Han Yijiang,Wu Hao,Ji Haosen,et al.Correlation between age of Kasai portoenterostomy and early prognosis for biliary atresia[J].Journal of Clinical Pediatric Surgery,2023,22(03):225-231.[doi:10.3760/cma.j.cn101785-202210044-005]
胆道闭锁Kasai手术日龄与早期预后的关联性分析
- Title:
- Correlation between age of Kasai portoenterostomy and early prognosis for biliary atresia
- Keywords:
- Biliary Atresia; Prognosis; Liver Function Test; Operative Age
- 摘要:
- 目的 探讨胆道闭锁(biliary atresia,BA) Kasai手术日龄与早期预后的关联性,为BA患儿Kasai手术时机提供参考。方法 采用回顾性研究方法,收集2019年1月至2021年12月浙江大学医学院附属儿童医院收治的BA患儿临床资料,包括一般资料(性别、手术时日龄)、肝功能、凝血功能及血氨指标。根据Kasai手术后3个月退黄情况分为未退黄组(n=47)和退黄组(n=66),计算手术时日龄的cut-off值;再根据此手术时日龄分为两组,比较Kasai手术后3个月的预后指标,包括碱性磷酸酶(alkaline phosphatase,ALP)、丙氨酸转氨酶(alanine aminotransferase,ALT)、天冬氨酸转氨酶(aspartate aminotransferase,AST)、直接胆红素(direct bilirubin,DBIL)、术后DBIL/术前DBIL、γ-谷氨酰转移酶(gamma-glutamyltransferase,GGT)、总胆汁酸(total bile acid,TBA)、总胆红素(total bilirubin,TBIL)、血小板计数(platelet count,PLT)、天冬氨酸转氨酶与血小板比值指数(aspartate aminotransferase-to-platelet ratio index,APRI)、国际标准化比值(international normalized ratio,INR)。结果 共收集病例113例,男49例,女64例;手术日龄59.00(40.50,69.00) d。对未退黄组和退黄组的各项术前指标进行单因素分析,结果显示两组手术日龄[64(52,79) d比55(33,67) d]、AST[202.00(138.00,332.00) U/L比147.50(100.00,242.00) U/L]、间接胆红素(indirect bilirubin,IBIL)[(70.60±20.31)μmol/L比(79.96±27.13)μmol/L]、总蛋白(total protein,TP)[(55.88±6.59) g/L比(53.13±4.71) g/L]差异具有统计学意义(P＜0.05)。将单因素分析中P＜0.1的指标[手术时日龄、白蛋白(albumin,ALB)、ALT、AST、IBIL、TP、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)]纳入Logistic回归分析,结果显示手术时日龄(OR=0.974,95%CI:0.951~0.997,P=0.030)是Kasai手术后3个月退黄的独立影响因素。根据手术时日龄的cut-off值(46.5 d)分组,比较Kasai手术后3个月各项指标,结果显示手术时日龄≤46.5 d组的ALP[365.00(316.00,514.75) U/L比492.00(343.00,684.00) U/L]、ALT[(76.35±81.33) U/L比(134.09±97.45) U/L]、AST[67.50(41.50,99.50) U/L比112.00(79.00,168.00) U/L]、DBIL[2.55(1.78,6.95)μmol/L比9.80(3.60,36.80)μmol/L]、术后DBIL/术前DBIL[0.05(0.03,0.09)比0.12(0.05,0.54)]、TBA[45.50(25.93,92.93)μmol/L比106.20(41.20,187.50)μmol/L]、TBIL[9.65(6.98,15.43)μmol/L比21.50(10.40,66.90)μmol/L]及APRI[0.32(0.22,0.48)比0.62(0.41,0.93)]明显低于手术时日龄＞46.5 d组,差异具有统计学意义(P＜0.05)。结论 手术时日龄≤46.5 d组患儿早期预后指标较手术时日龄＞46.5 d组更好,尽早行Kasai手术可改善BA预后。
- Abstract:
- Objective To explore the correlation between age of Kasai portoenterostomy and early prognosis to provide references for timing of Kasai surgery in biliary atresia (BA) children.Methods Retrospective review was conducted for clinical data of hospitalized BA children from January 2019 to December 2021.General profiles (gender & operative age) and parameters of liver function,coagulation function and blood ammonia were collected.According to the jaundice clearance at 3 months post-operation,they were assigned into two groups of non-jaundice clearance (n=47) and jaundice clearance (n=66).The cut-off value of operative age was calculated.Then two groups were divided according to operative age.The prognostic parameters of Kasai portoenterostomy at 3 months post-operation were compared,including alkaline phosphatase (ALP),alanine aminotransferase (ALT),aspartate aminotransferase (AST),direct bilirubin (DBIL),postoperative DBIL/ preoperative DBIL,gamma-glutamyltransferase (GGT),total bile acid (TBA),total bilirubin (TBIL),platelet count (PLT),aspartate aminotransferase-to-platelet ratio index (APRI) and international normalized ratio (INR).Results A total of 113 cases were collected,including 49 males and 64 females. The operative age was 59.00 (40.50,69.00) days. Univariate analysis of the preoperative indexes of the non-jaundice clearance group and the jaundice clearance group showed that the age of operation(64 (52,79) d vs. 55 (33,67) d),AST (202.00 (138.00,332.00) U/L vs.147.50 (100.00,242.00) U/L),indirect bilirubin (IBIL) ((70.60±20.31)μmol/L vs.(79.96±27.13)μmol/L),total protein(TP) ((55.88±6.59)g/L vs.(53.13±4.71)g/L) between the two groups were statistically significant (P<0.05). The indexes with P<0.1 in univariate analysis [age of operation,albumin (ALB),ALT,AST,IBIL,TP,activated partial thromboplastin time(APTT)] were included in the multivariate Logistic regression analysis,and the results showed that the age of operation (OR=0.974,95%CI:0.951-0.997,P=0.030) was an independent factor influencing the jnundice clearance at 3 months after Kasai protoentrostomy. According to the cut-off value (46.5d) of the operative age group,the results showed that the levels of ALP(365.00 (316.00,514.75) U/L vs.492.00 (343.00,684.00) U/L),ALT ((76.35±81.33) U/L vs.(134.09±97.45)U/L),AST (67.50 (41.50,99.50) U/L vs.112.00 (79.00,168.00) U/L),DBIL (2.55 (1.78,6.95) μmol/L vs. 9.80 (3.60,36.80) μmol/L),postoperative DBIL/ preoperative DBIL(0.05 (0.03,0.09) vs.0.12 (0.05,0.54)),TBA (45.50 (25.93,92.93) μmol/L vs.106.20 (41.20,187.50) μmol/L),TBIL (9.65 (6.98,15.43) μmol/L vs.21.50 (10.40,66.90) μmol/L) and APRI (0.32 (0.22,0.48) vs.0.62 (0.41,0.93)) in the operation age ≤46.5 d group were significantly lower than those in the operation age > 46.5 d group, the difference was statistically significant (P<0.05).Conclusion Early prognostic parameters are superior in group with operative age≤46.5 days to group with operative age >46.5 days.And early Kasai portoenterostomy may improve the prognosis of BA.
参考文献/References:
[1] 孙溶涓,詹江华.胆道闭锁诊断方法的研究进展[J].临床肝胆病杂志,2022,38(7):1681-1685.DOI:10.3969/j.issn.1001-5256.2022.07.043. Sun RJ,Zhan JH.Research advances of diagnostics for biliary atresia[J].J Clin Hepatol,2022,38(7):1681-1685.DOI:10.3969/j.issn.1001-5256.2022.07.043.
[2] Al-Hussaini A,Abanemai M,Alhebbi H,et al.The epidemiology and outcome of biliary atresia:Saudi Arabian national study (2000-2018)[J].Front Pediatr,2022,10:921948.DOI:10.3389/fped.2022.921948.
[3] 赵宝红,钭金法,吕志宝,等.胆道闭锁预后相关因素的多中心研究[J].中华小儿外科杂志,2021,42(6):494-500.DOI:10.3760/cma.j.cn421158-20200805-00535. Zhao BH,Tou JF,Lyu ZB,et al.Multicenter study of prognostic factors for biliary atresia[J].Chin J Pediatr Surg,2021,42(6):494-500.DOI:10.3760/cma.j.cn421158-20200805-00535.
[4] He L,Ip DKM,Tam G,et al.Biomarkers for the diagnosis and post-Kasai portoenterostomy prognosis of biliary atresia:a systematic review and meta-analysis[J].Sci Rep,2021,11(1):11692.DOI:10.1038/s41598-021-91072-y.
[5] Du M,Wang JF,Tang Y,et al.Evaluation of perioperative complications in the management of biliary atresia[J].Front Pediatr,2020,8:460.DOI:10.3389/fped.2020.00460.
[6] 黄子寒,郑珊.γ-谷氨酰转肽酶在胆道闭锁诊断和预后评价中的研究进展[J].临床小儿外科杂志,2021,20(2):140-144,160.DOI:10.12260/lcxewkzz.2021.02.007. Huang ZH,Zheng S.Research advances of gamma-glutamyltransferase in the diagnosis and prognosis of biliary atresia[J].J Clin Ped Sur,2021,20(2):140-144,160.DOI:10.12260/lcxewkzz.2021.02.007.
[7] Chung PHY,Chan EKW,Yeung F,et al.Life-long follow-up and management strategies of patients living with native livers after Kasai portoenterostomy[J].Sci Rep,2021,11(1):11207.DOI:10.1038/s41598-021-90860-w.
[8] Khayat A,Alamri AM,Saadah OI.Outcomes of late Kasai portoenterostomy in biliary atresia:a single-center experience[J].J Int Med Res,2021,49(5):3000605211012596.DOI:10.1177/03000605211012596.
[9] Gad EH,Kamel Y,Salem TAH,et al.Short-and long-term outcomes after Kasai operation for type III biliary atresia:twenty years of experience in a single tertiary Egyptian center-a retrospective cohort study[J].Ann Med Surg (Lond),2021,62:302-314.DOI:10.1016/j.amsu.2021.01.052.
[10] Liu FR,Yeung F,Chung PHY.The outcome of Kasai portoenterostomy after day 70 of life[J].Front Pediatr,2022,10:1015806.DOI:10.3389/fped.2022.1015806.
[11] Uecker M,Kuebler JF,Schukfeh N,et al.Kasai procedure in patients older than 90 days:worth a cut[J].Eur J Pediatr Surg,2022,32(1):80-84.DOI:10.1055/s-0041-1740556.
[12] 吴晓霞,任红霞,靳园园,等.胆道闭锁Kasai手术后自体肝生存时间小于2年的危险因素分析[J].临床小儿外科杂志,2021,20(2):114-118.DOI:10.12260/lcxewkzz.2021.02.003. Wu XX,Ren HX,Jin YY,et al.Risk factors of native liver survival time under 2 years after Kasai operation for biliary atresia[J].J Clin Ped Sur,2021,20(2):114-118.DOI:10.12260/lcxewkzz.2021.02.003.
[13] Wang ZM,Chen YJ,Peng CH,et al.Five-year native liver survival analysis in biliary atresia from a single large Chinese center:The death/liver transplantation hazard change and the importance of rapid early clearance of jaundice[J].J Pediatr Surg,2019,54(8):1680-1685.DOI:10.1016/j.jpedsurg.2018.09.025.
[14] Ramos-Gonzalez G,Elisofon S,Dee EC,et al.Predictors of need for liver transplantation in children undergoing hepatoportoenterostomy for biliary atresia[J].J Pediatr Surg,2019,54(6):1127-1131.DOI:10.1016/j.jpedsurg.2019.02.051.
[15] Ge L,Zhan JH,Gao W,et al.Relevant factors for early liver transplantation after Kasai portoenterostomy[J].BMC Pediatr,2020,20(1):484.DOI:10.1186/s12887-020-02355-8.
[16] Hukkinen M,Kerola A,Lohi J,et al.Very low bilirubin after portoenterostomy improves survival of the native liver in patients with biliary atresia by deferring liver fibrogenesis[J].Surgery,2019,165(4):843-850.DOI:10.1016/j.surg.2018.10.032.
[17] Abdel-Aziz SAW,Sira MM,Gad EH,et al.Preoperative alkaline phosphatase is a potential predictor of short-term outcome of surgery in infants with biliary atresia[J].Clin Exp Hepatol,2019,5(2):155-160.DOI:10.5114/ceh.2019.85072.
[18] Yassin NA,El-Tagy G,Abdelhakeem ON,et al.Predictors of short-term outcome of Kasai portoenterostomy for biliary atresia in infants:a single-center study[J].Pediatr Gastroenterol Hepatol Nutr,2020,23(3):266-275.DOI:10.5223/pghn.2020.23.3.266.
[19] Liu YK,Peng CH,Wang K,et al.The utility of shear wave elastography and serum biomarkers for diagnosing biliary atresia and predicting clinical outcomes[J].Eur J Pediatr,2022,181(1):73-82.DOI:10.1007/s00431-021-04176-y.
[20] Leung DH.Hepatic fibrosis scores and serum biomarkers in pediatric hepatology[J].Clin Liver Dis (Hoboken),2017,9(5):125-130.DOI:10.1002/cld.634.
[21] Ihn K,Ho IG,Chang EY,et al.Correlation between gamma-glutamyl transpeptidase activity and outcomes after Kasai portoenterostomy for biliary atresia[J].J Pediatr Surg,2018,53(3):461-467.DOI:10.1016/j.jpedsurg.2017.10.001.
[22] 韩一江,胡书奇,陈宝海,等.GGT联合DBIL、APRI对胆道闭锁的诊断价值[J].天津医药,2022,50(1):11-14.DOI:10.11958/20211158. Han YJ,Hu SQ,Chen BH,et al.Diagnostic value of GGT plus DBIL and APRI for biliary atresia[J].Tianjin Med J,2022,50(1):11-14.DOI:10.11958/20211158.
[23] Shankar S,Bolia RS,Foo HW,et al.Normal gamma glutamyl transferase levels at presentation predict poor outcome in biliary atresia[J].J Pediatr Gastroenterol Nutr,2020,70(3):350-355.DOI:10.1097/MPG.0000000000002563.
[24] Zhang YM,Wang Q,Pu SY,et al.A novel model for predicting the clearance of jaundice in patients with biliary atresia after Kasai procedure[J].Front Pediatr,2022,10:837247.DOI:10.3389/fped.2022.837247.
[25] Sun S,Zheng S,Lu XX,et al.Clinical and pathological features of patients with biliary atresia who survived for more than 5 years with native liver[J].Pediatr Surg Int,2018,34(4):381-386.DOI:10.1007/s00383-018-4231-7.
[26] Hanalio?lu D,?zen H,Karhan A,et al.Revisiting long-term prognostic factors of biliary atresia:a 20-year experience with 81 patients from a single center[J].Turk J Gastroenterol,2019,30(5):467-474.DOI:10.5152/tjg.2019.18590.
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备注/Memo
收稿日期:2022-10-22。
基金项目:国家中心自主设计项目(S20C0004)
通讯作者:钭金法,Email:toujinfa@zju.edu.cn