原位肝移植术后胆道并发症的预防和处理

目的探讨肝脏移植术后胆道并发症的危险因素以及胆道并发症的预防和治疗手段。方法对2004年1月至2005年12月中山大学附属第一医院施行的368例同种原位肝移植患者的临床资料进行分析总结。结果368例肝移植患者中与胆道相关的并发症共36例，发生率为9．8％（36／368）；其中单纯吻合口胆瘘7例，误伤和遗漏副肝管所致胆瘘1例，吻合口狭窄5例，肝内胆管狭窄3例，胆管扭曲继发胆道狭窄1例，肝内胆管结石2例，胆瘘后继发胆道狭窄2例，胆道狭窄合并肝内胆汁瘤形成2例，胆道狭窄合并胆泥形成2例，胆道铸型综合征5例，胆道出血1例，肝内脓肿3例及括约肌功能失调2例。所有36例发生胆道并发症患者中，23例经非手术治疗而治愈；13例进行开腹手术治疗，其中7例为接受再次肝脏移植。所有因胆道并发症导致患者死亡5例，死亡原因为严重胆道感染和腹腔感染，占该组肝移植患者死亡的13．9％。结论肝移植术后胆道并发症临床处理棘手，应注重预防。胆道并发症大多可经非手术治疗而获得满意的疗效；如经反复多次放射和内窥镜治疗无效以及同时伴有肝动脉栓塞或狭窄且治疗无效时，应考虑尽早进行手术治疗或行再次肝移植术。

Prophylaxis and management of biliary complications after orthotopic liver transplantation

OBJECTIVE: To investigate the risk factors of biliary complications after orthotopic liver transplantation (OLTx) and the relevant prevention and management strategies. METHODS: The clinical data of 368 patients undergoing allograft orthotopic liver transplantation, 282 males and 86 females, aged 47.5 (8 - 73), were collected and analyzed retrospectively. RESULTS: Of the 368 OLTx patients, 36 (9.8%) experienced biliary complications, including simple anastomosis biliary leakage (7 cases), biliary leakage due to injury and omission of accessory hepatic duct (1 case), anastomosis stricture (5 cases), intrahepatic bile duct stricture (3 cases), bile duct stricture secondary to bile duct twist (1 case), calculus of intrahepatic duct (2 cases), bile duct stricture secondary to biliary leakage (2 cases), bile duct stricture combined with intrahepatic biloma (2 cases), bile duct stricture combined with biliary sludge (2 cases), biliary cast syndrome (5 cases), hemobilia (1 case), intrahepatic abscess (3 cases) and Oddi's sphincter dysfunction (2 cases). Among the 36 patients with biliary complications, 23 were cured by nonsurgical therapies; and 13 patients needed abdominal surgical interventions, including retransplantation in 7 cases. CONCLUSION: Biliary complications after OLT are difficult to treat. Most of these complications can be cured conservatively, such as radiological intervention and endoscopic treatment. When the patients are unresponsive to nonsurgical therapies, or when they suffer from hepatic arterial embolism or arterial stricture simultaneously, surgical interventions, even retransplantation should be considered.