肝移植术后胆道铸型的全蛋白质表达

肝移植术后胆道铸型综合征(biliary cast syndrome,BCS)是肝移植术后严重影响患者手术存活牢及生活质量的并发症,其发生率为4%～18%~([1]).肝移植术后BCS的胆道铸型形成机制尚未彻底阐明.胆道铸型中是否存在一些和其形成有关或对铸型形成有预警作用的蛋白质还不清楚,为此,我们收集了4份外形完整、颜色质地各异的铸型标本,拟对其进行全蛋白质分析,以期了解胆道铸型中蛋白质的表达情况.     

肝移植术后胆道铸型综合征

胆道铸型综合征（ biliary cast syndrome, BCS ）是肝移植术后胆道并发症的一种。“胆道铸型”（biliarycast，BC）这一概念最早由美国的Waldram医生于1975年提出。BCS由Stall教授于1977年正式提出，是指肝移植术后在肝内外胆道内形成的胆道树样铸型坏死物“胆道铸型”充填于胆道，同时可伴有一处或多处非吻合口胆道上皮坏死或狭窄，并由此而导致的一系列临床症状，发生率约为7％～30％。     

肝移植术后胆道铸型综合征患者胆道介入治疗的护理

对103例肝移植术后胆道铸型综合征(BCS)患者进行胆道介入治疗,结果102例患者行纤维胆道镜取胆道铸型(BC)成功,1例扩张窦道时不慎T管脱落而改作十二指肠镜取BC;住院7～30 d出院.随访6～12个月,4例中度坏死患者发生肝内胆道轻度狭窄,经再次介入治疗好转;8例重度坏死伴移植肝功能恢复不良患者再次接受肝移植,其中4例因多脏器衰竭死亡,4例恢复正常.余均未再发生BCS.提出术前做好细致的心理疏导、患者准备,术中积极配合医生完成操作.术后做好生命体征的监测、现察记录胆汁的性状等,是提高治疗成功率及促进患者早日康复的重要措施.     

肝移植术后胆道铸型综合征的临床表现与病理分型

目的 总结肝移植术后胆道铸型综合征(BCS)的病理分型与临床表现.方法 回顾性分析103例肝移植术后BCS患者的临床表现、辅助检查、治疗方案及转归.患者通过纤维胆道镜检查,按照胆道上皮损伤程度分出不同类型.全部病例随访12个月,统计各组非吻合口狭窄的发生时间、部位及程度.结果 103例BCS患者中,武警总医院发生59例,该院总BCS发生率为9.1%.BCS多数有黄疸、尿色深、陶土色大便、皮肤瘙痒及发热等临床症状;部分无临床症状.化验指标可表现为谷氨酸转氨酶、γ-谷氨酰转肽酶、碱性磷酸酶、总胆红素、直接胆红素等升高,外周血白细胞总数升高等.胆道造影可表现为胆道树不同程度的充盈缺损,按照胆道树的形态及充盈缺损的范围,将造影结果归纳为4种类型.纤维胆道镜检查可见固体物质充填于胆道,部分患者伴有胆道上皮坏死.根据胆道镜检查按胆道上皮坏死范围将BCS由轻到重分为6种类型:Ⅰ型14例,Ⅱ型18例,Ⅲ型27例,Ⅳ型23例,Ⅴ型13例,Ⅵ型18例.从Ⅰ型至Ⅳ型患者出现临床症状及胆道狭窄概率逐渐增加,取出BC后需支撑时间逐渐延长,胆道造影见充盈缺损范围逐渐扩大.BCS总病死率13.6%,再次移植病死率44.0%.总治愈率54.0%、总好转率71.0%、总狭窄发生率29.0%.结论 (1)根据胆道镜检查BCS的病理类型主要有6种,临床症状主要有黄疸、发热等,胆道造影主要有4种表现.(2)临床症状及胆道造影表现主要取决于病理类型.     

肝移植术后胆道铸型综合征的放射介入治疗

目的 研究肝移植术后胆道铸型综合征(BCS)的放射介入治疗,总结治疗经验.方法 回顾性分析2002年4月至2006年4月间的103例肝移植术后BCS受者的临床资料.根据纤维胆道镜下胆道上皮病变程度不同,将BCS受者分成轻度组32例、中度组53例和重度组18例.所有受者均进行不同程度的放射介入治疗,对各组治疗前、后的指标数据进行比较,并观察治疗效果.结果 轻、中度组治疗后症状明显好转,各项肝功能指标与治疗前比较,差异有统计学意义(P＜0.05);重度组症状无明显改变.随访12个月,轻度组未发现非吻合口狭窄;中度组12例因支撑管移位而出现坏死部位轻到中度狭窄;重度组在观察期内严重狭窄的发生率达100%,均出现严重的梗阻性黄疸.结论 对轻、中度BCS受者,放射介入治疗效果较好;重度BCS受者应尽早行2次肝移植手术.     

肝移植术后胆道铸型综合征103例治疗体会

目的总结治疗肝移植术后胆道铸型综合征（BCS）的经验。方法回顾性分析103例肝移植术后BCS病人的治疗方法及转归。术后〈3个月病人出现较重梗阻症状或合并有胆道感染时，以PTBD外引流管置换T型管。术后≥3个月病人，行纤维胆道镜治疗。BC取出后，对有吻合口以上胆道上皮坏死者，以支撑管支撑3～6个月。病人按照病变程度分成单纯BC组、中度坏死（累及肝门部及以下胆道上皮）BC组、重度坏死（累及肝内外各级胆管）BC组，统计各组在治疗前后1周的肝功酶指标（GPT、GGT、ALP、TB、DB），用SPSS11．5软件行统计学分析。结果经过治疗后，单纯BC组32例，在随访过程中，未发现再有BC出现，各项肝功酶均在正常范围。中度坏死BC组53例，经支撑管支撑3～6个月后，治疗前后各项肝功指标有显著性差异（P〈0．05）。重度坏死BC组18例，9例因经济原因未能再次移植死于多脏器衰竭，1例死于急性梗阻性化脓性胆管炎。8例接受了再次肝移植。其中4例围手术期死于多脏器衰竭，3例行再次肝移植后恢复正常未再有BCS存在，1例出现再次肝移植后BCS，行三次肝移植未再发现BCS存在。结论BCS大多可通过纤维胆道镜取BC和后续的支撑管支撑治疗而解除梗阻症状，明显改善BCS病人的生活质量，降低BCS的再次移植率。BC合并肝内外胆管弥漫坏死者应尽早再次移植。     

原位肝移植术后胆道铸型综合征的预防和处理

目的探讨供肝切取过程中,门静脉灌注液对原位肝移植术后发生胆道铸型综合症的预防价值,以及胆道镜在临床处理胆道铸型综合症中的应用。方法回顾性分析2002年5月至2003年12月期间的137例原位肝移植患者术后胆道铸型综合症的发生情况;比较供肝门静脉灌注UW液(UW组;65例)和灌注HCA液 UW液(HCA UW组;72例)患者胆道并发症的发生率。总结胆道镜在铸型综合症中的治疗和临床价值。结果137例肝移植受者中有17例(12.4%)在术后1-3个月发生胆道铸型综合症;UW组发生率为20.0%(13/65),HCA UW组发生率为5.56% (4/72),两组比较,差异有统计学意义(P<0.05)。17例受者均经胆道镜成功取出胆道内铸型,预后良好。结论供肝切取过程中,门静脉灌注HCA液 UW液,能预防肝移植术后发生胆道铸型综合症。胆道镜可以有效地取出胆道内铸型。     

胆道镜联合介入治疗肝移植术后胆道阻塞的处理技巧

目的 探讨胆道镜联合介入方法 在肝移植术后胆道阻塞诊治中的作用.方法 回顾性分析36例肝移植术后出现胆道狭窄伴有不同程度铸型形成的病人资料,所有病人均经T管途径实施了换管、窦道扩张、胆道镜治疗、置管支撑引流.结果 26例治疗有效,有效率72.2%,8例得到控制,2例接受再次肝移植.结论 胆道镜联合介入方法 是一种有效的肝移植术后胆道阻塞治疗方法 .     

肝移植术后胆道并发症病因及预防

目的分析原位肝移植术后胆1道并发症的病因。方法回顾性分析307例尸体供肝和40例活体供肝原位肝移植的临床资料,总结术后胆道并发症的病因。结果40例活体肝移植受体术后胆道并发症的发生率5.0%,307例尸体供肝肝移植受体术后胆道并发症的发生率为18.9%;肝内胆道狭窄和胆道铸型结石形成等严重胆道并发症在活体肝移植和放置“T”管的尸肝移植未发生。结论缺血时间尤其热缺血时间是导致严重胆道并发症的最主要的原因,放置“T”管引流能降低胆道并发症的发生率。     

肝移植术后胆道并发症病因分析

目的探讨原位肝移植术后胆道并发症的病因.方法回顾性分析235例尸体供肝和36例活体供肝原位肝移植的临床资料,总结术后胆道并发症的病因.结果36例活体肝移植受体术后胆道并发症的发生率为5.6%,235例尸体供肝肝移植受体术后胆道并发症的发生率为19.1%;肝内胆道狭窄和胆道铸型结石形成等严重胆道并发症在活体肝移植中未发生.讨论缺血时间尤其热缺血时间是导致严重胆道并发症的最主要的原因,所留取的受体胆道长度也是影响胆道并发症的一个主要因素.     

肝移植后胆道铸型综合征病人中HLA抗体检测的临床意义

目的 研究肝移植受者体内的HLA致敏状态与胆道铸型综合征的关系以及HLA抗体在预测免疫因素引起胆道铸型综合征中的作用.方法 收集52例肝移植病人术前术后8个时间点系列血清共416份,用ELISA法检测受者血清中HLA抗体,将52例病人分为两组,20例无胆道铸型综合征者为对照组,32例发生胆道铸型综合征者设为实验组,分析两组间HLA抗体水平有无显著性差异,及与主要生化指标变化的关系.结果 胆道铸型综合征组术后HLA抗体阳性率显著高于对照组(P<0.05),胆道铸型综合征临床症状恢复时间与HLA-Ⅱ类抗体的出现时间呈负相关性.结论 HLA-Ⅱ类抗体的动态监测可作为胆道铸型综合征发生的预警信号.     

High levels of soluble Major Histocompatibility Complex class I related chain A (MICA) are associated with biliary cast syndrome after liver transplantation

BackgroundThe biliary cast syndrome (BCS) is a frequent problem following liver transplantation. The pathogenesis of this complication is not well understood. Previous research has demonstrated that the soluble form of MICA (sMICA) is significantly higher in patients with chronic liver disease and hepatocellular carcinoma (HCC) than in healthy volunteers. The aim of this study is to investigate the possible involvement of sMICA in the formation of BCS after liver transplantation.MethodsSerum soluble MICA was retrospectively evaluated in pre- and post-transplant sera from 133 consecutive primary liver transplant patients and in sera from 88 healthy volunteers using sandwich ELISA. Normal distribution of serum sMICA was described by the data obtained from healthy population and sMICA concentration that was greater than the upper bound 95% normal range was considered as high levels of sMICA. Patient records were reviewed to identify patients who developed BCS.ResultsThe results demonstrated that 37.6% of patients with end-stage liver diseases had significantly higher pre-transplant serum sMICA than in healthy population. 34.4% of recipients with post-transplant high levels of sMICA developed BCS. In contrast, 17.3% of patients with post-transplant normal levels of sMICA developed BCS. The risk of BCS development is significantly associated with the presence of post-transplant high levels of sMICA (P = 0.0365). Further analysis disclosed that patients with decreased post-transplant sMICA following liver transplantation had a lower incidence rate of BCS than those with remained high levels of sMICA after transplantation (10.5% vs. 38.7%, P = 0.0302). Furthermore, log-rank test showed that BCS occurrence was significantly associated with dynamic changes of sMICA among different groups (P = 0.0188).ConclusionsBiliary cast syndrome is more likely to develop in recipients who have post-transplant high levels of sMICA. The data suggested that sMICA might have some immunologic effect on BCS development following liver transplant. Monitoring of serum sMICA could have a prognostic value in assessment of patients with liver transplantation.     

Liver transplantation for Budd-Chiari syndrome: A retrospective study

A retrospective study was performed on 11 patients who underwent orthotopic liver transplantation for Budd-Chiari syndrome (BCS), 3 of whom had fulminant type BCS and 8, chronic type BCS. Both the 3- and 5-year actuarial survival rates were 64%, after one patient with fulminant, and three with chronic disease died of sepsis or multiple organ failure following transplantation. Anticoagulation therapy in the early postoperative period was tailored to each individual patient. Most of the patients received heparin for several days and were then converted to Coumadin therapy, although some were not given heparin in the immediate postoperative period but were instead commenced on oral Coumadin after the prothrombin time had recovered to wihtin the normal range. All the long-term survivors had received Coumadin therapy and there was no recurrence of BCS and no early thrombotic or hemorrhagic event. One patient developed late thrombosis of the portal vein despite having received apparently adequate Coumadin therapy. It was thus concluded that liver transplantation is an effective therapy for both fulminant and chronic BCS, and that immediate postoperative heparinization is not mandatory for all patients.     

肝移植术后胆道并发症的介入治疗

目的探讨原位肝移植术后胆道并发症的介入治疗疗效。方法回顾性分析我院2002年6月至2005年9月诊治的173例原位肝移植患者的临床资料。结果术后出现胆道并发症14例(8.1%),其中胆管狭窄6例,胆管狭窄合并胆漏1例,胆泥淤积或结石3例,肝断面胆漏2例(劈离式肝移植患者),T管拔除后胆漏1例,Oddi括约肌功能失常1例。除1例胆道狭窄再次行肝移植,因发生严重感染导致肝功能衰竭死亡外,其余患者经介入治疗均获得满意的效果。结论介入治疗是诊断和治疗肝移植术后胆道并发症的首选方法。     

大网膜袖套法在背驮式肝移植中的应用

目的：探讨背驮式肝移植中应用带蒂大网膜袖套法预防和治疗胆漏的方法及临床应用价值。方法：回顾性分析我院18例背驮式肝移植病人应用带蒂大网膜袖套法包绕胆总管吻合口的临床资料。结果：14例因存在肝移植术后胆漏的高危因素而在术中应用此方法，其中1例于术后第8天出现胆漏，经充分引流后痊愈，其他13例未出现任何胆道并发症；另4例因背驮式肝移植术后出现胆漏、内科治疗无效而行胆总管再次吻合时应用此方法．术后痊愈出院。结论：带蒂大网膜袖套法操作简单、创伤小，可有效预防和治疗背驮式肝移植术后胆漏。     

Budd-Chiari syndrome: portacaval shunt and subsequent liver transplantation

The Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction, which often leads to death as a result of portal hypertension and liver failure. Therapeutic approaches vary widely from conventional medical therapy to liver transplantation. If and when a patient suffering with BCS needs surgery remains a matter of contention. However, it is well accepted that portacaval shunt surgery and orthotopic liver transplantation represent efficient surgical treatments of this condition. We report on a patient with an eventful course after BCS was diagnosed. After portacaval shunt surgery the patient had acute liver failure and had a successful orthotopic liver transplantation.     

Liver transplantation for Budd-Chiari syndrome: A challenging but handable procedure

BackroundEstablishing venous outflow in liver transplantation for patients with Budd-Chiari syndrome is crucial and requires various surgical techniques. The outcomes of these patients exibits distinct problems including vasculary thrombosis and biliary complications.MethodsIn this single center study, the outcomes and surgical features of 33 patients with Budd-Chiari syndrome who were carried out liver translantation (27 patients from living donor). Another group was formed among patients underwent liver transplantation due to other etiologies and the outcomes were compared.ResultsThe most-seen type was the classical type of Budd-Chiari syndrome (25, 75.8%). For twenty-six patients inherited or acquired prothrombotic disorders were identified (78.2%) in Budd-Chiari group. Average follow-up was 29.7 ± 15.5 months. We have observed no recurrence of disease in our BCS patients. When the two groups was compared in terms of thrombotic complications, there was a significantly increased risk in BCS group (p = 0.014). Our 1 and 3-year survival rates for the BCS group were 81.8% and 78.8%, respectively. In the control group, 1 and 3-year survival rates were 93.3% and 88.9%, respectively. Log-rank test analyses showed no statistically significant results.ConclusionLiver transplantation with individual surgical and postoperative treatment strategy for patients with Budd-Chiari syndrome provides comparable outcomes.