title: International incidence and outcomes of biliary atresia.
abstract: OBJECTIVE
  International trends in incidence and outcomes of biliary atresia (BA) are controversial and a wide range of estimates have been reported worldwide. We reviewed the population-based literature to assess international variation of BA incidence and outcomes, and to assess the evidence for seasonal variation in incidence, centralization of Kasai hepatoportoenterostomy, and newborn screening.
  
  
  METHODS
  We conducted a systematic review (registration number CRD42011001441) of observational or interventional research within MEDLINE, EMBASE, and the Cochrane Database, which reported incidence, prevalence, or outcomes of infants with BA. Population-based studies, defined by inclusion of an entire population or representative sample, were included. Outcomes included overall survival, native liver survival (NLS), and time to Kasai hepatoportoenterostomy. Single- or multicenter studies were excluded unless those centers captured all potential patients within a jurisdiction. Two independent data extractors reviewed the abstracts and articles.
  
  
  RESULTS
  A total of 40 studies were included following review of 3128 references. A wide range of incidence was reported internationally. Ten-year overall survival ranged from 66.7% to 89%. NLS ranged from 20.3% to 75.8% at 1 to 3 years and 24% to 52.8% at 10 years. Earlier age at Kasai was a predictor of improved NLS. Seasonality was reported in 11 studies, and 3 reported an increased incidence during the months of August to March. The evidence for centralization of Kasai to high-volume centers is promising but does not account for all case-mix, provider, or health system factors involved in volume-outcome relations. Stool color card screening resulted in earlier Kasai and improved NLS in Taiwan.
  
  
  CONCLUSIONS
  Large, international studies could help fill the gaps in knowledge identified by this review.
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada. cajimenez@cheo.on.ca
authors.forename: Carolina
authors.initials: C
authors.lastname: Jimenez-Rivera
authors.forename: Kheira S
authors.initials: KS
authors.lastname: Jolin-Dahel
authors.forename: Kyle J
authors.initials: KJ
authors.lastname: Fortinsky
authors.forename: Peter
authors.initials: P
authors.lastname: Gozdyra
authors.forename: Eric I
authors.initials: EI
authors.lastname: Benchimol
mesh_terms: D001656:Biliary Atresia / Q000175:diagnosis / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy; D002648:Child; D014943:Global Health; D006801:Humans; D015994:Incidence; D011379:Prognosis; D012017:Referral and Consultation; D012621:Seasons; D016019:Survival Analysis