经导管肝动脉化疗栓塞术后胆管损伤的临床意义

目的 观察经导管肝动脉化疗栓塞术（TACE）治疗肝脏恶性肿瘤后继发胆管损伤的发生率、影响因素和临床过程.方法 对1240例患者做TACE 2 680次,术前影像学检查均无明确胆系异常表现,18例于术后3周～3个月出现胆管损伤并发症.采用回顾性调查,观察TACE术后胆管损伤的发生率、临床表现、转归以及影响因素.结果肝转移性肿瘤TACE后胆管损伤的发生率为8.8%（13/148）,肝细胞性肝癌（HCC）组为0.5%（5/1092）.胆管损伤的影像学表现有局灶性胆管扩张4例、多发性肝内胆管扩张8例、囊性病灶或胆汁瘤6例.3例多灶胆管损伤表现为轻度黄疸,2例对保守治疗反应良好,1例于出现黄疸后2周死于肝功能衰竭.4例胆汁瘤合并感染,3例采取经皮穿刺置管引流和抗生素治疗,其中2例死于感染囊腔破入腹腔、继发化脓性腹膜炎,1例治愈;1例仅用抗生素治愈.与胆管损有关的病死率为16.7%（3/18）.其余11例无相关症状.统计学分析显示：无肝硬变背景的肝转移瘤患者TACE术后胆管损伤发生率明显高于有肝硬变的HCC患者（P〈0.01）;其他高危因素有肿瘤为少血供型（P〈0.01）和用铂类制剂与碘油乳化后做超选择性栓塞（P〈0.01）.结论 认识TACE后继发胆管损伤的影像学表现可避免误诊,特别是肿瘤复发.对存在胆管损伤高危因素患者,适当减少碘油乳化的化疗剂（特别是铂类）剂量,有可能降低胆系缺血损伤并发症.

Clinical implications of bile duct injury after transcatheter arterial chemoembolization

Objective To evaluate the incidence, risk factors, and clinical course of bile duct injury after transcatheter arterial chemoembolization (TACE) for treatment of hepatic malignancy. Methods A total of 1240 consecutive patients with hepatic malignancies underwent 2680 TACE procedures. None of these patients were found to have any radiographic evidence of biliary abnormalities pre-TACE. Eighteen patients developed bile duct injuries at 3 weeks to 3 months after TACE. A retrospective review of medical records and imaging studies were carried out to evaluate the occurrence of TACE-induced bile duct injury, the clinical outcome, and the statistical significance of potential predisposing factors. Results The TACE-induced bile duct injuries occurred in 13 of 148 patients with liver metastatic tumors (8.8%), 5 of 1092 patients with HCC (0.5%). Biliary injuries, including focal (n=4) and multiple intrahepatic bile duct dilatation (n=8), and cystic lesion or biloma(n=6), were identified on the follow-up imaging studies after TACE. Three patients with multiple bile duct injuries had mild jaundice at the presentation, two of them responded well to the conservative treatment, one died of irreversible deterioration of liver function at 2 weeks after the onset of jaundice. Four patients with a large biloma had associated serious bacterial infections; 3 of which were treated with percutaneous catheter drainage and antibiotics, 2 of them died of purulent peritonitis due to rupture of the cystic lesions and 1 cured with antibiotic. The remaining 11 patients were asymptomatic. The mortality related to the biliary injury occurred in 3 patients (16.7%). The incidences of bile duct injury were higher in patients with metastatic tumors in non-cirrhotic livers than in patients with hepatocellular carcinoma associated with cirrhosis (P<0.01), higher in patient with hypovascular lesions (P<0.01), and higher in patients using an emulsion of lipiodol-platinum for selective embolization of distal arterial branches (P<0.01). Conclusions Knowledge of imaging findings of TACE-induced bile duct injuries can help interventional radiologists to have prompt correct diagnosis. Adjustment in the amounts of iodized oil and chemotherapeutic agents (ie, cisplatin) in patients with high risk factors may reduce ischemic biliary injuries after TACE.