Prophylactic oral antibiotic use for the prevention of cholangitis after Kasai portoenterostomy in patients with biliary atresia: a systematic review and meta-analysis.

BACKGROUND: Cholangitis is one of the most common and serious complications following Kasai portoenterostomy (KP) in patients with biliary atresia (BA). There is heterogeneity in antibiotic usage protocols across centers, and the efficacy of prophylactic oral antibiotics in preventing cholangitis remains unclear. This study aimed to assess the efficacy of prophylactic oral antibiotics in preventing cholangitis after KP in patients with BA. METHODS: A systematic review and meta-analysis were conducted, incorporating all eligible studies published or presented as abstracts from inception to July 6th, 2026. Inclusion criteria required original data comparing the incidence of cholangitis in BA patients who received prophylactic oral antibiotics after KP versus those who did not receive. The primary outcome was the incidence of cholangitis within the follow-up period. Secondary outcomes included the native liver survival (NLS) rate and jaundice clearance rate. Subgroup analysis was conducted in the incidence of cholangitis according to study design [randomized controlled trial (RCT) and retrospective cohort vs. cross-sectional]. The Cochrane Risk of Bias tool, Newcastle-Ottawa Scale (NOS), and NOS-xs were used to assess the risk of bias. Heterogeneity among studies was assessed by the chi-square test, and the random-effects model or the fixed-effects model was selected according to heterogeneity. RESULTS: Six studies, comprising 516 BA patients, met eligibility criteria. No statistically significant difference was observed in the incidence of cholangitis between the antibiotics and non-antibiotics groups [56.91% (177/311) vs. 56.59% (116/205), P = 0.75, OR=0.88, 95% CI: 0.41-1.92]. Similar results were found in subgroup analysis. In contrast, the NLS rate was significantly lower in the non-antibiotics group [54.35% (75/138) vs. 36.17% (34/94), P = 0.006, OR=2.15, 95% CI: 1.25-3.69]. Jaundice clearance rates did not differ significantly between the antibiotics and non-antibiotics groups [42.71% (85/199) vs. 38.56% (59/153), P = 0.94, OR=0.97, 95% CI: 0.40-2.34]. CONCLUSION: Current evidence does not support the protective effect of prophylactic oral antibiotics against cholangitis following KP in BA. Further high-quality, prospective randomized controlled trials are warranted to clarify causality and optimize antibiotic stewardship.