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Eur J Pediatr Surg 2021; 31(01): 080-085
DOI: 10.1055/s-0040-1715614
Original Article

The Intestinal Flora at Kasai Procedure in Children with Biliary Atresia Appears Not to Affect Postoperative Cholangitis

Omid Madadi-Sanjani
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Nagoud Schukfeh
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Marie Uecker
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Stefanie Eckmann
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Jens Dingemann 
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Benno M. Ure
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Claus Petersen
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
,
Joachim F. Kuebler
1   Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Abstract

Introduction Evidence supports long-term oral antibiotic prophylaxis to prevent cholangitis after Kasai procedure. Data regarding perioperative intravenous prophylaxis are lacking. Ascending pathogens from the intestine are made responsible for recurrent cholangitis. Therefore, we analyzed the flora in the upper jejunum during the Kasai procedure and their potential impact on postoperative cholangitis.

Materials and Methods In 26 patients, swabs were taken at the bowel prepared for the Roux-en-Y-loop. Our postoperative protocol includes intravenous third-generation cephalosporins for 2 weeks and rectal steroids starting at day 4. Cholangitis was defined as the postoperative reappearance of acholic stools or increase of serum bilirubin in combination with fevers or increase of inflammatory parameters. In this scenario, Tazocin was administered for another 2 weeks.

Results Swabs remained sterile in nine patients (34.6%). In 17 patients (65.4%), gram-positive and gram-negative pathogens were identified; all belonging to physiological intestinal flora. A total of 96.2% pathogens were covered by the antibiotic prophylaxis. The cholangitis incidence was 55.6% in the sterile cohort, and 23.5% in the gram-positive and gram-negative cohort (p = 0.06). In the cholangitis cohort, no significant differences were detected for the age at Kasai and the pre- and postoperative total bilirubin.

Conclusion We found that our antibiotic regiment covered bacteria in the upper gastrointestinal (GI) tract in the majority of our patients at the time of Kasai. Nonetheless, a significant proportion of patients developed signs of cholangitis. There was no higher rate of cholangitis in patients with resistant bacteria. Thus, our data do not support the hypothesis of extended postoperative intravenous antibiotics to prevent ascending cholangitis.

Keywords

biliary atresia - cholangitis - intestinal flora - antibiotics

Supplementary Material



Publication History

Received: 20 May 2020

Accepted: 14 July 2020

Article published online:
20 August 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Asai A, Miethke A, Bezerra JA. Pathogenesis of biliary atresia: defining biology to understand clinical phenotypes. Nat Rev Gastroenterol Hepatol 2015; 12 (06) 342-352
    Google Scholar
  • 2 Petersen C, Davenport M. Aetiology of biliary atresia: what is actually known?. Orphanet J Rare Dis 2013; 8: 128
    CrossrefPubMedGoogle Scholar
  • 3 Reuben A. The sensei of Sendai: correcting the uncorrectable. Hepatology 2003; 37 (04) 952-955
    CrossrefPubMedGoogle Scholar
  • 4 Davenport M, Ong E, Sharif K. et al. Biliary atresia in England and Wales: results of centralization and new benchmark. J Pediatr Surg 2011; 46 (09) 1689-1694
    CrossrefPubMedGoogle Scholar
  • 5 Chardot C, Buet C, Serinet M-O. et al. Improving outcomes of biliary atresia: French national series 1986-2009. J Hepatol 2013; 58 (06) 1209-1217
    CrossrefPubMedGoogle Scholar
  • 6 Arnon R, Annunziato RA, D'Amelio G, Chu J, Shneider BL. Liver transplantation for biliary atresia: is there a difference in outcome for infants?. J Pediatr Gastroenterol Nutr 2016; 62 (02) 220-225
    CrossrefPubMedGoogle Scholar
  • 7 Ginström DA, Hukkinen M, Kivisaari R, Pakarinen MP. Biliary atresia-associated cholangitis: the central role and effective management of bile lakes. J Pediatr Gastroenterol Nutr 2019; 68 (04) 488-494
    CrossrefPubMedGoogle Scholar
  • 8 Baek SH, Kang J-M, Ihn K, Han SJ, Koh H, Ahn JG. The Epidemiology and etiology of cholangitis after kasai portoenterostomy in patients with biliary atresia. J Pediatr Gastroenterol Nutr 2020; 70 (02) 171-177
    CrossrefPubMedGoogle Scholar
  • 9 Liu J, Dong R, Chen G, Dong K, Zheng S. Risk factors and prognostic effects of cholangitis after Kasai procedure in biliary atresia patients: a retrospective clinical study. J Pediatr Surg 2019; 54 (12) 2559-2564
    CrossrefPubMedGoogle Scholar
  • 10 Bu L-N, Chen H-L, Chang C-J. et al. Prophylactic oral antibiotics in prevention of recurrent cholangitis after the Kasai portoenterostomy. J Pediatr Surg 2003; 38 (04) 590-593
    CrossrefPubMedGoogle Scholar
  • 11 Decharun K, Leys CM, West KW, Finnell SM. Prophylactic antibiotics for prevention of cholangitis in patients with biliary atresia status post-Kasai portoenterostomy: a systematic review. Clin Pediatr (Phila) 2016; 55 (01) 66-72
    CrossrefPubMedGoogle Scholar
  • 12 Mones RL, DeFelice AR, Preud'Homme D. Use of neomycin as the prophylaxis against recurrent cholangitis after Kasai portoenterostomy. J Pediatr Surg 1994; 29 (03) 422-424
    CrossrefPubMedGoogle Scholar
  • 13 Lien T-H, Bu L-N, Wu J-F. et al. Use of lactobacillus casei rhamnosus to prevent cholangitis in biliary atresia after Kasai operation. J Pediatr Gastroenterol Nutr 2015; 60 (05) 654-658
    CrossrefPubMedGoogle Scholar
  • 14 Biner B, Oner N, Celtik C. et al. Ceftriaxone-associated biliary pseudolithiasis in children. J Clin Ultrasound 2006; 34 (05) 217-222
    CrossrefPubMedGoogle Scholar
  • 15 Bor O, Dinleyici EC, Kebapci M, Aydogdu SD. Ceftriaxone-associated biliary sludge and pseudocholelithiasis during childhood: a prospective study. Pediatr Int 2004; 46 (03) 322-324
    CrossrefPubMedGoogle Scholar
  • 16 Musiime GM, Seale AC, Moxon SG, Lawn JE. Risk of gentamicin toxicity in neonates treated for possible severe bacterial infection in low- and middle-income countries: systematic review. Trop Med Int Health 2015; 20 (12) 1593-1606
    CrossrefPubMedGoogle Scholar
  • 17 Ramachandran P, Safwan M, Balaji MS. et al. Early cholangitis after portoenterostomy in children with biliary atresia. J Indian Assoc Pediatr Surg 2019; 24 (03) 185-188
    CrossrefPubMedGoogle Scholar
  • 18 Ishak K, Baptista A, Bianchi L. et al. Histological grading and staging of chronic hepatitis. J Hepatol 1995; 22 (06) 696-699
    CrossrefPubMedGoogle Scholar
  • 19 Lopez RN, Ooi CY, Krishnan U. Early and peri-operative prognostic indicators in infants undergoing hepatic portoenterostomy for biliary atresia: a review. Curr Gastroenterol Rep 2017; 19 (04) 16
    CrossrefPubMedGoogle Scholar
  • 20 Chusilp S, Sookpotarom P, Tepmalai K. et al. Prognostic values of serum bilirubin at 7th day post-Kasai for survival with native livers in patients with biliary atresia. Pediatr Surg Int 2016; 32 (10) 927-931
    CrossrefPubMedGoogle Scholar
  • 21 Sasaki H, Tanaka H, Wada M. et al. Analysis of the prognostic factors of long-term native liver survival in survivors of biliary atresia. Pediatr Surg Int 2016; 32 (09) 839-843
    CrossrefPubMedGoogle Scholar
  • 22 Luo Y, Zheng S. Current concept about postoperative cholangitis in biliary atresia. World J Pediatr 2008; 4 (01) 14-190
    CrossrefPubMedGoogle Scholar
  • 23 Hirsig J, Kara O, Rickham PP. Experimental investigations into the etiology of cholangitis following operation for biliary atresia. J Pediatr Surg 1978; 13 (01) 55-57
    CrossrefPubMedGoogle Scholar
  • 24 Hirsig J, Rickham PP, Briner J. The importance of hepatic lymph drainage in experimental biliary atresia. Effect of omentopexy on prevention of cholangitis. J Pediatr Surg 1979; 14 (02) 142-145
    CrossrefPubMedGoogle Scholar
  • 25 Nakajo T, Hashizume K, Saeki M, Tsuchida Y. Intussusception-type antireflux valve in the Roux-en-Y loop to prevent ascending cholangitis after hepatic portojejunostomy. J Pediatr Surg 1990; 25 (03) 311-314
    CrossrefPubMedGoogle Scholar
  • 26 Saeki M, Nakano M, Hagane K, Shimizu K. Effectiveness of an intussusceptive antireflux valve to prevent ascending cholangitis after hepatic portojejunostomy in biliary atresia. J Pediatr Surg 1991; 26 (07) 800-803
    CrossrefPubMedGoogle Scholar
  • 27 Ogasawara Y, Yamataka A, Tsukamoto K. et al. The intussusception antireflux valve is ineffective for preventing cholangitis in biliary atresia: a prospective study. J Pediatr Surg 2003; 38 (12) 1826-1829
    CrossrefPubMedGoogle Scholar
  • 28 Calinescu AM, Wilde JCH, Korff S, McLin VA, Wildhaber BE. Perioperative complications after Kasai hepatoportoenterostomy: data from the Swiss National Biliary Atresia Registry. Eur J Pediatr Surg 2019; DOI: 10.1055/s-0039-1692686.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Wong ZH, Davenport M. What happens after kasai for biliary atresia? a european multicenter survey. Eur J Pediatr Surg 2019; 29 (01) 1-6
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Patel A, Mao K-R, McNeil JC, Kaplan SL, Vallejo JG. Fever and reversible laboratory abnormalities associated with prolonged use of piperacillin-tazobactam in children. Pediatr Infect Dis J 2015; 34 (08) 849-850
    CrossrefPubMedGoogle Scholar
  • 31 McWilliam SJ, Antoine DJ, Smyth RL, Pirmohamed M. Aminoglycoside-induced nephrotoxicity in children. Pediatr Nephrol 2017; 32 (11) 2015-2025
    CrossrefPubMedGoogle Scholar
  • 32 Best EJ, Gazarian M, Cohn R, Wilkinson M, Palasanthiran P. Once-daily gentamicin in infants and children: a prospective cohort study evaluating safety and the role of therapeutic drug monitoring in minimizing toxicity. Pediatr Infect Dis J 2011; 30 (10) 827-832
    CrossrefPubMedGoogle Scholar
  • 33 Cammann S, Timrott K, Vonberg R-P. et al. Cholangitis in the postoperative course after biliodigestive anastomosis. Langenbecks Arch Surg 2016; 401 (05) 715-724
    CrossrefPubMedGoogle Scholar
  • 34 Goessmann H, Lang SA, Fichtner-Feigl S. et al. (Biliodigestive anastomosis: indications, complications and interdisciplinary management). Chirurg 2012; 83 (12) 1097-1108
    CrossrefPubMedGoogle Scholar
  • 35 Howard ER, Davenport M. The treatment of biliary atresia in Europe 1969-1995. Tohoku J Exp Med 1997; 181 (01) 75-83
    CrossrefPubMedGoogle Scholar
  • 36 Ecoffey C, Rothman E, Bernard O, Hadchouel M, Valayer J, Alagille D. Bacterial cholangitis after surgery for biliary atresia. J Pediatr 1987; 111 (6 Pt 1): 824-829
    CrossrefPubMedGoogle Scholar
  • 37 Pang W-B, Zhang T-C, Chen Y-J. et al. Ten-year experience in the prevention of post-Kasai cholangitis. Surg Infect (Larchmt) 2019; 20 (03) 231-235
    CrossrefPubMedGoogle Scholar
  • 38 Kelly DA, Davenport M. Current management of biliary atresia. Arch Dis Child 2007; 92 (12) 1132-1135
    CrossrefPubMedGoogle Scholar
  • 39 Stringer MD, Davison SM, Rajwal SR, McClean P. Kasai portoenterostomy: 12-year experience with a novel adjuvant therapy regimen. J Pediatr Surg 2007; 42 (08) 1324-1328
    CrossrefPubMedGoogle Scholar
  • 40 Wong KKY, Fan AH, Lan LCL, Lin SC, Tam PK. Effective antibiotic regime for postoperative acute cholangitis in biliary atresia--an evolving scene. J Pediatr Surg 2004; 39 (12) 1800-1802
    CrossrefPubMedGoogle Scholar
  • 41 Meyers RL, Book LS, O'Gorman MA. et al. High-dose steroids, ursodeoxycholic acid, and chronic intravenous antibiotics improve bile flow after Kasai procedure in infants with biliary atresia. J Pediatr Surg 2003; 38 (03) 406-411
    CrossrefPubMedGoogle Scholar
  • 42 Wu ET, Chen HL, Ni YH. et al. Bacterial cholangitis in patients with biliary atresia: impact on short-term outcome. Pediatr Surg Int 2001; 17 (5-6): 390-395
    CrossrefPubMedGoogle Scholar