Xie Hua,Lu Zhengchen,Ding Zequan,et al.Factors related to an initial episode of cholangitis after Kasai procedure in patients with biliary atresia[J].Journal of Clinical Pediatric Surgery,2025,(10):940-945.[doi:10.3760/cma.j.cn101785-202405071-007]
Ⅲ型胆道闭锁患儿葛西手术后首次胆管炎发作相关因素分析
- Title:
- Factors related to an initial episode of cholangitis after Kasai procedure in patients with biliary atresia
- Keywords:
- Biliary Atresia; Kasai Procedure; Cholangitis; Gamma-glutanmyl transterase; Root Cause Analysis
- 摘要:
- 目的 探讨Ⅲ型胆道闭锁(biliary atresia,BA)患儿葛西手术(Kasai procedure,KPE)后6个月内胆管炎首次发作的相关因素。方法 采用回顾性研究方法,收集2021年1月至2023年3月在南京医科大学附属儿童医院新生儿外科接受KPE且有术后1年完整随访信息的Ⅲ型BA患儿临床资料,包括患儿接受KPE时年龄、性别、围手术期血液生化指标、肝纤维化等级,以及胆管炎首次发作的时间、住院时长、发作时及治疗后血液生化指标、抗生素使用情况等。依据术后6个月内有无胆管炎发作,分为胆管炎发作组(n=56)和无胆管炎发作组(n=55),统计分析影响胆管炎发作及胆管炎首次发作时间的相关因素。结果 本研究纳入Ⅲ型BA患儿111例中,56例(56/111,50.5%)术后6个月内至少发作1次胆管炎,首次发作时间为术后40.5(26.3,60.0)d;其中24例(24/56,42.9%)胆管炎发作前黄疸已清除;首次发作时静脉使用抗生素时长为(13.9±6.4)d;接受静脉抗生素治疗后,50例(50/56,89.3%)直接胆红素较治疗前下降;46例(46/56,82.1%)首选抗生素为头孢哌酮舒巴坦钠(其中10例症状无缓解、9例(9/56,16.1%)血培养阳性,更换为碳青霉烯类抗生素),10例因胆管炎首次发作在KPE后2周内或于外院抗感染治疗症状无缓解而直接使用碳青霉烯类抗生素。9例血培养阳性者中,6例(6/9,66.7%)为肺炎克雷伯菌肺炎亚种。单因素分析显示,KPE后2周内直接胆红素下降速率在胆管炎发作组中显著增高[无胆管炎发作组为1.9(-0.2~4.36)μmol/L/ d,胆管炎发作组为3.4 (1.5~5.9)μmol/L/ day,U=1 058.000,P=0.004];单因素Logistic回归分析显示,OR=1.212,95%CI:1.067~1.376,P=0.003;多因素Logistic回归分析显示,OR=1.242,95%CI:1.062~1.453,P=0.007。胆管炎发作组患儿KPE前(r=-0.304,P=0.023)和术后2周内(r=-0.447,P=0.0005)谷氨酰转肽酶(gamma-glutamyl transterase,GGT)水平与胆管炎首次发作时间呈负相关。KPE后2周内直接胆红素下降速率是术后6个月内有无胆管炎发作的独立影响因素。结论 Ⅲ型BA患儿KPE后2周内退黄速率过快与术后6个月内胆管炎发作相关。KPE前和术后2周内GGT水平越高,胆管炎首次发作的时间越早。
- Abstract:
- Objective To explore the associated factors for an initial episode of cholangitis within 6 months after Kasai procedure (KPE) in patients with Type Ⅲ biliary atresia (BA). Methods From January 2021 to March 2023,the relevant clinical data were retrospectively reviewed for 111 children with type Ⅲ BA undergoing KPE with complete 1-year follow-ups.Age at KPE,gender,perioperative blood biochemical parameters,liver fibrosis grade,timing of an initial episode of cholangitis and length of hospitalization stay were recorded at the time of onset and after treatment and antibiotic dosing.According to the postoperative presence or absence of cholangitis within 6 months,they were assigned into two groups of cholangitis (n=56) and non-cholangitis (n=55).Factors influencing the occurrence of cholangitis and timing of an initial episode were analyzed. Results Among them,56 cases (56/111,50.5%) experienced at least one episode of cholangitis within 6 months with a median time to an initial episode of 40.5(26.3,60.0) day.The duration of intravenous antibiotic use at an initial episode was (13.9±6.4) day.Among these cases with episode of cholangitis,46 children were initially treated with cefoperazone-sulbactam.Nine had positive blood cultures with approximately 66.7% of positive cultures as Klebsiella pneumoniae.After antimicrobial therapy for an initial episode of cholangitis in these 56 cases,50 showed a direct decline in serum bilirubin levels as compared to admission.Univariate analysis revealed that the decline rate of direct bilirubin within 2 weeks after KPE was significantly higher in cholangitis group (median [IQR],3.4 [1.5-5.9]μmol/L/day) than in non-cholangitis group (1.9 [-0.2-4.36]μmol/L/day; U=1058.000,P=0.004).Univariate Logistic regression analysis yielded an odds ratio (OR) of 1.212(95% confidence interval [CI]:1.067-1.376,P=0.003) while multivariate Logistic regression analysis offered an OR of 1.242(95%CI:1.062-1.453,P=0.007).In cholangitis group,gamma-glutamyl transferase (GGT) level before KPE (r=-0.304,P=0.023) and within 2 weeks postoperatively (r=-0.447,P=0.0005) were significantly negatively correlated with time to an initial cholangitis episode.The decline rate of direct bilirubin within 2 weeks after KPE was an independent influencing factor for the development of cholangitis within 6 months postoperatively. Conclusions A rapid decline rate of direct bilirubin within 2 weeks post-KPE is associated with cholangitis episodes within 6 months after KPE.And higher GGT levels before KPE and within 2 weeks after surgery are correlated with an earlier onset of initial cholangitis episode.
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备注/Memo
收稿日期:2024-5-27。
基金项目:国家自然科学基金(82370523)
通讯作者:唐维兵,Email:twbcn@njmu.edu.cn