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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2022, Vol. 11 ›› Issue (02) : 149 -153. doi: 10.3877/cma.j.issn.2095-3232.2022.02.008

临床研究

Kasai手术对胆道闭锁患儿肝移植疗效的影响
李晓斌1, 冯啸1, 谢云亮1, 杨洲1, 杨卿1, 傅斌生1,†(), 易述红1, 杨扬1, 陈规划1   
  1. 1. 510530　广州，中山大学附属第三医院岭南医院肝脏外科暨器官移植科　中山大学器官移植研究所　广东省器官移植研究中心
  • 收稿日期:2021-11-30 出版日期:2022-04-10
  • 通信作者: 傅斌生
  • 基金资助:
    国家自然科学基金面上项目(2020GZRPYMS04); 广东省基础与应用基础研究基金(2020A1515010302)

Effect of Kasai operation on clinical efficacy of liver transplantation in children with biliary atresia

Xiaobin Li1, Xiao Feng1, Yunliang Xie1, Zhou Yang1, Qing Yang1, Binsheng Fu1,†(), Shuhong Yi1, Yang Yang1, Guihua Chen1   

  1. 1. Department of Hepatobiliary Surgery, Department of Organ Transplantation, Lingnan Hospital, the Third Affiliated Hospital of Sun Yat-sen University, Organ Transplantation Institute of Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510530, China
  • Received:2021-11-30 Published:2022-04-10
  • Corresponding author: Binsheng Fu
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李晓斌, 冯啸, 谢云亮, 杨洲, 杨卿, 傅斌生, 易述红, 杨扬, 陈规划. Kasai手术对胆道闭锁患儿肝移植疗效的影响[J]. 中华肝脏外科手术学电子杂志, 2022, 11(02): 149-153.

Xiaobin Li, Xiao Feng, Yunliang Xie, Zhou Yang, Qing Yang, Binsheng Fu, Shuhong Yi, Yang Yang, Guihua Chen. Effect of Kasai operation on clinical efficacy of liver transplantation in children with biliary atresia[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2022, 11(02): 149-153.

目的

探讨Kasai手术对胆道闭锁（BA）患儿行肝移植术疗效的影响。

方法

回顾性分析2013年10月至2020年10月在中山大学附属第三医院岭南医院行肝移植术的105例BA患儿临床资料。患儿监护人均签署知情同意书，符合医学伦理学规定。其中男61例，女44例；年龄4~168个月，中位年龄8个月。根据肝移植术前是否行Kasai手术，分为Kasai组（51例）和非Kasai组（54例）。比较两组肝移植术前一般情况、围手术期情况和术后并发症发生情况。对患儿进行随访，比较两组肝移植术后生存率。两组年龄、儿童终末期肝病模型（PELD）评分、移植物重量与受体体重比（GRWR）比较采用秩和检验或t检验。两组肝移植术后并发症发生率比较采用χ2检验。生存分析采用Kaplan-Meier法和Log-rank检验。

结果

Kasai组移植时年龄为11（28）个月，明显大于非Kasai组的7（2）个月（Z=5.005，P<0.05）；而PELD评分为8（22）分，明显低于非Kasai组的21（10）分（Z=-5.211，P<0.05）；GRWR为（3.0±0.9）%，亦明显低于非Kasai组的（3.4±0.7）%（t=-2.275，P<0.05）。Kasai组24%（12/51）采用全肝移植，非Kasai组94%（51/54）采用活体或劈离式肝移植（χ2=8.443，P<0.05）。Kasai组肝移植术后并发症发生率为12%（6/51），非Kasai组为17%（9/54），差异无统计学意义（χ2=0.515，P>0.05）。Kasai组肝移植术后1、2、3、5年生存率分别为94.1%、88.7%、83.5%、83.5%，非Kasai组相应为92.6%、90.4%、87.9%、78.1%，差异无统计学意义（χ2=0.001，P>0.05）。

结论

Kasai手术能有效延迟BA患儿肝移植需求，改善术前条件，降低肝移植手术风险和难度，且与直接行肝移植患儿术后生存率相当。

关键词: 胆道闭锁, Kasai手术, 儿童, 肝移植, 存活率
Objective

To evaluate the effect of Kasai operation on the clinical efficacy of liver transplantation in children with biliary atresia (BA).

Methods

Clinical data of 105 children with BA who underwent liver transplantation in Lingnan Hospital, the Third Affiliated Hospital of Sun Yat-sen University from October 2013 to October 2020 were retrospectively analyzed. The informed consents of the patients' guardians were obtained and the local ethical committee approval was received. Among them, 61 children were male and 44 female, aged from 4 to 168 months old, with a median age of 8 months old. According to whether Kasai operation was performed before liver transplantation, the patients were divided into the Kasai group (n=51) and non-Kasai group (n=54). Preoperative general conditions, perioperative conditions and incidence of postoperative complications were compared between two groups. The children were followed up. The survival rate after liver transplantation was compared between two groups. Age, pediatric end-stage liver disease (PELD) score and the graft-to-recipient weight ratio (GRWR) between two groups were compared by rank-sum test or t test. The incidence of complications after liver transplantation between two groups was compared by Chi-square test. Survival analysis was performed by Kaplan-Meier method and Log-rank test.

Results

In the Kasai group, the age of children undergoing liver transplantation was 11(28) months, significantly older than 7(2) months in the non-Kasai group (Z=5.005,P<0.05). In the Kasai group, the PELD score was 8(22), significantly lower compared with 21(10) in the non-Kasai group (Z=-5.211,P<0.05). In the Kasai group, the GRWR was (3.0±0.9)%, significantly lower than (3.4±0.7)% in the non-Kasai group (t=-2.275,P<0.05). Total liver transplantation was adopted in 24%(12/51) of patients in the Kasai group, whereas living or split liver transplantation was performed in 94%(51/54) of patients in the non-Kasai group (χ2=8.443,P<0.05). The incidence of complications after liver transplantation in the Kasai group was 12%(6/51) and 17%(9/54) in the non-Kasai group with no significant difference between two groups (χ2=0.515,P>0.05). In the Kasai group, the 1-, 2-, 3- and 5-year survival rates after liver transplantation were 94.1%, 88.7%, 83.5% and 83.5%, and 92.6%, 90.4%, 87.9% and 78.1% in the non-Kasai group with no significant difference between two groups (χ2=0.001,P>0.05).

Conclusions

Kasai operation can effectively postpone the requirement of liver transplantation in BA children, improve the preoperative conditions, lower the risk and difficulty of liver transplantation, and yield equivalent survival rate compared with that of their counterparts undergoing immediate liver transplantation.

Key words: Biliary atresia, Kasai procedure, Child, Liver transplantation, Survival rate
表1 Kasai组和非Kasai组胆道闭锁患儿肝移植术前一般情况比较
参数 性别（例） 移植时年龄[月，M(QR)] 体重[kg，M(Q R )] TB [μmol/L，M(QR)] 胆碱酯酶[U/L，M(QR)] WBC [×109/L，M(QR)] INR [M(QR)] PELD [分，M(QR)] ALB [g/L，M(QR)] Plt [×109/L，M(QR)]
男 女
Kasai组 31 20 11(28) 9(8) 150(227) 3 716(2 155) 07(8) 1.3(0.4) 08(22) 37(9) 151(177)
非Kasai组 30 24 7(2) 7(2) 306(172) 2 535(1 017) 12(10) 1.6(1.0) 21(10)0 32(7) 158(118)
统计值 χ2=0.295 Z=5.005 Z=4.063 Z=-5.161 Z=4.587 Z=-3.388 Z=-3.219 Z=-5.211 Z=3.507 Z=-0.588
P值 0.587 <0.001 <0.001 <0.001 <0.001 0.001 0.001 <0.001 <0.001 0.577
表2 Kasai组和非Kasai组胆道闭锁患儿肝移植围手术期情况比较
参数 无肝期时间(min，±s) 冷缺血时间[min，M(QR)] 术中出血量[ml，M(QR)] 手术时间(min，±s) ICU住院时间[d，M(QR)]
Kasai组 56±15 367（251） 200（300） 446±86 3（2）
非Kasai组 58±14 355（301） 200（150） 464±86 3（3）
统计值 t=-0.865 Z=0.178 Z=0.827 t=-1.099 Z=-1.103
P值 0.389 0.859 0.408 0.274 0.270
参数 GRWR (%，±s) 总住院时间[d，M(QR)] 供肝类型（例） 劈离式供肝（例）
全肝 活体 劈离 左半肝 右半肝 右三叶 左外叶
Kasai组 3.0±0.9 31（19） 12 14 25 2 2 1 20
非Kasai组 3.4±0.7 35（21） 3 25 26 1 2 0 23
统计值 t=-2.275 Z=-1.562 χ2=8.443 -
P值 0.026 0.118 0.015 0.771
表3 Kasai组和非Kasai组胆道闭锁患儿肝移植术后并发症情况（例）
术后并发症 Kasai组 非Kasai组
门静脉血栓形成 2 1
门静脉吻合口狭窄 0 1
肝动脉血栓形成 1 0
肝动脉吻合口狭窄 1 1
胆管吻合口狭窄 0 2
创面胆漏 1 2
肠瘘 1 2
图1 Kasai组和非Kasai组胆道闭锁患儿肝移植术后Kaplan-Meier生存曲线注：Kasai组51例，非Kasai组54例
[1]
Wong KKY, Wong CWY. A review of long-term outcome and quality of life of patients after Kasai operation surviving with native livers[J]. Pediatr Surg Int, 2017, 33(12):1283-1287.
[2]
Özen J, Beime J, Brinkert F, et al. Short- and long-term results of liver transplantation according to age at transplant: a single-center experience of 351 children[J]. Transpl Int, 2021, 34(7):1251-1260.
[3]
Yang J, Gao W, Zhan J, et al. Kasai procedure improves nutritional status and decreases transplantation-associated complications[J]. Pediatr Surg Int, 2018, 34(4):387-393.
[4]
Lakshminarayanan B, Davenport M. Biliary atresia: a comprehensive review[J]. J Autoimmun, 2016(73):1-9.
[5]
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.
[6]
Jain V, Burford C, Alexander EC, et al. Prognostic markers at adolescence in patients requiring liver transplantation for biliary atresia in adulthood[J]. J Hepatol, 2019, 71(1):71-77.
[7]
Wang Z, Chen Y, Peng C, 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.
[8]
Shirota C, Murase N, Tanaka Y, et al. Laparoscopic Kasai portoenterostomy is advantageous over open Kasai portoenterostomy in subsequent liver transplantation[J]. Surg Endosc, 2020, 34(8):3375-3381.
[9]
Tam PKH, Chung PHY, St Peter SD, et al. Advances in paediatric gastroenterology[J]. Lancet, 2017, 390(10099):1072-1082.
[10]
Hartley JL, Davenport M, Kelly DA. Biliary atresia[J]. Lancet, 2009, 374(9702):1704-1713.
[11]
Harpavat S, Garcia-Prats JA, Anaya C, et al. Diagnostic yield of newborn screening for biliary atresia using direct or conjugated bilirubin measurements[J]. JAMA, 2020, 323(12):1141-1150.
[12]
Qiao G, Li L, Cheng W, et al. Conditional probability of survival in patients with biliary atresia after Kasai portoenterostomy: a Chinese population-based study[J]. J Pediatr Surg, 2015, 50(8):1310-1315.
[13]
Wong TC, Fung JYY, Cui TYS, et al. The risk of going small: lowering GRWR and overcoming small-for-size syndrome in adult living donor liver transplantation[J]. Ann Surg, 2021, 274(6):e1260-1268.
[14]
Chung PHY, Chok KSH, Wong KKY, et al. Determining the optimal timing of liver transplant for pediatric patients after Kasai portoenterostomy based on disease severity scores[J]. J Pediatr Surg, 2020, 55(9):1892-1896.
[15]
Miller CM, Quintini C, Dhawan A, et al. The international liver transplantation society living donor liver transplant recipient guideline[J]. Transplantation, 2017, 101(5):938-944.
[16]
LeeVan E, Matsuoka L, Cao S, et al. Biliary-enteric drainage vs primary liver transplant as initial treatment for children with biliary atresia[J]. JAMA Surg, 2019, 154(1):26-32.
[17]
Neto JS, Feier FH, Bierrenbach AL, et al. Impact of Kasai portoenterostomy on liver transplantation outcomes: a retrospective cohort study of 347 children with biliary atresia[J]. Liver Transpl, 2015, 21(7):922-927.
[18]
Ge L, Zhan J, Gao W, et al. Relevant factors for early liver transplantation after Kasai portoenterostomy[J]. BMC Pediatr, 2020, 20(1):484.
[19]
Sokol RJ, Shepherd RW, Superina R, et al. Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop[J]. Hepatology, 2007, 46(2):566-581.
[20]
de Carvalho NMN, Torres SM, Cavalcante JCB, et al. Hepatoportoenterostomy surgery technique[J]. J Pediatr Surg, 2019, 54(8):1715-1718.
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