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Introduction: Aim of the study was to carry out a 5-year survey of German patients with biliary atresia (BA) and to launch a discussion regarding the feasibility of voluntary registries in unregulated healthcare systems. Methods: A retrospective analysis of German BA patients born between 2001 and 2005, based on data collected from the voluntary European Biliary Atresia Registry (EBAR), was carried out and supplemented by data from all BA patients who underwent liver transplantation at the only 4 pediatric transplantation centers (pLTx) in Germany which are so far not registered at EBAR. Survival rates were calculated using Kaplan- Meier analysis and compared by Cox regression to determine the predictive value of age at surgery and the influence of the center size (fewer or more than 5 patients / study period) on overall survival and survival with native liver. Results: A critical review of the 148 German EBAR charts revealed that 11 patients (7.4 % ) had no biliary atresia. The remaining 137 patients from EBAR together with 46 BA patients who underwent LTx without prior registration at EBAR were evaluated with a median follow-up of 39 months (range: 25 - 85 months). 29 hospitals performed a total of 159 Kasai procedures, but only 7 centers treated 5 or more patients (116 patients, range: 5 - 68), and 22 hospitals performed less than 5 KP (43 patients, range: 1 - 4). Primary LTx was performed in 21 patients (11.5 % ) and 3 patients died without surgical intervention. 16 patients were lost to follow-up (8.7 % ). Overall survival after 2 years was 83.3 % (139 patients), including 105 patients (63 % ) who had undergone LTx and 34 patients (20.3 % ) with native liver. 28 patients died (16.7 % ), 8 after LTx (5.8 % ). The experience of the center was the only factor with a significant predictive value for jaundice- free survival with native liver (p = 0.001). Conclusion: 25 % of all German BA patients were not registered at EBAR, and 29 clinics were involved in the surgical management of BA patients. Therefore a new approach consisting of an internet-based decentralized registry for rare neonatal liver diseases is outlined which could improve the future management of patients with BA. The centralization of such patients at experienced centers with higher caseloads is necessary in Germany and would improve the outcome of patients with biliary atresia. [ABSTRACT FROM AUTHOR]