Wang Lei,Lan Zhaoping,Gao Qi,et al.Analysis of risk factors for cholangitis after Kasai procedure in biliary atresia children[J].Journal of Clinical Pediatric Surgery,2023,22(11):1039-1044.[doi:10.3760/cma.j.cn101785-202211061-007]
胆道闭锁患儿Kasai手术后胆管炎的危险因素分析
- Title:
- Analysis of risk factors for cholangitis after Kasai procedure in biliary atresia children
- Keywords:
- Biliary Atresia; Cholangitis; Root Cause Analysis; Surgical Procedures; Operative; Child
- 摘要:
- 目的 探讨胆道闭锁(biliary atresia,BA)Kasai手术后发生胆管炎的危险因素。方法 回顾性分析西安交通大学附属儿童医院2018年1月至2020年9月收治的109例因BA行Kasai手术患儿的临床资料。收集并记录性别、手术时日龄[＜60 d、60~90 d(含60 d)、≥90 d]、术前体重、心血管畸形、EB病毒(Epstein-Barr virus,EBV)感染、巨细胞病毒(cytomegalovirus,CMV)感染、术前肝脏弹性模量值、术前肝功能指标[总胆红素(total bilirubin,TBIL)、直接胆红素(direct bilirubin,DBIL)、谷草转氨酶(aspartate aminotransferase,AST)、谷丙转氨酶(alanine aminotransferase,ALT)、碱性磷酸酶(alkaline phosphatase,ALP)、谷氨酰转肽酶(glutamyl transpeptidase,GGT)、总胆汁酸(total bile acid,TBA)、白蛋白(albumin,ALB)、总胆固醇(total cholesterol,TC)]、手术时长、术后禁食时长、术后住院时长、术后激素使用情况、术后6个月内黄疸消退情况以及术后胆管炎发生情况;根据术后是否出现胆管炎分为胆管炎组(n=71)和非胆管炎组(n=38);采用卡方检验或非参数检验进行单因素分析,采用Logistic回归进行多因素分析。结果 109例患儿中,7例(7/109,6.4%)术后1个月黄疸完全消退,41例(41/109,37.6%)术后3个月黄疸完全消退,53例(53/109,48.6%)术后6个月黄疸完全消退;随访期内共发生胆管炎71例(71/109,65.1%),术后3个月内发生胆管炎51例(51/109,46.8%),术后6个月内发生胆管炎60例(60/109,55.0%);早期胆管炎34例(34/71,47.9%),复发性胆管炎40例(34/71,56.3%)。两组术前肝功能(TBIL、DBIL、ALT、AST、ALP、GGT、TBA、TC、ALB)比较,差异均无统计学意义(P＞0.05);两组男性占比[64.7%(33/51)比35.3%(18/51)]、术前体重[4.54(4.03,5.00)kg比4.50(3.90,4.54)kg]、合并心血管畸形比例[63.6%(42/66)比36.4%(24/66)]、术前彩超检查肝右叶弹性模量值[12.80(10.50,15.60)kPa比10.70(8.70,14.70)kPa]、术前EB病毒感染率[62.7%(47/75)比37.3%(28/75)]、手术时长[(3.42(2.92,3.70)h比3.24(2.90,3.75)h]、术后禁食时长[3.00(3.00,3.29)d比3.00(3.00,4.00)d]、术后激素使用率[54.8%(17/31)比45.2%(14/31)]、住院时长[23.00(18.00,27.00)d比24.00(20.00,28.00)d]比较,差异均无统计学意义(P＞0.05);术前CMV感染患儿胆管炎的发生率明显低于术前无CMV感染的患儿[50%(13/26)比74.1%(40/54),χ2=4.549,P=0.033],差异有统计学意义;术后6个月内黄疸消退患儿胆管炎的发生率明显低于黄疸未消退患儿[50.9%(27/53)比78.6%(44/56),χ2=9.153,P=0.002],差异有统计学意义;多因素Logistic回归分析结果显示,手术时日龄(OR=2.764,95%CI:1.017~7.515,P＜0.05)及术后6个月内黄疸是否消退(OR=0.283,95%CI:0.123~0.653,P＜0.05)是影响BA术后胆管炎发生的危险因素。结论 手术时日龄60~90 d及术后6个月内黄疸未消退是BA患儿Kasai手术后发生胆管炎的危险因素;选择合适的手术时机以及早期退黄能降低胆管炎的发生率。
- Abstract:
- Objective To explore the risk factors of cholangitis after Kasai procedure for BA children.Methods Retrospective analysis of clinical data of 109 infants undergoing Kasai surgery for BA admitted to Xi’an Jiaotong University Affiliated Children’s Hospital from January 2018 to September 2020.Collect and record gender,operative age[＜60 d、60~90 d(60 d)、≥90 d],operating age,preoperative weight,cardiovascular malformations,Epstein-Barr virus infection,CMV infection,preoperative liver elastic modulus,preoperative liver function indexes[total bilirubin(TBIL), direct bilirubin(DBIL),Aspartate aminotransferase (AST),alanine aminotransferase (ALT),alkaline phosphatase (ALP),Glutamate transpeptidase (GGT),total bile acid (TBA),albumin (ALB),total cholesterol (TC)],operation duration,postoperative fasting time,postoperative hospital stay,postoperative hormone dosing,clearnace of jaundice within 6 months and occurrence of cholangitis.According to whether or not cholangitis occurred postoperatively,they were divided into two groups of cholangitis and non-cholangitis.Chi-square test or non-parametric test was utilized for univariate analysis and logistic regression for multivariate analysis.Results Among the 109 children,7(7/109,6.4%) cases had complete jaundice clearance within 1 month after operation,41(41/109,37.6%)cases had complete jaundice clearance within 3 months,and 53(53/109,48.6%) cases had complete jaundice clearance within 6 months; During the follow-up period,there were 71(71/109,65.1%)cases of cholangitis,51(51/109,46.8%) cases of cholangitis occurred within 3 months postoperatively,60(60/109,55.0%) cases of cholangitis occurred within 6 months postoperatively; 34(34/71,47.9%) cases of early cholangitis, 40(34/71,56.3%) cases of recurrent cholangitis.There was no statistically significant difference in liver function(TBIL、DBIL、ALT、AST、ALP、GGT、TBA、TC、ALB) between the two groups before operation(P＞0.05).There were no statistically significant differences between the cholangitis group and non-cholangitis group in male and female{[ 64.7%(33/51)vs.65.5%(38/58)]、[35.3%(18/51)vs.34.5%(20/58)]},preoperative weight[4.54(4.03 5.00)kg vs.4.50(3.90 4.54)kg ],cardiovascular malformation{[63.6%(42/66) vs.67.4%(29/43)]、[ 36.4%(24/66) vs.32.6%(14/43)]},elastic modulus of the right lobe of liver examined by preoperative color ultrasound[12.80(10.50~15.60)kPa vs.10.70(8.70~14.70)kPa],preoperative EBV infection{[62.7%(47/75) vs.75.0%(3/4)]、[37.3%(28/75) vs.25.0%(1/4)]},surgical duration[(3.42(2.92~3.70)h vs.3.24(2.90~3.75)h],postoperative fasting duration[3.00(3.00~3.29)d vs.3.00(3.00~4.00)d],postoperative hormone use or not{[ 54.8%(17/31) vs.69.2%(54/78)]、[ 45.2%(14/31) vs.30.8%(24/78)]},hospitalization duration [23.00(18.00~27.00)d vs.24.00(20.00~28.00)d],(P>0.05).The age of operation between the two groups was statistically significant [60%(39/65) vs.80.6%(29/36) vs.37.5%(3/8)?
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] 中华医学会小儿外科学分会肝胆外科学组.胆道闭锁Kasai术后胆管炎诊疗专家共识(2022版)[J].中华小儿外科杂志,2022,43(9):769-774.DOI:10.3760/cma.j.cn421158-20220427-00308. Group of Hepatobiliary Surgery,Branch of Pediatric Surgery,Chinese Medical Association:Expert Consensus on Diagnosing and Treating Cholangitis after Kasai Operation for Biliary Atresia (2022 Edition)[J].Chin J Pediatr Surg,2022,43(9):769-774.DOI:10.3760/cma.j.cn421158-20220427-00308.
[3] 詹江华,卫园园.胆道闭锁患儿Kasai术后胆管炎病因及诊疗状况[J].天津医药,2016,44(7):803-806.DOI:10.11958/20160236. Zhan JH,Wei YY.Etiology and management of cholangitis after Kasai operation for biliary atresia in children[J].Tianjin MedJ,2016,44(7):803-806.DOI:10.11958/20160236.
[4] 王培,冯杰雄.胆道闭锁术后胆管炎抗生素分级治疗的多中心研究方案[J].临床小儿外科杂志,2019,18(11):922-926.DOI:10.3969/j.issn.1671-6353.2019.11.006. Wang P,Feng JX.Antibiotic grading treatment of cholangitis post-Kasai portoenterostomy:a multi-center study protocol[J].J Clin Ped Sur,2019,18(11):922-926.DOI:10.3969/j.issn.1671-6353.2019.11.006.
[5] 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(3):10-12.DOI:10.3969/j.issn.1671-6353.2007.03.004. Shen C,Zheng S,Wang W,et al.Effect of operative age on the prognosis of Kasai procedure with biliary atresia[J].J Clin Ped Sur,2007,6(3):10-12.DOI:10.3969/j.issn.1671-6353.2007.03.004.
[6] 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.
[7] Di Dato F,Ranucci G,de Ville de Goyet J,et al.Unusual clinical course for untreated malformative biliary atresia infant:is portal hypertension an important driver of liver fibrosis?[J].J Pediatr Gastroenterol Nutr,2021,72(2):216-219.DOI:10.1097/MPG.0000000000002932.
[8] Liu J,Dong R,Chen G,et al.Risk factors and prognostic effects of cholangitis after Kasai procedure in biliary atresia patients:a retrospective clinical study[J].J Pediatr Surg,2019,54(12):2559-2564.DOI:10.1016/j.jpedsurg.2019.08.026.
[9] Okubo R,Nio M,Sasaki H,et al.Impacts of early Kasai portoenterostomy on short-term and long-term outcomes of biliary atresia[J].Hepatol Commun,2021,5(2):234-243.DOI:10.1002/hep4.1615.
[10] 李明明,潘永康,卢朝祥.不同年龄段胆道闭锁患儿γ-谷氨酰转肽酶研究分析[J].中华小儿外科杂志,2022,43(6):511-516.DOI:10.3760/cma.j.cn4211582021043000224. Li MM,Pan YK,Lu CX.Analysis of γ-glutamyl transpeptidase in children with biliary atresia at different ages[J].ChinJ Pediatr Surg,2022,43(6):511-516.DOI:10.3760/cma.j.cn4211582021043000224.
[11] Yerina SE,Ekong UD.Biliary atresia/neonatal cholestasis:what is in the horizon?[J].Pediatr Clin North Am,2021,68(6):1333-1341.DOI:10.1016/j.pcl.2021.08.002.
[12] Chen G,Zheng S,Sun S,et al.Early surgical outcomes and pathological scoring values of older infants (≥ 90 d old) with biliary atresia[J].J Pediatr Surg,2012,47(12):2184-2188.DOI:10.1016/j.jpedsurg.2012.09.002.
[13] 熊希倩,詹江华,胡晓丽,等.胆道闭锁患儿肝纤维化及炎症细胞浸润与Kasai术后胆管炎的关系[J].天津医药,2018,46(7):692-695.DOI:10.11958/20180078. Xiong XQ,Zhan JH,Hu XL,et al.Correlation between liver fibrosis,inflammatory infiltration and postoperative cholangitis after Kasai operation for children with biliary atresia[J].Tianjin Med J,2018,46(7):692-695.DOI:10.11958/20180078.
[14] 丁彩琳,陈亚军.二维剪切波弹性成像在胆道闭锁中的研究进展[J].临床小儿外科杂志,2022,21(6):571-575.DOI:10.3760/cma.j.cn101785-202011032-014. Ding CL,Chen YJ.Research advances of two-dimensional shear wave elastography in biliary atresia[J].J Clin Ped Sur,2022,21(6):571-575.DOI:10.3760/cma.j.cn101785-202011032-014.
[15] 胡思佳,白玉作.巨细胞病毒感染对胆道闭锁患儿预后影响的meta分析[J].中华小儿外科杂志,2016,37(5):342-346.DOI:10.3760/cma.j.issn.0253-3006.2016.05.005. Hu SJ,Bai YZ.Effects of cytomegalovirus infection on the prognosis of children with biliary atresia:a Meta-analysis[J].Chin J Pediatr Surg,2016,37(5):342-346.DOI:10.3760/cma.j.issn.0253-3006.2016.05.005.
[16] Zhao YL,Xu XD,Liu GX,et al.Prognosis of biliary atresia associated with cytomegalovirus:a meta-analysis[J].Front Pediatr,2021,9:710450.DOI:10.3389/fped.2021.710450.
[17] 陈扬,詹江华.胆道闭锁Kasai术后自体肝生存情况研究进展[J].天津医药,2016,44(7):829-833.DOI:10.11958/20160237. Chen Y,Zhan JH.Research advances on the survival status of autologous liver in children with biliary atresia after Kasai operation[J].Tianjin Med J,2016,44(7):829-833.DOI:10.11958/20160237.
[18] 葛军涛.胆道闭锁Kasai术后胆管炎的病因及治疗[J].中华小儿外科杂志,2013,34(5):387-390.DOI:10.3760/cma.j.issn.0253-3006.2013.05.017. Ge JT.Causes and treatments of cholangitis after Kasai operation for biliary atresia[J].Chin J Pediatr Surg,2013,34(5):387-390.DOI:10.3760/cma.j.issn.0253-3006.2013.05.017.
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备注/Memo
收稿日期:2022-11-29。
基金项目:西安市卫生健康委项目(2023ms09)
通讯作者:高琪,Email:851004877@qq.com