Prevention, diagnosis and treatment of biliary complications after liver transplantation

Objective To study the prevention, diagnosis and treatment of biliary complications after liver transplantation. Methods One hundred and twenty-three recipients who had received liver transplantation between April 1993 and November 2001 were retrospectively reviewed. Results Biliary complication was diagnosed cholangiographyically in 11 patients. Nine patients were cured, 1 patient was unproved and 1 patient died. The incidence for biliary complications was 8.9% (11/123),and the mortality was 0.8% (1/123). The incidence of biliary complicatins due to T tube was 4.2% (5/ 119). The incidence of biliary complications due to hepatic artery was 1. 6% (2/123). In recipients with WIT>3 min and CIT>8 h, the incidence of biliary complications elevated significantly. Conclusion The most important reason for biliary complications was preservative and ischemic injury. While repairing donor liver, damage to the blood supply system of donor liver bile ducts should be avoided. Meticulous T tube placement may reduce the     

Malignant biliary obstruction: treatment with interventional radiology

Objective To evaluate the method of palliative drainage by means of metallic indwelling stents or plastic tubes for patients with malignant biliary obstruction.Methods From January 1995 to Febuary 2001, 243 consecutive patients (161 men and 82 women; aged 26-91 years, mean of 61.3 years) with malignant biliary obstruction were treated with transhepatic placement of metallic stents and/or plastic tubes. Among them, 47 patients had pancreatic carcinoma, 98 cholangiocarcinoma, 28 metastatic carcinoma and 60 hepatic carcinoma. 169 stents of nine types were used in this series. After stenting, 47 patients were treated for local tumors. Procedure- and device-related complications were recorded. Patient survival and stent patency rates were calculated with Kaplan-Meier survival analysis.Results One hundred and three patients underwent successfully stent placement for the first time. Others had their stents installed 1 - 2 weeks after catheterization. Stents were used in 132 patients. Ninety-five patients were     

Role of interventional endovascular therapy for delayed hemorrhage after pancreaticoduodenectomy

Background Delayed massive hemorrhage （DMH） after pancreaticoduodenectomy （PD） is a sedous complication and one of the most common causes of mortality after PD. Its ideal management remains unclear. This paper is to present our experience in the endovascular treatment of patients with DMH after PD using different techniques and materials.Methods During a seven years period, 19 patients （fifteen men, four women） with DMH arter PD were treated with endovascular procedures, including transcatheter arterial embolization （TAE） with coils embolization in eight cases, with coils plus N-butyl-2-cyanoacrylate （NBCA）-Lipiodol mixture in six cases, and stent-graft placement in five cases. The mean age of the patients was 58.2 years. Follow-up, including clinical condition, liver function tests, and Doppler ultrasound examinations, was documented.Results The immediate technical success rate was 84.2% （16/19）. There were no significant procedure-related complications. Hemostasis was not achieved with interventional procedures in three patients： one died of uncontrolled bleeding four days after the second TAE, and two patients required emergency laparotomy without re-angiography because of worsening clinical status. Among the 16 patients with successfully stopped bleeding who became hemodynamically stable after the procedure without evidence of further bleeding, two patients died during the peri-interventional procedure period because of multiple organ failure, and fourteen patients survived to hospital discharge. The mean length of follow-up was 14.6 months. Recurrent bleeding after discharge did not occur in any of these cases. Clinical and laboratory follow-up findings were unremarkable. Doppler ultrasound examinatation verified patency of the hepatic artery in the four patients with stent-graft placement during the follow-up period （5 months-29 months; mean, 15.3 months）.Conclusions Interventional endovascular procedure is a safe and technically feasible solution to control DMH. The first-line treatment for the bleeding is TAE. Stent-graft placement with preservation of the organ arterial flow, if technicallypossible, is a valuable alternative to TAE and surgical intervention for management of DMH.     

Surgical techniques of arterialized orthotopic liver transplantation in rats

Background  Recently, much attention has been paid to hepatic artery reconstruction in rat liver transplantation, which can prevent bile duct ischemia and preserve better liver structure. In this study, three methods of graft arterialization, including sleeve, cuff, and stent anastomosis, were conducted and the results were compared.
Methods  Orthotopic liver transplantation (OLT) with rearterialization was conducted in 90 rats, which were divided into sleeve, cuff, and stent groups (n=30 in each). Ninety-six rats received OLTs with standardized two-cuff technique without rearterialization as a control. The sleeve technique included an end-to-end anastomosis between the donor common hepatic artery and recipient proper hepatic artery, or between the donor celiac artery and recipient common hepatic artery. Cuff technique involved an anastomosis between the donor common hepatic artery and recipient common hepatic artery. In the stent technique, the recipient hepatic artery and donor hepatic artery were connected using an intraluminal polyethylene stent. The arterial anastomosis time and arterial patency rate in each group were recorded. The liver graft survival and bile duct complication rates were measured.
Results  The total surgical time of OLT with rearterialization was (118.3±12.9) minutes in the sleeve group, (106.2±11.6) minutes in the cuff, (93.8±10.2) minutes in the stent, and (88.2±9.6) minutes in the control. The corresponding anhepatic phase was (19.6±2.8), (19.2±2.2), (18.6±1.8), and (20.0±2.5) minutes respectively in the sleeve, cuff, stent, and control groups. One-week survival rate was 86.5% in the control, and 86.7% in the groups with rearterialization. No significant difference was detected in the survival rate between them (P>0.05). The incidence of biliary complications in non-rearterialized group (17.7%) was significantly higher than that in the rearterialized group (6.7%, P<0.05). No significant difference was found in the incidence of biliary complications among the three rearterialized groups (P>0.05).
Conclusions  The OLT with rearterialization is more physiological than that without rearterialization, and leads to a lower rate of bile duct complications. Among the three methods of rearterialization, sleeve anastomosis is associated with a higher survival rate, allowing less dissection and less injury to the surrounding tissues.

     

Hemodynamic Changes on Color Doppler Flow Imaging and Intravenous Contrast-enhanced Ultrasound for Assessing Transplanted Liver and Early Diagnosis of Complications

The value of color Doppler flow imaging （CDFI） and intravenous contrast-enhanced ultrasound （CEUS） for assessing the transplanted liver and early diagnosing complications by examining hemodynamic changes was discussed. Seventy-five patients with orthotopic liver transplantation （OLT） underwent CDFI. The following parameters were measured： peak systolic velocity （PS）, resistance index （RI） and Doppler perfusion index （DPI） of the hepatic artery （HA）, time average velocity （TAV） of portal vein （PV） and velocity of hepatic vein （HV） in different stages postoperation, And 11 patients of them received CEUS. Thirty healthy subjects were enrolled as controls, The results showed that： （1） In 23 patients without obvious complications, TAV of PV within 15 days post-operation was significantly higher than in controls （P〈0.05）, PS and DPI of HA within 7 days postoperation were lower, but RI was higher than in controls （P〈0.05）; （2） When the hepatic artery thrombosis （HAT） occurred, PS and DPI of HA were obviously decreased, but TAV of PV significantly increased like a high saw-tooth wave; （3） While rejection occurred, both TAV of PV and PS of HA were decreased with the increase in RI of HA, and the triphasic wave of HV disappeared and displayed as saw-tooth wave; （4） The incidence of biliary complications in liver transplantation was increased when DPI was reduced; （5） Seven cases of hepatic carcinoma relapse after OLT demonstrated hyperecho in the arterial phase and hypoecho in the portal and later phase on CEUS; （6） In 2 cases of HA thrombus, there was no visualized enhancement in arterial phase of CEUS, but enhancement during the portal vein and parenchymal phase. It was concluded that the hemodynamic changes of PV, HA and HV in the transplanted liver are valuable for assessing the transplanted liver and early diagnosing complications on CDFI and CEUS.     

Revascularization for Iliac-femoral Artery Pseudoaneurysm with Greater Saphenous Vein

Objective To investigate the role of revascularization procedures with autologous greater saphenous vein in surgical management of iliac-femoral artery pseudoaneurysm in parenteral drug abusers. Methods Twenty-one patients with iliac-femoral artery pseudoaneurysm caused by parenteral drug abuse from 2004 to 2007 were enrolled. Among them,15 patients were male and 6 were female; their average age was 31.3 years. The size of pseudoaneurysms ranged from 3.0 cm to 7.5 cm. Common femoral artery and distal external iliac artery were often involved. We performed arterial reconstruction on these patients with autologous greater saphenous vein as a graft after excising iliac-femoral artery pseudoaneurysm through a single curved inguinal incision. All patients were followed up,and the complications were recorded. Results The surgical procedures were finished without intraoperative mortality or perioperative complications. All patients were free of claudication symptoms after the surgery except one case with preoperative popliteal artery stenosis. One case of infection and wound tissue fistula was found later. One case had inguinal incisional hematoma and another complained of numbness in thigh skin. Conclusions The use of autologous greater saphenous venous grafts for arterial reconstruction after pseudoaneurysm excision in drug abusers is safe and effective. This technique offers more advantages than arterial ligation alone without revascularization. An optimal greater saphenous venous graft is a prerequisite for revascularization.     

Diagnosis and treatment of biliary sludge, cast and stone following liver transplantation

Objective： To investigate etiological facts and treatment of biliary sludge, cast and stone following orthotopic liver transplantation（OLT）. Methods： A review was made using data collected from 81 cases with OLTs performed in our center from February 2003 to January 2004, and confirmed by retrospective study. Etiological factors of biliary sludge, cast and stone following OLT were analyzed, and treatment of biliary sludge, cast and stone following OLT were discussed. Result： Nine cases of biliary sludge, cast and stone were diagnosed and the incidence rate was 11.1%. Of these, five were biliary sludge and cast, 2 were bile stone and 2 were necrotic debris. Two cases with hepatic artery embolism received retransplantation and survived. The other one with hepatic artery embolism was ameliorated with nasobiliary drainage by ERCP. Two cases with biliary sludge and cast were resolved by non-operative treatment. Four cases were reoperated, 2 resolved and 2 cases died. Conclusion： Biliary injury and ischemia reperfusion injury, reject reaction, infection and changes of bile kinetics are the important factors causing biliary sludge, cast and stone following OLT. Shortening the time of cold and heat ischemia reperfusion injury of liver, reducing the injury of the blood supply of donor bile duct, actively preventing and early treating of infection and rejection reaction might reduce the incidence rate of biliary sludge, cast and stone following OLT.     

Thoraco-abdominal Aorta Revascularization through a Retroperitoneal Approach

Objective To investigate the application of the retroperitoneal approach in aortic surgery. Methods We collected and analyzed data of 7 patients in Macau who presented with aortic diseases from 2007 to 2008 and were treated with aorta repair through retroperitoneal approach. Demographic features as well as intraoperative and postoperative data were analyzed. One case of thoracoabdominal aneurysm and 4 cases of abdominal aneurysm received artificial graft, among which hybrid iliac artery reconstruction with Zenith stent covering the ostium of the left subclavian artery was performed in 2 cases of infrarenal abdominal aneurysm. Aortic-iliac artery bypass was performed in 2 cases of aortoiliac occlusion. Results No operative or early postoperative death was observed. No perioperative intestinal adhesion or ureteral obstruction was found. One case reported delayed paraplegia and graft infection as postoperative complications. The complications were partially removed 3 months later after rehabilitation. Conclusion Retroperitoneal approach is a safe and feasible technique, which associated with a low incidence of postoperative pulmonary complications.     

Clinical application of interventional techniques in the treatment of Budd-Chiari syndrome

Objective To evaluate the clinical value of various kinds of interventional techniques in the treatment of Budd-Chiari syndrome (BCS).Methods Multiple techniques such as recanalization of the inferior vena cava (IVC) under the guidance of marker and multi-angled fluoroscopy, recanalization of the hepatic vein with a transjugular approach, PTA, Z-expandable metallic stent (Z-EMS) implantation and modified TIPSS were used to treat 103 patients with BCS.Hesults Of 103 patients with BCS, 59 patients with obstruction of IVC were treated using recanalization of IVC. Seventeen patients with hepatic vein obstruction had their hepatic veins recanalized. The rest of the patients were given other methods of interventional treatment. Of all the subjects, 101 successfully underwent their procedures, with a success rate of 98.06% ; and only 2 failed to recanalization of the IVC. Fifty-three patients were treated using PTA for the first time, with a success rate of 100%. In the 48 patients undergoing Z-EMS implantation for the first time, the success rate was 95.8%. Five patients were treated with modified TIPSS. After these interventional treatments, the success rate was 100%. Two patients died 16 h and 72 h respectively after operation because of DIC and severe hemoptysis. SevenS-two patients were followed up for 1 -94 months (with a mean of 42. 3 months). The mean follow-up of a BCS patient treated with PTA was 52. 1 months, resulting in a primary patent rate of 59.4% and a restenosis rate of 40. 6%. The mean follow-up of BCS treated with stenting was 33.5 months, with a primary patent rate of 87.5% and a restenosis rate of 12. 5%. Eight patients died 7 -64 months after the interventional procedure.Conclusion Flecanalization of IVC or the hepatic vein transjugularly, PTA, Z-EMS implantation and modified TIPSS can be regarded as safe and effective micro-invasive methods in the treatment of BCS.     

Clinical outcomes of Ex Vivo liver resection and liver autotransplantation for hepatic alveolar echinococcosis

The effectiveness of liver autotransplantation for patients with partial hepatic alveolar echinococcosis was analyzed.We retrospectively studied 6 patients with hepatic alveolar echinococcosis who underwent liver autotransplantation in our hospital from 2008 to 2010.We also summarized the surgical indications of liver autotransplantation for hepatic alveolar echinococcosis and our experience in the management of postoperative complications of liver autotransplantation.Of 6 patients,5 achieved good curative results,and one died of multiple organ failure caused by portal vein thrombosis.Main complications included postoperative bleeding,bile leak and small-for-size liver graft syndrome.Liver autotransplantation offers a new approach to cure hepatic alveolar echinococcosis with non-resectable lesions.It could be the most effective method to cure intractable hepatic alveolar echinococcosis if correct handling in operation and proper prevention of complications are performed.But the long-term outcomes are still needed to be confirmed in longer follow-up.     

肝移植术后早期肝动脉缺血与胆道并发症及肝动脉介入治疗的价值

目的 探讨肝移植术后早期肝动脉缺血对胆道并发症发生和预后的影响,以及早期肝动脉介入治疗的价值.方法 自2003年10月至2007年6月,在中山大学附属第三医院收治720例原位肝移植(OLT)患者中,共有32例在移植术后4～65(25±15)d彩超发现肝动脉缺血并经肝动脉造影(DSA)和(或)CT肝动脉成像证实,其中肝动脉狭窄(HAS)30例,肝动脉血栓(HAT)2例.32例中,20例接受了肝动脉介入治疗.以再次肝移植及患者死亡为观察终点,随访32例患者的临床转归.结果 20例(62.5%)发生胆道并发症,包括单纯胆总管狭窄2例,肝内外胆管狭窄13例,肝内胆管狭窄5例,同时合并胆漏2例、胆汁瘤4例、胆源性肝脓肿3例.20例中,8例为HAS接受了成功的肝动脉介入治疗者,但治疗时间均在发现HAS 2周后;10例为HAS未接受肝动脉介入治疗者;1例为HAT溶栓开通者;1例为HAS支架治疗失败者.20例患者中位随访时间262 d(22～517 d),死亡10例,再次肝移植6例,健在4例;6、12、24个月移植肝累积存活率分别为60.0%、34.9%和0.12例未发生胆道并发症,其中9例为HAS接受了成功的肝动脉介入治疗者,其治疗时间均在发现HAS 2周内;2例为HAS病检提示急性排斥反应者,均及时应用抗排斥药物冲击治疗;1例为HAT溶栓失败接受再次肝移植者.该12例中位随访时间952 d(14～1398 d),死亡3例,再次肝移植1例,健在8例;6、12、24个月移植肝累积存活率分别为75.0%、66.7%和66.7%.结论 肝移植术后早期肝动脉缺血是引起胆道并发症的重要原因,早期成功的肝动脉介入治疗有助于减少胆道并发症、提高患者的预后.     

肝移植术后并发症的介入治疗

目的:探讨肝移植术后并发症介入治疗的应用。方法:对终末期肝病及肝癌肝移植术及介入处理相关资料进行回顾性分析,并对5例肝移植术后并发肝动脉狭窄及血栓形成的患者行球囊扩张、溶栓、内支架置入术。结果:2例肝动脉狭窄的患者经球囊扩张后临床症状缓解;其中1例发生吻合口出血,置入带膜支架,症状缓解。3例肝动脉血栓形成患者经溶栓后肝动脉血流得到恢复。结论:介入治疗对肝移植术后并发肝动脉狭窄及血栓形成的患者进行治疗是可行的,但须谨慎实施,以免发生出血等并发症,介入技术对肝移植术后早期并发症的诊断和处理有重要价值。     

肝移植术后肝动脉血栓形成的诊治

目的总结肝移植术后动脉并发症血栓形成的诊治程序,降低病死率,改善预后.方法回顾性分析本中心成人肝移植术后肝动脉血栓形成(HAT)的临床经过.结果540例共7例发生HAT,分别经溶栓、取栓术和再次移植术治疗,手术效果明显,溶栓失败者出现胆道并发症.结论彩色多普勒、螺旋CT及血管造影有助于及时诊断,果断手术是理想的治疗手段.     

肝脏移植术后早期肝动脉血栓形成的介入治疗

目的 评价用介入技术治疗原位肝移植（OLT）后早期肝动脉血栓形成（HAT）的安全性和疗效。方法 对9例OLT后早期HAT患者进行了介入治疗。男性8例、女1例,年龄32-63岁（平均47.6岁）,9例均表现为术后转氨酶、胆红素进行性增高。HAT发生于移植术后16h-10d（平均5d）,超声波检查提示HAT、为血管造影证实。介入治疗方法有肝动脉内留置导管持续低剂量溶栓和肝动脉内支架置入术,同时经静脉给予低剂量肝素。肝动脉内溶栓期间间隔12h复查超声波。结果 溶栓治疗成功7例,占78％（7／9）,复查血管造影显示肝固有动脉有血流通过,肝内动脉分支显影,肝功能明显改善,肝动脉内留置导管时间为12h-9d（平均4．8d）。7例溶栓成功的患者均有不同程度的肝固有动脉吻合口处狭窄,其中6例狭窄程度〉90％、进行了肝动脉狭窄区血管内支架置入术。溶栓治疗失败2例。1例于溶栓开始后12h发生腹腔内出血,做急诊开腹探察、发现肝动脉吻合口出血,随即做再次吻合。1例留置导管溶栓7d后未能开通肝动脉阻塞,但向肝脏供血的侧枝建立、肝功能有所改善,未做进一步治疗。7例治疗成功者术后随访2-14个月（中位值6个月）,一般情况良好,复查超声波显示肝动脉血流通畅。结论 经导管血管内介入技术是治疗OLT后早期HAT的有效方法,有较高的安全性。     

肝动脉支架置入术治疗原位肝移植术后肝动脉狭窄的远期疗效

目的 评估肝动脉支架置人治疗肝移植术后肝动脉狭窄的远期疗效.方法 2003年11月至2007年8月间,中山大学附属第三医院共26例确诊为肝移植术后肝动脉狭窄或闭塞患者,其中18例采用了同轴导管技术进行肝动脉支架置入术治疗.对所有患者的临床疗效及肝动脉通畅性进行评估.结果 支架置入术后2个月内有3个患者死亡,1例患者接受再移植.其余14例患者随诊时间均超过2个月.中位随诊时间为21.7个月(2.3～37.2个月).支架术后7例患者肝动脉保持通畅.4例(28.5%)患者出现肝动脉再狭窄.其中2例患者分别于术后5.1和20.5个月接受了再移植治疗.3例患者虽然肝动脉保持通畅,但仍分别死于多器官功能衰竭、肝脓肿和胆道感染.Kaplan-Meier曲线显示1、2和3年患者的生存率分别为76%、76%和76%,移植肝存活率分别为69.5%、69.5%和48.0%,原发性肝动脉通畅率分别为63%、63%和63%.结论 肝移植术后肝动脉狭窄可以采用支架置人成功进行治疗,可以获得令人满意的1、2和3年患者生存率、移植肝存活率和原发性肝动脉通畅率.     

再次肝移植血管并发症的防治

目的探讨再次原位肝移植后血管并发症的防治方法.方法例1病人因慢性排斥反应再次行原位肝移植术,术后发现肝动脉血栓形成,行血栓取出、溶栓、再血管化手术.例2因胆管坏死再次行原位肝移植术, 术后发现下腔静脉狭窄,行下腔静脉球囊扩张、内支架置入术.结果例1术后彩超未能探及肝动脉血流.例2下腔静脉复通.结论慢性排斥反应再次肝移植利用受体肝动脉进行吻合,可能增加肝动脉血栓形成机会.预防的关键是重新选择受体肝动脉吻合支,第3次肝移植是优先选择方案.原下腔静脉吻合口关闭后若疑有狭窄可能,应于狭窄段近心端重新寻找吻合段.球囊扩张、内支架置入术是治疗下腔静脉狭窄的有效方法.     

肝移植术后肝动脉血栓形成的诊治经验分析

目的 总结肝脏移植术后肝动脉血栓形成的预防、诊断及治疗经验。方法回顾性分析1993年4月至2003年9月完成的198例肝脏移植的临床资料。96例采用肝动脉连续吻合法(第1组),102例采用肝动脉间断吻合方法(第2组)。术后常规以多普勒超声监测肝动脉血流。结果第1组有6例术后发生肝动脉血栓形成,发生率为6．3％(6／96);第2组有1例发生肝动脉血栓形成,发生率为1．0％(1／102),显著低于1组(x^2=4．027,P=0．045)。在这7例发生肝动脉血栓形成的患者中,除1例为术后剖腹探查发现外,6例均为彩色超声检查发现。其中6例行急诊肝动脉取栓术,重建肝动脉血流。取栓术后,3例发生严重的胆道并发症,其中2例已死亡,1例需接受再次肝移植;另3例中,1例死于肾功能衰竭,2例健康存活至今。另外1例采取保守治疗,后死于肿瘤复发。肝动脉血栓形成的病死率为57．1％(4／7)。结论预防肝动脉血栓形成的关键在于提高血管吻合技术。术后常规超声定期检查有助于早期发现和早期治疗。中后期肝动脉血栓形成的后果是引起严重的胆道并发症。     

肝移植术后肝动脉栓塞和狭窄的诊治

目的：探讨肝移植术后肝动脉栓塞和肝动脉狭窄的诊治方法。方法：回顾性研究我院2例肝移植病人术后出现肝动脉栓塞和肝动脉狭窄的临床表现和影像学所见,结果：发生肝动脉栓塞和狭窄的病人,1例死亡,1例发生肝灶状坏死。结论：肝动脉重建或再次肝移植是解决肝动脉栓塞和肝动脉狭窄的关键。     

Vascular and biliary complications after liver transplantation: interventional treatment

目的：评价血管造影和胆道造影诊治肝移植术后血管及胆道并发症的价值。方法：46例原位肝移植术后B超提示血流速度不畅或频谱异常、下肢水肿或黄疸的患16例,进行腹腔动脉造影10例次,下腔静脉造影并球囊扩张或支架置入6例次,经皮肝穿门静脉造影并支。架置入2例次,经皮肝穿胆道造影并引流4例次。结果：肝动脉血栓形成2例,1例经性溶栓治疗后部分开通;肝动脉狭窄4例,1例球囊扩张后狭窄减轻;所有下腔静脉和门静脉阻塞或狭窄行球囊扩张及 置放支撑架后临床症状好转;4例胆道狭窄和吻合口瘘行经皮肝穿胆道造影引流（PTCD）治疗后黄疸减轻。结论：对肝移植术后出现的血管和胆道并发症,血管造影和胆道造影不仅可明确诊断,而且能同时进行处理并取得较好的近期疗效。