient's small intestine replaces the ducts. It bypasses the liver and drains directly to the duodenum.
  6. Closing Wound Site: The liver is placed back into the abdominal cavity, and the surgical site is sutured (stitched or glued).

After the Kasai Operation

The aftercare provided and the at-home management strategies prescribed after surgery plays a significant role in patient recovery. Let’s explore the common care guidelines followed in the hospital before discharge and home remedies to abide after hospital release.

In Hospital Recovery

After the surgery, the healthcare professionals ensure the delivery of overall postoperative care. The standard care protocol includes the following:

  1. Wound Dressing: The surgical site is covered with dressings after suturing. Appropriate wound management is important for infection prevention and enhanced recovery. 
  2. Drainage: A urinary catheter is inserted to drain urine and measure output. Place an abdominal drain to remove excess fluid and blood from the liver.
  3. Transfer: The baby will be moved to the recovery area.
  4. Feeding: The parent will not be allowed to feed the baby for 48 to 72 hours. A nasogastric tube is attached from the baby's nose into the stomach and provides necessary nutrition.
  5. Medications: Pain-relieving medicines are provided through the nasogastric tube during the surgery. Antibiotics are administered intravenously (IV) for three to five days.
  6. Fluid Management: IVs administer fluids and blood products to balance the body's salt, sugar, and water levels.
  7. Discharge: The baby is released from home after seven to ten days, depending on the baby's recovery. 

In Hospital expectation for Kasai Procedure

At Home Recovery

It is important to abide by the surgeon's instructions after discharge from the hospital. Some general aspects to consider during at-home recovery are:

  1. Weight Monitoring: Parents are asked to weigh the baby weekly to monitor its growth appropriately. 
  2. Physiological Attention: Regularly assess the baby's temperature, stool, urine, and general health for signs of infection and jaundice. 
  3. Wound Management: Clean the surgical area as instructed by the doctor. 
  4. Medicine Administration: Administer medications such as antibiotics, vitamins, steroids, etc., based on the baby's condition and the doctor's prescription.

At home recovery after Kasai procedure

First Follow-Up Appointment

The first follow-up appointment is usually scheduled two weeks after hospital discharge to monitor liver function and growth.

The baby should also see a gastroenterologist and paediatric surgeon. Post-surgery, the patient should visit their doctor for five years to monitor the liver.

During the first follow-up visit, the patient can expect:

  1. Physical Assessment: This includes evaluating the abdominal region to detect fluid accumulation or tenderness. Along with the abdominal area, the surgeon also checks the vitals, like body temperature, heart rate, respiration, and more.
  2. Surgical Site Evaluation: The surgeon assesses the surgical wound to detect any abnormality or infection development around it.
  3. Seeking Parent's Feedback: General feedback about the recovery observed and the current hepatic functioning of the baby. It includes a discussion of an infant's stool patterns, urine colour and amount, digestive function, and any potential complications like dizziness, redness, pain, etc.
  4. Blood Tests:  To detect the body's hepatic functioning and bile flow, these tests are prescribed in the first follow-up.
  5. Ultrasound: Another important aspect of the Kasai procedure is its scar (hepatic fibrosis), which suggests damage progression. Thus, this test is used to measure the size of the scarring and ensure good hepatic recovery.

Risk of Kasai Procedure

Like any other surgical procedure, the congenital disease treatment poses specific adverse healthcare indications. The prominent risks of the Kasai procedure include:

  1. Wound Infection: The most common early complication can be treated with oral antibiotics or additional care.
  2. Cholangitis: A bile duct infection can cause fever and jaundice when bile flows through the liver-bowel connection.
  3. Scarring: Hepatic fibrosis is a progressive complication that can lead to complete hepatic failure. The worsening of this complication can lead to severe conditions like cirrhosis.
  4. Ascites: It is a rare post-surgical risk associated with excessive lymphatic fluid release in the abdominal cavity. This leads to the development of Chylous ascites and can be managed through diuretics.
  5. Procedure Failure: The procedure may fail after three months, leading to symptom recurrence and potential damage. In such cases, a liver transplant would be necessary. However, Gunadi et al. (2018) showed a success rate of 58%, allowing patients to live fully. Ensuring patient safety and process efficacy is crucial.

Risk of Delayed Kasai Surgery

Early treatment of congenital issues like BA can enable newborns to live their lives to the complete capacity. The significance of the surgery can also be understood by knowing the complexities related to a delayed treatment. The most prominent risks are listed below:

  1. Reduced Procedure Success: Studies have shown that the procedure is more effective within three months of the baby's birth. The complications associated with the surgery increase significantly if it is prolonged.
  2. Obstructed Bile Flow: BA progression in infants is linked to restricted bile transmission, worsening jaundice symptoms, and causing cirrhosis and cholangitis.
  3. Restricted Growth: Impairment of the biliary tract becomes the reason for poor digestion and nutrition absorption. Thus limiting the infant's growth and increasing hepatic damage.
  4. Liver Transplant: Progressive BA with no early treatment can necessitate transplantation to ensure survival. Early Kasai surgery can limit liver damage and reduce the chances of performing a transplant.

Risk of Delay in kasai surgery

When is Consultation with the Doctor Needed?

Contact your surgeon immediately if you observe signs of infection or liver dysfunction after surgery, such as:

  1. High Fever: If the baby shows persistently increased body temperature (above 100 F).
  2. Surgical Site Infection: The wound may exhibit redness, pain, or discharge, indicating an infectious reaction.
  3. Dizziness: If the newborn seems confused or disoriented with frequent fainting incidents. Then, it can be an emergency to consult a doctor.
  4. Pain: Constant and unbearable discomfort in the abdominal region or surgical site is another indication to be concerned about.

  5. Bleeding: Unexplainable bleeding from the surgical site, stools, or vomit.
  6. Irregular Bowel Movement: The absence of a bowel movement or watery stools (diarrhoea) for more than three days is a concerning symptom. Another indication includes white or pale-coloured stools.
  7. Recurring Symptom: Recurrent or worsening jaundice. This can imply the failure of the surgery and requires immediate attention.

Estimated Cost of Kasai Operation

The cost of Kasai Procedure ranges from ₹2,00,000 to ₹4,00,000. The cost varies based on factors like the type of surgery (open or laparoscopic), the patient's condition and the chosen location, hospital, and surgeon.

Procedure Name

Cost Value

Kasai Procedure

₹2,00,000 to ₹4,00,000

Takeaway

The Kasai procedure is crucial for babies with biliary atresia as it reduces liver damage and may eliminate the need for future transplantation. However, post-surgery care and consulting a doctor for any concerning symptoms are essential.

Have concerns about how to proceed further? HexaHealth is here to provide a trustworthy solution for your baby's treatment journey. Our expert panel of doctors and consultants can assist you throughout the surgery, including guidance on insurance claims and health loans. Contact us now for assistance.

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Frequently Asked Questions (FAQ)

It is a paediatric surgery for biliary atresia. It focuses on restoring proper bile flow and promotes natural liver functioning. The surgery includes bypassing bile directly into the small intestine to avoid duct blockage.

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The Kasai surgery is done when a baby is diagnosed with biliary atresia. It is a condition in babies where the bile gets blocked from flowing to the small intestine.

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A Kasai procedure is a form of surgery that removes the damaged bile ducts from the bottom of the liver. This restores bile flow through the liver using a small intestine portion.

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It is the primary treatment modality for a birth defect called Biliary Atresia. It leads to a congenital disability of the bile ducts, causing issues like jaundice, swollen belly, and digestion. If not treated timely, it can increase hepatic damage, resulting in liver cirrhosis and complete failure.

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Kasai surgery is the primary treatment available for BA. It is an early surgical intervention which promotes effective hepatic functioning. If the procedure is not done timely or fails, then the baby may require liver transplantation.

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According to research by Redkar et al., 2017 with 121 patients, the overall survival rate was almost 43% with native liver. The study also highlighted that 83% of patients showed no symptoms of jaundice after the operation.

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Some of the complications of the Kasai surgery include: 

  1. Bleeding 

  2. Intestinal Infection or Cholangitis

  3. Hepatic Fibrosis

  4. Ascites (fluid leakage and accumulation in the abdominal cavity)

  5. Recurrence of Symptoms

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After the Kasai procedure, the baby is usually hospitalised for 6-10 days. Post-op care is given during this time. The baby's progress is monitored for 3-5 years after discharge to prevent complications. Follow-ups are scheduled for the first 3 months after surgery.

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Owing to the digestive limitations and complexities associated with BA after Kasai surgery. The baby is prescribed with a specialised diet:

  1. Unique baby diet according to its specific condition for at least 1 year after operation.

  2. After 2-3 years, the baby must be provided with nutritional food. Thrice a day.

  3. Fat-soluble vitamin supplements

  4. Medium-chain Triglyceride (MCT) oil in food or supplements enhances growth and weight gain.

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The long-term prognosis of babies after the surgery is highly beneficial, with 5-10 years of survival with their liver. Some patients can also survive through adulthood after the treatment through appropriate care and lifestyle. However, in some cases, if the procedure fails after three months or the patient experiences symptoms, relapse after a few years. Then, a liver transplant may be needed.

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A gastroenterologist surgeon is considered the specialist for performing the surgery. While choosing or finding the best surgeon for the Kasai operation, you must consider the following:

  1. Referrals: Try acquiring recommendations from your known and trusted physician. Consider seeking referrals from family, friends, colleagues, and acquaintances for an efficient surgical gastroenterologist.
  2. Check Qualifications: Research the surgeon's professional qualifications before proceeding with the consultation. This would help in shortlisting the best doctor to meet your needs.
  3. Evaluate Experience: Ensure that the surgeon is skilled and experienced in the treatment you seek. Kasai surgery is highly complex, requiring accurate precision and skills.
  4. Check Credibility: Research about the hospitals they are associated with. Prefer the ones enrolled with NABH-accredited healthcare facilities. You can also check their reviews and patient testimonials.
  5. Consultations: Check the availability, location, and appointment scheduling process. Prefer a surgeon with minimal waiting time to avoid surgical complications.

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Yes, the surgery is covered by health insurance as it is a medically necessary procedure. Almost all insurance providers provide complete coverage for the operation. However, to know more, it would be ideal to contact your insurance provider and go through your policy documents thoroughly.

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Before the operation, blood tests are done to evaluate hepatic damage. An ultrasound accurately locates damaged bile ducts and the liver. The baby's weight, height, heart rate, pulse, and respiration are assessed to determine anaesthesia dosage. Pain medication and fluids are administered through an IV line.

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The Kasai procedure is performed on newborns to treat biliary duct damage from birth. It can help prevent liver transplantation if conducted within 3 months of the baby's birth. If it is delayed, the complications increase significantly with an increased chance of procedure failure.

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Both techniques are different in terms of their modality. The Kasai procedure helps restore the baby's bile flow and increases liver function. This allows the patient to sustain their liver. On the other hand, liver transplantation is considered in case of complete organ failure or excessive damage. It includes the replacement of the native liver (recipient) with another person's (donor).

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Witnessing your child undergoing such complex surgery can be emotionally and mentally exhausting. It is best to prepare for the procedure by:

  1. Discuss your concerns with the doctor.
  2. Ask about the procedure, its benefits, and risks from the surgeon in detail.
  3. Talk with healthcare professionals and seek a second opinion. This will also help you with your expectations from the surgery.
  4. Seek counselling to ensure that your health is not impacted.

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The signs and symptoms that suggest the need for surgery include:

  1. Persistent jaundice is the first sign of this condition; worsening symptoms may indicate BA.
  2. Pale/white stools occur when bilirubin release is impaired, leading to changes in stool appearance in newborns.
  3. Dark-coloured urine due to excessive bilirubin in the bloodstream.
  4. A swollen belly occurs due to reversed bile movement, causing digestive issues and stomach inflammation.
  5. An enlarged liver happens when bile flow is impaired in BA, leading to its accumulation and increasing the liver's size (hepatomegaly), potentially causing cirrhosis.
  6. An enlarged spleen occurs when fluid pressure increases between hepatic veins (portal hypertension), increasing spleen size (splenomegaly).

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The medical field continues researching and developing advanced patient safety and recovery techniques. Some of the ongoing studies include:

  1. Fligor et al. (2022) explored adjuvant treatment techniques with Kasai procedure for addressing conditions related to biliary atresia. These techniques can avoid complications like cholangitis and liver transplant. Although there was no specific development reported during the research conclusion.
  2. Another study by Pietrobattista et al., 2020 evaluated the impact of the Kasai procedure on other treatments and biliary atresia symptoms. This also reported no accurate result towards the advancements.

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The Kasai surgery is safe and successful in most cases. However, unlike other surgeries, Kasai surgery may have certain risks and complications like postoperative infection, bleeding from the surgical site, intestinal blockage, etc.

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Hepatic fibrosis after the surgery is another name for the kasai procedure scar. It is important for detecting and avoiding extensive liver damage after the operation.

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After surgery, the surgical site is covered with dressings and a drain is attached for urine disposal. The baby is then moved to a recovery room and not fed for 2-3 days. The hospital stay typically lasts 7-10 days, during which the baby receives pain medication and fluids through a nasal tube.

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Morio Kasai was a Japanese surgeon who invented the Kasai technique for treating biliary atresia in paediatric patients

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References

All the articles on HexaHealth are supported by verified medically-recognized sources such as; peer-reviewed academic research papers, research institutions, and medical journals. Our medical reviewers also check references of the articles to prioritize accuracy and relevance. Refer to our detailed editorial policy for more information.


  1. Siddiqui AI, Ahmad T. Biliary Atresia [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Oct 17]. link
  2. What You Should Know About the Kasai Procedure [Internet]. Verywell Health. [cited 2023 Oct 17]. link
  3. Biliary Atresia Surgery (Kasai Operation) [Internet]. HealthyChildren.org. [cited 2023 Oct 17].link
  4. Khayat A, Alamri AM, Saadah OI. Outcomes of late Kasai portoenterostomy in biliary atresia: a single-center experience. Journal of International Medical Research. 2021 May 1;49(5):030006052110125-030006052110125.link
  5. Degtyareva A, Razumovskiy A, Kulikova N, Ratnikov S, Filippova E, Gordeeva E, et al. Long-Term Effects of Kasai Portoenterostomy for Biliary Atresia Treatment in Russia. Diagnostics. 2020 Sep 11;10(9):686.link
  6. Treatment for Your Child’s Biliary Atresia: Kasai Procedure [Internet]. Saint Luke’s Health System. link
  7. Fligor SC, Hirsch TI, Tsikis ST, Adeola A, Puder M. Current and emerging adjuvant therapies in biliary atresia. Frontiers in Pediatrics [Internet]. 2022 Oct 14 [cited 2023 Oct 17];10. link
  8. Liver Transplant | Children’s Liver Foundation [Internet]. childrenliverindia.org. link
  9. Fligor SC, Hirsch TI, Tsikis ST, Adeola A, Puder M. Current and emerging adjuvant therapies in biliary atresia. Frontiers in Pediatrics [Internet]. 2022 Oct 14 [cited 2023 Oct 17];10. link
  10. Pietrobattista A, Mosca A, Liccardo D, Alterio T, Grimaldi C, Maria Sole Basso, et al. Does the Treatment After Kasai Procedure Influence Biliary Atresia Outcome and Native Liver Survival? Journal of Pediatric Gastroenterology and Nutrition. 2020 Jul 3;71(4):446–51.link
  11. Miyano T. Morio Kasai, MD, 1922–2008. Pediatric Surgery International. 2009 Mar 3;25(4):307–8.link
  12. Pontarelli EM, Goodhue CJ, Merritt RJ, Anselmo DM. Chylous ascites following Kasai portoenterostomy: Case study and review of the literature. Journal of Pediatric Surgery Case Reports. 2013 Jul;1(7):171–3.link
  13. Redkar R, Karkera PJ, Raj V, Bangar A, Hathiramani V, Krishnan J. Outcome of biliary atresia after Kasai’s portoenterostomy: A 15-year experience. Indian Pediatrics. 2017 Feb 2;54(4):291–4.link

Reviewer

Dr. Aman Priya Khanna

Dr. Aman Priya Khanna

MBBS, DNB General Surgery, Fellowship in Minimal Access Surgery, FIAGES

12 Years Experience

Dr Aman Priya Khanna is a well-known General Surgeon, Proctologist and Bariatric Surgeon currently associated with HealthFort Clinic, Health First Multispecialty Clinic in Delhi. He has 12 years of experience in General Surgery and worke...View More

Author

Charu Shrivastava

Charu Shrivastava

BSc. Biotechnology I MDU and MSc in Medical Biochemistry (HIMSR, Jamia Hamdard)

2 Years Experience

Skilled in SEO and passionate about creating informative and engaging medical content. Her proofreading and content writing for medical websites is impressive. She creates informative and engaging content that educ...View More

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