Prophylactic therapies for the prevention of cholangitis in pediatric patients undergoing kasai procedure: a systematic review

Introduction: Cholangitis is a frequent and severe complication following Kasai portoenterostomy in children with biliary atresia, significantly impacting native liver survival. Although prophylactic strategies such as antibiotics have been widely employed, their effectiveness remains inconclusive. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Comprehensive literature searches were performed in PubMed, Cochrane Library, Scopus, and Web of Science up to June 2025. Eligible studies included randomized controlled trials and observational cohorts evaluating prophylactic interventions to prevent cholangitis post-Kasai in pediatric patients. Data extraction focused on study characteristics, interventions, outcomes, and methodological quality assessed using RoB 2 and the Newcastle-Ottawa Scale. Results: Six primary studies involving 454 patients were included. One randomized controlled trial demonstrated that oral TMP-SMX or neomycin for six months postoperatively significantly reduced cholangitis recurrence compared to historical controls. Another study showed early intravenous antibiotics followed by oral TMP-SMX reduced cholangitis incidence. However, three retrospective cohorts found no significant benefit of antibiotic prophylaxis in reducing infection rates or improving transplant-free survival. One study evaluating Roux-en-Y limb length suggested that surgical configuration may influence cholangitis risk. Methodological quality ranged from low to high, with heterogeneity in interventions and follow-up duration. Conclusion: Oral prophylactic antibiotics, particularly TMP-SMX, may offer benefit in reducing postoperative cholangitis following the Kasai procedure. Nonetheless, current evidence remains inconsistent. Standardized multicenter trials are warranted to establish optimal preventive strategies.