New England Surgical Society

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Volume-Outcome Relationship in Portoenterostomy for Biliary Atresia in the United States
*Nathan Maassel, *Alex S Chiu, Robert A Cowles, Peter S Yoo, *Daniel G Solomon
Yale University School of Medicine, New Haven, CT

Objective:
The volume-outcome relationship for Kasai Portoenterostomy (KPE) to correct biliary atresia with native liver survival is difficult to study: the disease is rare, and small centers may offer KPE but not Liver Transplant (Txp). Therefore, single institution retrospection, and even administrative databases might not appropriately capture all outcomes. We sought to evaluate the rate of Txp following KPE performed at the same centers to determine if the volume of KPEs was associated with the rate of need for future Txp.
Design:
Retrospective review of the Childrenís Hospital Associationís (CHA) Pediatric Health Information System from 2013-2017.
Setting:
CHA-affiliated high-volume (>2 KPE/year) and low-volume (≤2 KPE/year) hospitals that performed at least 1 Txp on a previous KPE patient.
Patients:
Infants <120 days old with ICD-9 diagnostic codes for biliary atresia and procedure codes for KPE with/without a subsequent code for Txp.
Main Outcome Measure:
Need for transplant within the study period. Surgical complications and mortality were also collected.
Results:
182 KPEs were performed at 22 institutions that met inclusion criteria, 14 of which were low-volume (Mean 1.05 KPE/year) and 8 high-volume (Mean 2.75 KPE/year). There were no KPE mortalities but a higher rate of surgical complications following KPE at the high-volume centers (26% vs 9% p=0.006). There was no difference in age at KPE or age at Txp. Logistic regression demonstrated that patients at low-volume centers were twice as to require a subsequent transplant (OR 2.30 95%CI 1.15-4.59).
Conclusion:
Despite a higher rate of complications, high-volume centers have better short-term native liver survival following KPE. This finding has implications for the centralization of care for this rare, complex and morbid disease.


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