***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Although the Kasai operation is still the treatment of choice for infants with biliary atresia , the long-term success rate , as defined by survival without transplantation , is only about 25–40 % . It has been proposed that post-operative inflammatory changes affect the bile flow and eventually lead to cholangitis and liver failure . Recent case reports have suggested that the administration of steroids post-operatively can improve outcomes . Since 2004 , our unit has adopted a strict protocol for the use of post-operative steroids for patients who undergo Kasai operation . The aim of this study is to access the early outcomes of these patients . A retrospective analysis was carried out for all patients who received Kasai operation between 1996 and 2006 . For the treatment group , patients all received prednisolone at 4 mg/kg 1 week after operation as guided by protocol . The demographics and outcomes , including post operative bilirubin level , episodes of cholangitic attack , the need for early liver transplantation ( transplant within 1 year of Kasai ) , and transplantation-free survival , were noted . Statistical analysis was done using Fisher ’s exact test and unpaired t-test when appropriate . A value of P < 0.05 was considered to be statistically significant . Kasai operation was performed in 30 patients ( 11 boys and 19 girls ) during the study period . Thirteen patients received post-operative prednisolone according to protocol . The average age at operation and the mean preoperative bilirubin levels for the steroid and non-steroid group were not significantly different . A normal post-operative bilirubin ( defined as bilirubin level less than 20 μmol/L ) was achieved at 6 months in 7 ( 53.9 % ) patients who received steroid and 8 ( 47.0 % ) patients who did not ( P = 0.71 ) . A statistically significant reduction in the post-operative bilirubin level was also seen at 3 and 6 months in the steroid group . Early liver transplantation was required in 5 ( 38.5 % ) patients with steroid and 5 ( 29.4 % ) patients without it ( P = 0.60 ) . No significant difference in terms of cholangitic attack was observed . There was also no steroid-associated complication reported . We conclude that lower post-operative bilirubin level can be achieved with the routine use of prednisolone . However , there is no statistical improvement in terms of early liver transplantation and cholangitis . This may be attributed to the small sample size of our study population . Based on this pilot study , a multi-centre r and omized trial is needed OBJECTIVE : Postoperative adjuvant steroid treatment is reported to improve jaundice-free survival in biliary atresia ( BA ) patients and to reduce the need for early liver transplantation . However , evidence of all retrospective studies is very limited , although high-dose corticosteroids were favored . The aim of this dosage finding study was to test the most promising corticosteroid protocol in a smaller but representative series , in order to optimize the setting s of upcoming prospect i ve and long-term multicenter studies . METHODS : Our prospect i ve single-center and open-labeled pilot study on high-dose steroids included 49 consecutive BA patients . Basic data of the study group were not different from 29 controls . In the study group , 20 consecutive patients were treated after the Kasai with methylprednisolone ( 10 mg/kg day 1 to 5 and 1 mg/kg day 6 to 28 ) . RESULTS : Overall survival with native liver was 63 % after 6 months and 31 % after 2 yr , with no statistical difference between the study and control groups . After 2 yr , 27 % of all patients were still jaundice-free . With regard to predictive parameters , we found , 6 months after the Kasai , bilirubin < 20 μmol/L as highly sensitive ( 97 % ) and specific ( 93 % ) for jaundice-free survival with native liver . CONCLUSIONS : In contrast to previous reports , this pilot study shows that high-dose steroid pulses after Kasai procedure are not effective in postoperative adjuvant therapy protocol s and should be avoided in upcoming multicenter steroid studies . Therefore , we recommend extended and r and omized multicenter studies to pre-evaluate the supposed effectiveness of alternative steroid protocol s , by comparing , 6 months after the Kasai procedure , the number of patients with normal bilirubin BACKGROUND / PURPOSE Despite improvements in the surgical management of biliary atresia , the long-term incidence of progressive liver failure remains high . Because chronic inflammation involving both bile ducts and liver parenchyma contributes to the pathology , the authors have hypothesized that the liver damage may be altered using immunosuppressive therapy . The aim of this study was to examine the safety and efficacy of long-term steroid therapy in patients with biliary atresia . METHODS A retrospective analysis of all patients with biliary atresia treated with an hepatoportoenterostomy and postoperative steroid therapy at our 3 institutions was undertaken . Patients were treated uniformly with immunosuppressive doses of oral steroids for a minimum of 6 weeks after surgery . RESULTS Twenty-five infants with biliary atresia were treated with steroid therapy .  Overall survival rate was 22 patients ( 88 % ) with a mean follow-up period of 50 months . Nineteen patients ( 76 % ) became jaundice free with native liver function . Four patients ( 16 % ) did not respond to treatment and required transplantation . Age less than 12 weeks was a crucial predictor of success of adjuvant steroid therapy .  Cholangitis developed in 8 patients ( 32 % ) . There were no complications caused by steroid therapy . CONCLUSIONS Steroid administration at immunosuppressive doses markedly improves the clinical outcome within the first 5 years after surgery as measured by jaundice-free status and survival without liver transplantation when compared with concurrent reports . These results suggest that immunosuppressive therapy is safe and has a positive impact on the clinical course of this disease . However , a r and omized study is needed to ultimately prove such an hypothesis Controversy exists regarding the efficacy of corticosteroids on bile flow after Kasai portoenterostomy in biliary atresia ( BA ) . Fourteen patients who had BA and underwent Kasai portojejunostomy between November 1990 and March 1996 were subject of this study . Corticosteroid therapy ( " blast " type ) was used for inadequate bile drainage . Corticosteroid support was unnecessary in one patient with good bile drainage , and corticosteroids were aggressively used in the remaining 13 patients . Two patients who had no response to an initial blast subsequently responded and now are doing well . The remaining 11 patients responded to corticosteroids with varying degrees . Three had a limited response , and two ultimately underwent liver transplantation . There was one death caused by subdural hematoma . Three had an excellent initial response . However , one subsequently deteriorated because of intractable cholangitis , requiring liver transplantation . Ten survivors with native liver are anicteric with satisfactory growth and quality of life . Aggressive corticosteroid therapy is an important part of the management after Kasai portoenterostomy . The initial response to steroids does not necessarily reflect the final outcome PURPOSE This study tests the hypothesis that steroid administration improves the outcome of biliary atresia ( BA ) by evaluating the efficacy of postoperative steroid use on surgical outcomes in infants with BA . METHODS Steroid use and outcomes in patients with BA were retrospectively analyzed at a tertiary pediatric hospital . Institutional review board approval was obtained . RESULTS Kasai portoenterostomy ( PE ) was performed in 43 patients with BA treated from 1992 to 2004 ( 16 boys and 27 girls ) . Twenty-one PE patients received steroids and 22 did not . Portoenterostomy was successful in 24 patients ( 55.8 % ) with consistent serum bilirubin less than 2 mg/dL. Sixteen ( 66 % ) received postoperative steroids . A normal postoperative bilirubin was achieved at 6 months in 16 ( 76 % ) of 21 patients with steroids compared with 8 ( 37 % ) of 22 in untreated controls ( Fisher 's Exact test , P = .01 ) . Of the 43 patients , 19 ( 44 % ) required liver transplantation , including 7 ( 37 % ) of 19 with steroids vs 12 ( 63 % ) of 19 without ( P = .2 ) . Twenty-eight infants developed cholangitis ( fever with and without changes in hepatic function ) : 25 after PE and 3 after transplant . Of the 25 , 12 ( 48 % ) received steroids . Seven died ( 16 % ) ( range , 7 months to 4 years ) : 2 while awaiting transplantation ( received steroids ) and 5 after transplantation ( 1 received steroids and 4 were untreated ) . Survival was 86 % ( 18/21 ) in patients with steroids and 82 % ( 18/22 ) in those without . Transplant survival ( 74 % ) was comparable to previously reported historical controls ( 82 % ) . CONCLUSIONS The Kasai PE continues to be the procedure of choice in infants with BA younger than 3 months . A significantly improved clearance of postoperative jaundice and lower serum bilirubin levels were observed in patients receiving steroids . However , steroids had no effect on the incidence of cholangitis , need for liver transplantation , and overall survival . A prospect i ve study with st and ardized dose and length of steroid administration and longer period of follow-up is necessary to more accurately assess the effectiveness of steroids after PE The objective of this study was to evaluate adjuvant corticosteroids  after Kasai portoenterostomy for biliary atresia . The study consisted of a prospect i ve , 2‐center , double‐blind , r and omized , placebo‐controlled trial of  post – Kasai portoenterostomy corticosteroids ( oral prednisolone : 2 mg/kg/day from day 7 to day 21 and 1 mg/kg/day from day 22 to day 28 ) . The data were compared with χ 2 or Mann‐Whitney tests , as appropriate . Seventy‐one postoperative infants with type 3 biliary atresia were r and omized to receive either oral prednisolone ( n = 36 ) or a placebo ( n = 37 ) . At 1 month , the median bilirubin level was lower in the steroid group ( 66 versus 92 μmol/L , P = 0.06 ) , but no difference was evident at 6 ( P = 0.56 ) or 12 ( P = 0.3 ) months . The proportion of infants with a normal bilirubin level ( < 20 μmol/L ) at 6 ( 47 % versus 49 % , P = 0.89 ) and 12 months ( 50 % versus 40 % , P = 0.35 ) was not significantly different . The need for transplantation by 6 ( 12 % versus 13 % , P = 0.99 ) and 12 months ( 26 % versus 35 % , P = 0.47 ) was not significantly different . The steroid effect was more pronounced in younger infants ( less than 70 days at Kasai portoenterostomy , n = 51 ) , with a reduced bilirubin level at 1 month ( 64 versus 117 μmol/L , P = 0.01 ) and with a greater proportion with a normal bilirubin level at 12 months ( 54 % versus 37 % , P = 0.22 ) . Conclusion : There was a beneficial effect on the rate of reduction of bilirubin in the early postoperative period ( specifically in infants less than 70 days old at surgery ) , but this steroid regimen did not reduce the need for liver transplantation . ( HEPATOLOGY 2007;46:1821–1827 . 
    Output:
    
The present meta- analysis did not find a significant effect of steroid over st and ard therapy , either in normalizing serum bilirubin levels at six months or at delaying the need for early liver transplantation post-KP .