原位全肝移植术后肝内胆管狭窄的病因及诊治

目的 探讨原位全肝肝移植术后肝内胆管狭窄(intrahepatic biliary stricture,IBS)的发生原因及诊断和治疗方法.方法 回顾性分析自1999年2月至2007年2月间收治407例次原位全肝肝移植患者的临床资料.结果 407例次原位全肝肝移植术后共发生IBS 22例(5.4%).所有患者均通过核磁共振胆胰管成像(MRCP)和胆道造影获得诊断.供肝冷保存时间超过12 h(107例)、供受体ABO血型不符(13例)、术后肝动脉病变(5例)和原发病为重型乙型病毒性肝炎(91例)与肝移植术后IBS的发生显著相关(P＜0.05),其IBS的发生率分别为10例(9.3%)、4例、3例和10例(11.0%).肝移植术中放置胆道外引流管可降低IBS的发生率(2.5%).22例患者采用药物、内镜、放射介入、胆道外科手术及再次肝移植等方法治疗,有效率为77.3%(17例),治愈率为45.5%(11例),IBS相关的病死率为22.7%(5例),与IBS相关的移植物失功发生率为41.0%(9例).结论 供肝冷保存时间过长、供受体ABO血型不符、术后肝动脉病变及原发病为重型乙型病毒性肝炎等4项因素是肝移植术后IBS发生的高危因素.胆道造影和MRCP是诊断IBS的重要手段.根据胆管树的病变情况选择合适的治疗方法,是原位肝移植术后IBS患者获得良好疗效的关键.

Intrahepatic biliary strictures after orthotopic liver transplantation: a report of 407 cases

Objective To evaluate the causes, diagnosis, and management of intrahepatic biliary strictures (IBS) after orthotopic hepatic transplantation. Methods Clinical dates of 407 patients who underwent orthotopic liver transplantation from February 1999 to February 2007 were retrospectively reviewed. Results Among the 407 patients, 22(5.4%) patients developed IBS which was diagnosed by cholangiography and magnetic resonance cholangiopancreatography (MRCP). The incidence of IBS was statistically significantly associated with the duration of cold ischemic storage of allografts more than 12 h (107 cases), the use ABO incompatible grafts (13 cases), postoperative hepatic arterial occlusion (5 cases), and pretransplantation HBV-related fulminant or subacute hepatic failure (91 cases). While, the incidences of IBS of them were was10 cases, 4 cases, 3 cases, and 10 cases respectively. These patients with IBS were treated with drugs, endoscopic retrograde cholangiopancreatography (ERCP), transhepatic cholangiography (PTC), operation and retransplantation. Among these 22 IBS patients, 17 patients got improved, 9 was cured, 5 were died, and 22 lost the graft due to IBS. Conclusion The duration of cold ischemic storage of allografts (more than 12 h), the use ABO incompatible grafts, postoperative hepatic arterial occlusion, and pretransplantation HBV-related fulminant or subacute hepatic failure appear to be important risk factors that cause IBS. Cholangiography and MRCP are main measures to diagnose IBS. Management should be taken according to different types of IBS.