Zheng Lulu,Wu Yibo,Wu Wei,et al.Middle/long-term prognosis and influencing factors of Kasai portoenterostomy on type Ⅲ biliary atresia[J].Journal of Clinical Pediatric Surgery,2023,22(11):1045-1049.[doi:10.3760/cma.j.cn101785-202203017-008]
Ⅲ型胆道闭锁Kasai手术后患儿自体肝中长期生存情况的影响因素分析
- Title:
- Middle/long-term prognosis and influencing factors of Kasai portoenterostomy on type Ⅲ biliary atresia
- Keywords:
- Biliary Atresia; Prognosis; Root Cause Analysis; Surgical Procedures; Operative; Child
- 摘要:
- 目的 探讨Ⅲ型胆道闭锁(biliary atresia,BA)Kasai手术后中长期生存情况,并分析其影响因素。方法 回顾性分析2011年1月至2020年12月上海市儿童医院确诊为Ⅲ型BA并行Kasai手术患儿的临床资料,包括性别、术前肝功能及血常规、术前巨细胞病毒免疫球蛋白M(immunoglobulin M,IgM)水平、手术时年龄及术后6个月内退黄情况。手术时年龄≤60 d定义为早期手术组,>60 d定义为晚期手术组;采用免疫酶联反应法检测巨细胞病毒IgM抗体,并根据检测结果分为IgM阳性组和IgM阴性组;谷草转氨酶和血小板比值(aspartate aminotransferase-to-platelet ratio index,APRi)=谷草转氨酶×谷草转氨酶正常值上限-1×100×血小板数-1(计量单位:109/L),谷草转氨酶和血小板均为Kasai手术前1周内同一次采血结果,分为APRi值<0.6组和APRi值≥0.6组;Kasai手术后6个月内总胆红素水平至少1次小于2 mg/dL定义为退黄组,其余定义为非退黄组。采用Kaplan-Meier法计算BA患儿5年、10年自体肝生存率;BA患儿预后相关因素的单因素分析采用Log-rank检验,多因素分析采用Cox回归。结果 本研究共获取234例Ⅲ型BA患儿资料;男118例,女116例;手术时日龄(72.7±23.0)d;Kasai手术后5年、10年自体肝生存率分别为41.2%和38.9%。单因素分析结果显示:患儿性别、巨细胞病毒IgM抗体阳性、APRi值均不影响BA患儿Kasai手术后中长期生存情况(P>0.05);手术时年龄、术后6个月退黄率是BA患儿Kasai手术后中长期生存情况的影响因素(P<0.05)。多因素Cox回归分析结果显示:术后6个月退黄情况是Kasai手术后自体肝中长期生存情况的独立影响因素(HR=0.190,95%CI:0.125~0.291,P<0.05)。结论 Kasai手术通过重建胆道来引流胆汁,是治疗BA的首选手术方式之一。BA患儿Kasai手术后6个月内退黄情况是自体肝中长期生存情况的独立影响因素。
- Abstract:
- Objective To explore the middle/long-term native liver survival and examine its influencing factors of Kasai portoenterostomy for type Ⅲ biliary atresia (BA).Methods From January 2011 to December 2020,single-center retrospective analysis was performed for 234 type Ⅲ BA children undergoing Kasai portoenterostomy.Gender,operative age,liver function test,blood routine test,cytomegalovirus (CMV) IgM examination and aspartate aminotransferase-to-platelet ratio index (APRi) were recorded.Operative age ≤eerativewas defined as early operation group while operative age >60 days as late operation group.IgM antibodies against CMV were detected by immunoenzyme-linked reaction.They were assigned into two groups of IgM positive and IgM negative according to the detection results.Ratio index of aspartate aminotransferase-to-platelet=AST/(upper limit of AST) ×100/PLT(109/L).Aspartate aminotransferase and platelets were measured at the same time 1 week pre-Kasai.They were divided into two groups of APRi <0.6 and APRi of.Total bilirubin ≤2 mg/dL being more than once post-Kasai within 6 mouths was defined as jaundice-eliminating group and the rest as jaundice group.And 5/10-year native liver survival was calculated by Kaplan Meier method.Univariate analysis was performed by Log rank test and multibariate analysis by Cox regression.Results There were 118 boy and 116 girls with an average operative age of (72.7±23) days.The 5/10-year native liver survival rate was 41.2% and 38.9% respectively.Univariate Kaplan-Meier liver survival and Log Rank test analysis revealed that gender (χ2=0.01,P=0.91),CMV (χ2=1.3,P=0.25) and APRi (χ2=0,P=0.98) had no effect on native liver survival.Compared with late operative age group,native liver survival rate spiked markedly in early operative age group (χ2=7.6,P=0.006).Compared with total bilirubin level greater than or equal to 2 mg/dL,native liver survival rate rose significantly in <2 mg/dL of total bilirubin (χ2=74.6,P=<0.001).Multivariate Cox regression analysis showed that only total bilirubin <2 mg/dL within 6 months post-Kasai was an independent influencing factor of middle/long-term liver survival.Conclusions Total bilirubin <2 mg/dL within 6 months after Kasai portoenterostomy is an independent influencing factor of middle/long-term liver survival.
参考文献/References:
[1] Bezerra JA,Wells RG,Mack CL,et al.Biliary atresia:clinical and research challenges for the twenty-first century[J].Hepatology,2018,68(3):1163-1173.DOI:10.1002/hep.29905.
[2] Sanchez-Valle A,Kassira N,Varela VC,et al.Biliary atresia:epidemiology,genetics,clinical update,and public health perspective[J].Adv Pediatr,2017,64(1):285-305.DOI:10.1016/j.yapd.2017.03.012.
[3] de Vries W,de Langen ZJ,Groen H,et al.Biliary atresia in the Netherlands:outcome of patients diagnosed between 1987 and 2008[J].J Pediatr,2012,160(4):638-644.e2.DOI:10.1016/j.jpeds.2011.09.061.
[4] Zani A,Quaglia A,Hadzic[DD(-*8/9][HT6.]＇[HT6] N,et al.Cytomegalovirus-associated biliary atresia:an aetiological and prognostic subgroup[J].J Pediatr Surg,2015,50(10):1739-1745.DOI:10.1016/j.jpedsurg.2015.03.001.
[5] Grieve A,Makin E,Davenport M.Aspartate Aminotransferase-to-platelet ratio index (APRi) in infants with biliary atresia:prognostic value at presentation[J].J Pediatr Surg,2013,48(4):789-795.DOI:10.1016/j.jpedsurg.2012.10.010.
[6] Ohhama Y,Shinkai M,Fujita S,et al.Early prediction of long-term survival and the timing of liver transplantation after the Kasai operation[J].J Pediatr Surg,2000,35(7):1031-1034.DOI:10.1053/jpsu.2000.7765.
[7] Yang LY,Fu J,Peng XF,et al.Validation of aspartate aminotransferase to platelet ratio for diagnosis of liver fibrosis and prediction of postoperative prognosis in infants with biliary atresia[J].World J Gastroenterol,2015,21(19):5893-5900.DOI:10.3748/wjg.v21.i19.5893.
[8] Fanna M,Masson G,Capito C,et al.Management of biliary atresia in France 1986 to 2015:long-term results[J].J Pediatr Gastroenterol Nutr,2019,69(4):416-424.DOI:10.1097/MPG.0000000000002446.
[9] Nightingale S,Stormon MO,O’Loughlin EV,et al.Early posthepatoportoenterostomy predictors of native liver survival in biliary atresia[J].J Pediatr Gastroenterol Nutr,2017,64(2):203-209.DOI:10.1097/MPG.0000000000001289.
[10] Hukkinen M,Pihlajoki M,Pakarinen MP.Predicting native liver injury and survival in biliary atresia[J].Semin Pediatr Surg,2020,29(4):150943.DOI:10.1016/j.sempedsurg.2020.150943.
[11] 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.
[12] 董昆,杨体泉,董淳强,等.巨细胞病毒感染与胆道闭锁Kasai手术预后的关系[J].临床小儿外科杂志,2016,15(1):23-25,45.DOI:10.3969/j.issn.1671-6353.2016.01.007. Dong K,Yang TQ,Dong CQ,et al.Relationship between cytomegalovirus infection and prognosis of biliary atresia after Kasai operation[J].J Clin Ped Sur,2016,15(1):23-25,45.DOI:10.3969/j.issn.1671-6353.2016.01.007.
[13] Moore SW,Zabiegaj-Zwick C,Nel E.Problems related to CMV infection and biliary atresia[J].S Afr Med J,2012,102(11 Pt 2):890-892.DOI:10.7196/samj.6163.
[14] Xu Y,Yu JK,Zhang RZ,et al.The perinatal infection of cytomegalovirus is an important etiology for biliary atresia in China[J].Clin Pediatr (Phila),2012,51(2):109-113.DOI:10.1177/0009922811406264.
[15] Parolini F,Hadzic N,Davenport M.Adjuvant therapy of cytomegalovirus IgM+ve associated biliary atresia:Prima facie evidence of effect[J].J Pediatr Surg,2019,54(9):1941-1945.DOI:10.1016/j.jpedsurg.2018.12.014.
[16] Ueno T,Kodama T,Noguchi Y,et al.Clinical implications of serum Mac-2-binding protein (M2BPGi) during regular follow-up of patients with biliary atresia[J].Pediatr Surg Int,2018,34(10):1065-1071.DOI:10.1007/s00383-018-4317-2.
[17] Nakajima H,Koga H,Okawada M,et al.Does time taken to achieve jaundice-clearance influence survival of the native liver in post-Kasai biliary atresia?[J].World J Pediatr,2018,14(2):191-196.DOI:10.1007/s12519-018-0139-5.
相似文献/References:
[1]刘钢高昕刘树立黄柳明王伟邵培侯文英张军李龙.胆道闭锁葛西手术后肝内胆管扩张的治疗与预后分析[J].临床小儿外科杂志,2010,9(03):0.
LIU Gang,GAO Xin,LIU Shu-li,et al.The managements and prognosis of intrahepatic biliary dilatation with biliary atresia after Kasai procedure[J].Journal of Clinical Pediatric Surgery,2010,9(11):0.
[2]毛永忠,汤绍涛,阮庆兰,等.胆道闭锁肝组织MMP-1、MMP-2、TIMP-1的表达与预后研究[J].临床小儿外科杂志,2007,6(01):5.
[3]毛永忠,汤绍涛,阮庆兰,等.胆道闭锁肝脏组织MMP-2、TGF-β_1的表达及意义[J].临床小儿外科杂志,2007,6(03):5.
[4]沈淳,郑珊,王玮,等.手术年龄对胆道闭锁Kasai手术后预后影响的研究[J].临床小儿外科杂志,2007,6(03):6.
[5]马力,钟微,余家康,等.新生儿肠穿孔危重评分及预后分析[J].临床小儿外科杂志,2007,6(04):10.
[6]金龙 俞钢 陈丹 朱小春 葛午平 林炎坤. 产前诊断脐膨出胎儿80例结局分析[J].临床小儿外科杂志,2011,10(03):199.
[J].Journal of Clinical Pediatric Surgery,2011,10(11):199.
[7]方炜 丁力 张峰 胡英超 陈雨青. 婴幼儿法乐四联症手术治疗近期疗效的影响因素[J].临床小儿外科杂志,2011,10(06):403.
[J].Journal of Clinical Pediatric Surgery,2011,10(11):403.
[8]余梦楠 刘钢 黄柳明 王伟. 胆道闭锁术后反复发作性胆管炎的细菌谱分析及抗生素选择[J].临床小儿外科杂志,2012,11(03):187.
[J].Journal of Clinical Pediatric Surgery,2012,11(11):187.
[9]张金山 李龙 侯文英 刘树立. Ⅲ型胆道闭锁不同亚型与预后关系的探讨[J].临床小儿外科杂志,2012,11(04):244.
[J].Journal of Clinical Pediatric Surgery,2012,11(11):244.
[10]董淳强 杨体泉 董昆. 胆道闭锁术后早期胆管炎风险因素分析[J].临床小儿外科杂志,2013,12(05):348.
[11]詹江华,王智茹.聚焦胆道闭锁诊疗相关热点问题[J].临床小儿外科杂志,2023,22(03):201.[doi:10.3760/cma.j.cn101785-202212026-001]
Zhan Jianghua,Wang Zhiru.Focusing upon hot issues of diagnosing and treating biliary atresia[J].Journal of Clinical Pediatric Surgery,2023,22(11):201.[doi:10.3760/cma.j.cn101785-202212026-001]
[12]詹江华,孙溶涓,王智茹,等.日本《胆道闭锁临床实践指南》解读[J].临床小儿外科杂志,2023,22(03):205.[doi:10.3760/cma.j.cn101785-202212025-002]
Zhan Jianghua,Sun Rongjuan,Wang Zhiru,et al.Interpretations of Clinical Practice Guidelines for Biliary Atresia in Japan[J].Journal of Clinical Pediatric Surgery,2023,22(11):205.[doi:10.3760/cma.j.cn101785-202212025-002]
[13]韩一江,吴昊,季浩森,等.胆道闭锁Kasai手术日龄与早期预后的关联性分析[J].临床小儿外科杂志,2023,22(03):225.[doi:10.3760/cma.j.cn101785-202210044-005]
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(11):225.[doi:10.3760/cma.j.cn101785-202210044-005]
[14]赵一霖,吴晓霞,徐晓丹,等.巨细胞病毒感染对胆道闭锁Kasai手术预后影响的研究[J].临床小儿外科杂志,2023,22(03):232.[doi:10.3760/cma.j.cn101785-202212017-006]
Zhao Yilin,Wu Xiaoxia,Xu Xiaodan,et al.Prognosis of biliary atresia associated with cytomegalovirus[J].Journal of Clinical Pediatric Surgery,2023,22(11):232.[doi:10.3760/cma.j.cn101785-202212017-006]
[15]吴晓霞,刘文跃,孙雪,等.胆道闭锁患儿Kasai手术后频发胆管炎的危险因素及预后分析[J].临床小儿外科杂志,2023,22(03):244.[doi:10.3760/cma.j.cn101785-202212005-008]
Wu Xiaoxia,Liu Wenyue,Sun Xue,et al.Risk factors and prognosis of recurrent cholangitis after Kasai in biliary atresia patients[J].Journal of Clinical Pediatric Surgery,2023,22(11):244.[doi:10.3760/cma.j.cn101785-202212005-008]
备注/Memo
收稿日期:2022-3-7。
基金项目:上海市儿童医院院级课题临床研究培育专项(2021YLYM02)
通讯作者:吴一波,Email:yibo_wu1007@163.com