肝移植术后胆道狭窄的临床特点及治疗效果(附60例报告)

目的 探讨肝移植术后并发胆道狭窄的临床特点及治疗效果.方法 回顾性分析60例肝移植术后胆道狭窄患者的临床资料.并对其临床特点和治疗效果进行了分析和讨论.结果 肝移植术后胆道狭窄的主要症状为胆道梗阻和胆管炎表现.其平均诊断时间为术后(195.5±146.5)d.胆道狭窄早期,肝功能损害主要为血清丙氨酸转氨酶、总胆红素、谷氨酰转肽酶及碱性磷酸酶水平升高,而白蛋白降低;胆道狭窄晚期时,丙氨酸转氨酶水平下降,出现"胆酶分离"现象.经内窥镜逆行胰胆管造影(ERCP)检查发现,胆道狭窄部位为单纯吻合口狭窄6例;肝门部和/或合并吻合口狭窄11例;肝内胆管弥漫性狭窄11例;吻合口合并肝内胆管弥漫性/节段性狭窄32例.其它并发症还包括胆管内有异物、狭窄近端扩张、胆管扭曲及十二指肠乳头旁憩室等.经ERCP介入治疗,取出胆管内异物、坏死组织、结石以及狭窄段球囊扩张等处理后,33例患者治愈,18例好转,9例治疗无效.结论 肝移植术后胆道狭窄的临床表现既有特征性,又有多样性,且合并症较多;采用ERCP介入治疗胆道狭窄效果理想.     

ERCP诊治成人原位肝移植术后胆道并发症的临床研究

目的 :回顾性分析和评价内镜逆行胰胆管造影(ERCP)在成人原位肝移植胆道并发症诊疗中的作用。方法:38例成人原位肝移植术后胆道并发症患者实施61次ERCP,根据ERCP结果实施内镜治疗。结果:60次ERCP成功,成功率为98.36%(60/61)。ERCP明确胆道并发症原因后实施内镜治疗。并发症发生的部位为:供体肝胆管、受体胆管、胆管吻合口及十二指肠乳头。其中单纯胆管炎性狭窄7例,胆管炎性狭窄伴肝内外胆管铸型、胆泥或胆石形成10例;单纯胆管吻合口狭窄3例,狭窄伴肝内外胆管铸型、胆泥或胆石形成2例;胆管吻合口瘘2例,供体胆管与受体胆管直径差异过大1例;受体胆管过长、扭曲3例,受体胆管轻度扩张1例;十二指肠乳头狭窄2例,Oddi括约肌功能失调3例;T管脱落1例;胆道出血1例;ERCP插管失败1例。该组供体肝胆管并发症发生率最高,为44.74%(17/38);其次为胆管吻合口并发症,为21.05%(8/38)。治疗方式:乳头括约肌切开(EST)24.59%(15/61),乳头柱状球囊扩张(EPBD)16.39%(10/61),EST+EPBD 13.12%(8/61),扩张器扩张胆管36.07%(22/61),鼻胆管引流(ENBD)52.46%(32/61),胆管支架引流(ERBD)32.79%(20/61),取胆管铸型、胆泥或结石19.67%(12/61),胆道冲洗24.59%(15/61)。结论:ERCP具有诊疗一体化优点,已成为成人原位肝移植术后胆道并发症微创治疗的主要方法和重要治疗手段。     

肝移植术后胆道并发症的内镜治疗

目的:探讨内镜下逆行胰胆管造影术(ERCP)在治疗肝移植术后胆道并发症方面的临床疗效.方法:回顾性分析2002年8月-2012年12月采用ERCP治疗8例肝移植术后胆道并发症患者的临床资料,其中胆道狭窄5例(吻合口狭窄4例,肝内型胆道狭窄1例),胆瘘1例,胆石和胆泥形成2例.8例患者共行ERCP治疗21次,对胆道狭窄患者行括约肌切开、胆管扩张、鼻胆管引流和内支架置放术等治疗;对胆瘘患者行鼻胆管引流及塑料内支架置放术等治疗;对结石患者行括约肌切开、鼻胆管冲洗引流术及取石网篮取石等治疗.结果:ERCP手术成功率为100％ (21/21);4例吻合口狭窄、1例胆瘘和2例结石患者均治愈,1例肝内型胆道狭窄治疗未成功,建议再次肝移植;术后胆道感染的发生率为14.3％(3/21),胰腺炎发生率为19.0％ (4/21),经对症治疗后均痊愈.结论:ERCP是治疗肝移植术后胆道并发症微创、安全和有效的方法.     

良性胆管狭窄行胆肠Roux-en-Y吻合术后再手术临床分析

目的 探讨良性胆管狭窄行胆肠Roux-en-Y吻合术后再手术的原因和再手术的方法.方法 回顾性分析良性胆管狭窄行胆肠Roux-en-Y吻合术后28例再次手术患者的临床资料.文中数据统计分析计量资料采用t检验,多因素分析采用Stepwise logistic回归分析.结果 再次手术原因为残余结石合并胆管狭窄10例,单纯吻合口狭窄11例,胆管狭窄6例,吻合口漏和十二指肠漏1例.再手术方式为:肝叶或肝段切除+胆肠Roux-en-Y吻合术18例,肝正中裂劈开+胆肠Roux-en.Y吻合术5例,右半肝切除术1例,吻合口狭窄段切除+胆肠Roux-en-Y吻合术1例,腹腔引流+十二指肠造瘘+空肠造瘘术1例,胆管切开取石+T管引流术2例,术后发生并发症13例.结论 胆道再手术病情复杂,手术难度高,详细了解病情和正确的手术方式是良性胆管狭窄再手术成功的关键.     

原位肝移植术后胆道结石的临床研究

目的 探讨原位肝移值术后胆道结石的诊治。方法 回顾性分析2000年1月至2003年1月完成的206例原位肝移值的临床资料，总结术后胆道结石的防治经验。结果11例病人术后并发胆道结石，发病率为5．3%。表现为颗粒样结石和胆泥两种形式。发生部位在胆总管者7例，在肝内胆道者1例。胆泥和颗粒样结石的首次诊断时间分别平均为138d和306d。胆道感染是胆道结石发作的主要症状。11例病例中有7例合并不同程度的胆道狭窄。主要依靠经“T”管照影或FRL、P(endoscopic reirograde cholangiopancreatography)术明确诊断。FRCP术是主要的非手术治疗手段，7例胆总管结石经1～3次ERCP术后痊愈。4例肝内胆道结石中合并弥漫性胆道狭窄者有3例，其中2例行再次肝移植术。结论 胆道狭窄是肝移植术后胆道结石的主要原因，胆道黏膜的缺血坏死合并胆道感染是胆泥形成的主要机制。ERCP术对胆总管绵石有良好疗效，对合并弥漫性胆道狭窄的肝内胆道结石病人肝脏再移值往往不可避免。     

内镜逆行胰胆管造影术治疗肝移植术后并发胆管结石受者临床分析

目的探讨肝移植术后并发胆管结石受者行内镜逆行胰胆管造影术(ERCP)治疗的安全性和有效性。 方法回顾性分析南京军区福州总医院肝胆外科2005年1月至2015年12月肝移植术后并发胆管结石受者的临床资料。24例受者胆管结石确诊主要依据T管造影、MRCP或ERCP。确诊胆管结石受者均采用ERCP下行球囊扩张联合胆道塑料支架置入治疗,术中采用地西泮镇静,同时密切监测生命体征。观察肝移植术后并发胆管结石受者结石类型、狭窄情况、ERCP治疗情况及其治疗前后肝功能指标变化。采用Wilcoxon符号秩和检验比较ERCP治疗前后受者血清总胆红素(TBil)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)、ALT和AST水平变化。P<0.05为差异有统计学意义。 结果24例受者中胆总管结石20例(包括单纯胆总管结石11例、胆总管结石合并胆管狭窄9例),肝内、外胆管结石4例。肝移植至并发胆管结石平均间隔时间(604±215)d。19例发生在术后12～66个月,余5例发生在术后3个月内。11例胆总管结石受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架引流治疗,治疗有效。9例胆总管结石合并胆管狭窄受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架＋鼻胆管引流治疗,其中8例治疗有效;1例因重度胆管狭窄,反复内镜取石不能取尽,继发感染再次行肝移植。4例肝内、外胆管结石受者均采用柱状球囊扩张＋取石篮取石＋左、右肝管置入内支架＋鼻胆管引流治疗,治疗有效。受者内镜治疗后血清TBil、ALP和GGT分别为31、179和247 mmol/L,均低于内镜治疗前水平(43、273和385 mmol/L),差异均有统计学意义(z＝0.042、0.001、0.004,P均<0.05)。截至2017年12月,24例受者随访时间为1～2年,4例因原发性肝癌复发分别于肝移植术后9、5、34、25个月死亡,1例因上消化道出血于肝移植术后34个月死亡,1例因重度胆管狭窄行二次肝移植并于2014年4月因肝脓肿继发感染性休克死亡,1例因感染性休克于肝移植术后33个月死亡,其余17例随访期间未见结石再发。 结论内镜下行球囊扩张联合塑料支架置入治疗原位肝移植术后并发胆管结石安全、有效,可作为目前原位肝移植术后并发胆管结石的首选治疗方案。     

45例肝移植术后胆管狭窄的治疗体会

目的 探讨肝移植术后胆管狭窄的治疗方法及其效果.方法 回顾性分析45例肝移植术后胆管狭窄患者的临床资料.45例患者胆管狭窄的发生部位为吻合口狭窄8例、肝总管狭窄4例、肝门部狭窄12例、肝内胆管弥漫性狭窄16例及肝内、外胆管多发性狭窄5例.45例患者采用的治疗方法主要为:经十二指肠镜逆行胆管造影介入治疗;经皮肝穿刺胆管造影介入治疗;胆肠吻合术及再次肝移植术.结果 45例患者的总治愈率为64.4%(29/45),好转率为20.0%(9/45).介入治疗的治愈率为24.4%(11/45),好转率为20.0%(9/45),无效率为55.6%(25/45);与胆管狭窄相关的死亡率为15.6%(7/45).25例经介入治疗无效的患者中,有4例接受了胆肠吻合术,2例治愈,2例好转;其余21例(肝内胆管弥漫性狭窄16例.肝内、外胆管多发性狭窄5例)发生了移植肝功能丧失,其中5例因肝功能衰竭死亡,16例接受了再次肝移植术,术后有2例死于围手术期真菌感染.随访期间,有2例患者因肝癌复发而死亡,其余36例存活良好.结论 对于肝移植术后胆管吻合口狭窄和肝外及肝门部胆管狭窄,介入治疗效果较好.肝内胆管弥漫性狭窄和肝内、外多发性胆管狭窄经介入治疗无效时应尽早行再次肝移植术.     

原位肝移植术后胆管狭窄影像学特点

目的探讨肝脏移植术后胆管狭窄的影像学特点及发生机理。方法45例肝脏移植术后病人行MRCP检查,其中19例术后1至25月出现黄疸,15例行ERCP检查确认胆管狭窄并植入支架。分析胆管狭窄的部位、范围和程度,结合发病机制阐述其影像学特点。结果MRCP显示26例无黄疸病人中25例存在不同程度的胆管吻合口狭窄。19例黄疸病人中4例确诊为胆管炎,2例为吻合口狭窄,2例非吻合口狭窄病人表现为肝总管狭窄,11例非吻合口狭窄累及肝管、汇合部、二级分支,形成肝门附近胆管弥漫性狭窄。MRCP往往放大胆管狭窄程度,对4例肝内胆管小结石以及2例胆瘘显示欠佳。8例胆管非吻合口狭窄病人有长时间的供肝热缺血或冷缺血。结论胆管吻合口狭窄在肝脏移植术后无论是否伴有胆道梗阻均较普遍,非吻合口狭窄程度、范围不一,其影像学特征性表现与发病机理是一致的,MRCP是诊断胆管狭窄的较理想无创检查手段。     

原位肝移植术后胆管吻合口狭窄的介入治疗

目的 总结经皮介入技术治疗原位肝移植(OLT)术后胆管吻合口狭窄的经验.方法 回顾性分析2004年5月至2009年12月间25例OLT术后胆管吻合口狭窄患者的资料.其中22例行胆道外引流,3例第2次肝移植者行内外引流.25例的治疗方式包括单纯经皮经肝穿刺胆管引流术(PTBD)4例,PTBD配合球囊扩张术14例,PTBD配合胆道支架置入术7例(胆道内涵管5例,胆道金属支架2例).结果 PTBD手术成功率为100%,25例经介入治疗后15例(60%)治愈,10例(40%)好转,有效率达100%.7例首次行PTBD时引流管未能通过胆管狭窄段,其中3例于引流1周后再次调整引流管,成功通过狭窄段,余4例于引流术后4～8周时胆管狭窄段完全闭塞.引流期间发生胆道感染6例(24%),患者均未出现严重手术相关并发症.结论 经皮介入技术是治疗OLT术后胆管吻合口狭窄的一种安全、有效的方法.首次PTBD或PTBD后应短期内使引流管尽可能通过狭窄段,以免狭窄处永久闭塞.

Abstract：

Objective To describe the technique, efficacy, and safety of percutaneous interventional therapy for anastomotic biliary strictures after orthotopic liver transplantation (OLT).Methods From May 2004 to December 2009, 25 patients with anastomotic biliary strictures afte OLT were enrolled in our study. The modalities of biliary drainage included external drainage in 22patients, and external-internal drainage in 3 patients who underwent re-transplantation. All patients accepted percutaneous interventional therapy in our hospital, including single PTBD in 4 patients,PTBD combined with balloon dilation in 14 patients, balloon dilation and plastic stent implantation in 5 patients, balloon dilation and metallic stent implantation in 2 patients. The drainage catheters were exchanged every 1 to 3 months. Results The success rate of PTBD was 100%. Of the all 25patients, 15 (60 %) patients were cured, and 10 (40 %) patients were improved. The effective rate was 100 %. The drainage catheters failed to pass through the narrow bile duct when initial PTBD in 7 patients, and success was achieved in 3 patients by operation again after biliary drainage for one week.In the other 4 patients, anastomotic bile ducts were occluded, which was confirmed by cholangiography after biliary drainage for 4 to 8 weeks. The rate of biliary tract infection was 24 % (6/25). No serious procedure-related complications occurred in the all 25 patients. Conclusion PTBD combined with balloon dilation and biliary stenting is a effective and safe therapeutic modality for anastomotic biliary strictures after OLT, which can improve the patients' clinical symptoms and elevate patients' quality of life. To avoid bile duct occlusion, the drainage catheters should be passed through the narrow segments of bile duct when initial PTBD.     

逆行胰胆管造影在肝移植中的应用

目的探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植术后胆道并发症中的应用。方法对本院肝移植术后出现胆道并发症的16例患者进行ERCP检查,并根据情况分别行鼻胆管引流(ENBD)和/或内镜下乳头切开取石(EST)等治疗。结果ERCP确诊16例肝移植术后胆道并发症,发生率为9.47%,其中胆道结石6例,胆道狭窄3例,吻合口漏2例,胆道结石伴左肝管狭窄1例,吻合口胆漏伴胆道结石3例,1例示供受体胆管比例不一致,供体胆管相对狭窄,所有患者都得到有效治疗。结论内镜下ERCP是诊断和治疗肝移植术后胆道并发症的一种安全而有效的手段,可作为非手术治疗中的首选。     

Covered metal stents for the treatment of biliary complications after orthotopic liver transplantation

Background

Biliary complications, a major source of morbidity after orthotopic liver transplantation (OLT), are increasingly being treated by endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic management has been shown to be superior to percutaneous therapy and surgery. Covered self-expandable metal stents (CSEMSs) may be an alternative to the current endoscopic standard treatment with periodic plastic stent replacement.

Objective

To assess the safety and efficacy of temporary CSEMS insertion for biliary complications after OLT.

Methods

From November 2001 to December 2009, the 242 OLT performed in 226 patients included 67 cases that developed post-OLT leaks or strictures (29.6%), excluding ischemic biliary complications. CSEMSs were used in 22 patients (33%), 18 male and 4 female, with an overall median age of 55 years (range, 29-69). In-house OLT patients underwent an index ERCP at 26 days (range, 8-784) after OLT. Their records were reviewed to determine ERCP findings, technical success, and clinical outcomes.

Results

ERCP with sphincterotomy was performed in all 22 patients, revealing 18 with biliary strictures alone (82%), 3 with strictures and leaks (14%), and 1 with strictures and choledocholithiasis (4%). All strictures were anastomotic. All patients had 1-2 plastic stents inserted across the anastomosis (11 had prior balloon dilation); stones were successfully removed, for an initial technical success rate of 100% (22/22). CSEMSs, were placed at the second ERCP in 14 patients, at the third in 7, and at the fourth in 1. With a median follow-up of 12.5 months (range, 3-25) after CSEMS removal, 21/22 patients (95.5%) remain stricture free and one relapsed, requiring repeat CSEMS insertion. Four patients experienced pain after CSEMS insertion. At CSEMS removal, migration was noted in 5 cases, into either the distal duodenum (n = 4) or the proximal biliary tree (n = 1), and embedding was seen in 1 case. There were no serious complications; no patients needed hepatojejunostomy.

Conclusions

ERCP is a safe first-line approach for post-OLT biliary complications. It was highly successful in a population with anastomotic leaks and strictures. The therapeutic role of ERCP to manage biliary complications after OLT in the long term is not well known. In our experience, the high rate (close to 95%) of efficacy and its relative safety allowed us to use CSEMS to manage refractory biliary post-OLT strictures. CSEMS insertion may preclude most post-OLT hepatojejunostomies.     

A study on postoperative bile duct stricture with intrahepatic stones

From January 1976 through December 1988 we encountered ninety nine cases of intrahepatic stones. Eight of them were complicated with postoperative bile duct strictures which were formed on cholangiojejunostomy in 5 cases, cholangioduodenostomy, hepatic hilum and common hepatic duct in 1 case, respectively. Six cases of them are anastomotic strictures. The stones were mainly composed of bilirubin calcium. We guessed that the bile duct stricture resulted from cholangiojejunostomy without Roux-en-Y in 1 case and anastomotic insufficiency in 5 cases. Intrahepatic stones were removed by percutaneous transhepatic cholangioscopy (PTCS), and the treatment for the stricture was cholangiojejunostomy in 1 case and the dilatation by PTCS in 5 cases, including 3 endoprostheses by pig-tail silicone catheter and 2 internal-external biliary drainage. Two patients who did not undergo cholangioscopic dilatation died of sepsis due to cholangitis. Three of 5 patients who underwent endoscopic dilatation by PTCS could return to social life without recurrence of gallstones. In other two cases an endoprosthetic catheter was removed by PTCS because of dislodgement or obstruction of the catheter after confirming anastomotic strictures had improved. Authors recommended that PTCS should be applied for postoperative bile duct stricture complicated with intrahepatic stone.     

十二指肠镜在诊治腹腔镜胆道术后并发症中的应用价值

目的探讨十二指肠镜在诊断及治疗腹腔镜胆道术后并发症的应用价值。方法自2002年1月至2008年6月,应用十二指肠镜诊治腹腔镜胆道术后并发症患者123例,根据具体类型进行针对性治疗,并对十：二指肠镜治疗效果进行回顾性分析。结果123例胆道并发症者中,胆道残余结石58例,56例结石排出;胆汁漏40例,38例治愈,避免开腹手术;胆总管下端狭窄11例,全部治愈;三管汇合处狭窄8例行胆道支架治疗,5例远期效果满意;肝门部胆管狭窄2例,胆管完全横断4例,经ERCP明确诊断后均行外科手术。：本组十二指肠镜治疗总的并发症发生率为4．88％,无严重并发症。结论针对腹腔镜胆道术后并发症,十二指肠镜是一种微创、安全、有效的诊断和治疗方法,对于胆管残余结石、胆汁漏、胆管下端狭窄疗效确切;对于胆管部分狭窄,十二指肠镜下胆道内支架作为一种可选择的治疗手段,使多数患者免受开腹手术之苦。     

肝移植术后胆道并发症的诊断与治疗

目的 探讨肝移植术后胆道并发症的诊断与治疗.方法 分析2007-2009年肝移植术后不同类型胆道并发症的患者的临床资料,评价胴道并发症的类型,处理方式及术后恢复情况.结果 肝移植术后胆道并发症患者23例,包括胆漏患者12例,计胆管吻合口漏7例,肝断面胆管漏3例,胆囊管漏1例,迷走胆管漏1例;移植术后胆管狭窄患者11例,其中吻合口狭窄4例,非吻合口性狭窄7例.7例吻合口漏患者中,胆管重建2例(Roux-en-Y吻合和胆肠襻式Warren吻合);胆道吻合口修补1例;单纯依靠外引流管引流1例,活体双供肝肝移植的患者剖腹探查纠正胆漏失败后行再次肝移植1例;行经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)植入支架2例.肝断面胆管漏3例中,行肝断面胆管缝扎1例,ERCP联合B超引导下穿刺引流2例,引流2个月后胆漏闭合,拔除引流管,但是随后又出现胆道狭窄,ERCP术后,病情好转.胆囊管漏1例,行胆囊管缝扎.迷走胆管漏1例,行胆囊床缝扎.吻合口狭窄的患者4例,3例经ERCP治愈,1例行胆肠吻合重建胆道后治愈.非吻合口性狭窄的7例,行ERCP治疗3例,ERCP失败后,行经皮肝穿刺胆管引流(percutaneous transhepatic cholangiographic drainage,PTCD)1例;再次肝移植3例,2例患者术后恢复良好,1例死于严重感染.结论 肝移植术后胆道并发症危害大,关键在于预防.     

胆道镜治疗术后肝内胆管结石并狭窄13年经验总结：附697例报告

目的:总结胆道镜治疗术后肝内胆管结石并狭窄的经验,提高肝内胆管结石并狭窄的治疗效果。方法:回顾2000年1月—2012年12月应用胆道镜经T管窦道治疗术后肝内胆管结石并狭窄的697例患者临床资料,分析技术要点,评价疗效。结果:672例患者取净结石,结石取净率96.4%。胆道镜共发现1 306支肝内胆管狭窄,其中1 297支狭窄得到解除,狭窄解除率99.3%。狭窄解除、结石取净后患者胆管壁恢复光滑。9例患者出现严重并发症,均经治疗后痊愈。结论:规范的胆道镜治疗能有效解除术后肝内胆管狭窄,取净结石;肝内胆管狭窄的发现及处理是胆道镜治疗的优势,应根据不同狭窄类型分别对待;萎缩肝段切除和术中取石在肝内胆管结石治疗中仍具有重要作用。     

原位肝移植术后胆道并发症治疗经验

目的总结原位肝移植术后胆道并发症的治疗经验。方法1999年2月至2004年2月,我中心采用胆总管-胆总管端端吻合术施行原位肝移植236例,96例采用置“T”管引流的胆管间断吻合;39例采用未置“T”管的胆管间断吻合技术;101例采用未置“T”管、前壁间断后壁连续的胆管吻合。结果全组术后32例(13·3%)发生胆道并发症,其中胆管狭窄24例(10·0%),胆漏6例(2·5%),胆管结石2例(0·8%)。3组胆道并发症发生率分别为17·7%、15·4%和7·9%,其中肝门部/肝内胆管狭窄发生率分别为8·3%,2·6%和1·0%。第3组胆道并发症发生率和胆管狭窄发生率显著降低(P<0·05)。20例胆管狭窄患者接受放射和/或内镜介入治疗,其中单纯吻合口狭窄治愈率90%,肝门部/肝内胆管狭窄治愈率60%。结论弃用“T”管的胆管前壁间断后壁连续的吻合方式能显著减少胆道并发症;非缺血相关性胆管吻合口狭窄和单纯肝门部胆管狭窄应首选介入治疗。     

Partial biliary obstruction caused by chronic pancreatitis. An appraisal of indications for surgical biliary drainage.

This paper presents a retrospective review of 38 patients with intrapancreatic bile duct strictures secondary to chronic alcoholic pancreatitis. The strictures were identified by endoscopic retrograde cholangiopancreatography (ERCP). All patients with pancreatic cancer and gallstone pancreatitis were excluded. The mean alkaline phosphatase and total bilirubin values were 344 +/- 57 IU/dl and 4.4 +/- 0.7 mg/dl, respectively. The mean stricture length was 3.9 +/- 0.5 cm, and the mean common bile duct (CBD) diameter was 1.8 +/- 0.2 cm. The degree of bilirubin and alkaline phosphatase elevation did not correlate with stricture length or the severity of bile duct dilatation. Eighteen of the 38 patients received surgical biliary drainage (BD) as part of their initial therapy, and 20 patients did not. Liver function tests, intrapancreatic stricture length, and the degree of proximal CBD dilation were comparable in these two groups. Patients not undergoing BD did well clinically as only one patient required BD over an average follow-up period of 3.8 years. In conclusion, bypass of these strictures is usually unnecessary, and most patients may be safely treated without operation.     

胆囊切除术后问题的内镜诊断和治疗

目的 探讨内镜在胆囊切除术后问题病因诊断和治疗的应用价值。方法 对386例胆囊切除术后问题病人行逆行胆胰管造影（ERCP）检查明确病因后,对胆管结石者行括约肌切开术（EST）和乳头气囊扩张术（EPBD）后取石;对乳头炎性狭窄者行EST或EPBD治疗;对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱（SOD）者行EPBD治疗;对乳头肿瘤和肝门胆管癌行胆管内支架（EMBE）;对化脓性胆管炎、继发性胆总管多发结石、结石难以一次取净及术后胆瘘、胆管中段狭窄者行ENBD。结果 371例（96.1％）ERCP成功。未发现异常30例。胆管结石243例,235例经1-3次内镜取石后取净。乳头炎性狭窄39例,经EST或EPBD治疗1次成功。乳头旁憩室压迫乳头开口9例,SOD 7例,行EPBD治疗1次成功。胆管中段狭窄16例,11例行ENBD成功。乳头肿瘤6例,肝门胆管狭窄5例,行内支架治疗后黄疸减退。胆囊切除术后胆瘘6例,行ENBD治疗成功,避免再次外科手术。胃十二指肠溃疡6例。胆囊管结石残留4例。总的并发症发生率5.7％。结论 ERCP能及早发现胆囊切除术后问题确切病因并给予相应内镜治疗。     

The experience of biliary tract complications after liver transplantation

AIM: To report the morbidity and mortality of patients who undergo liver transplantation with or without T-tube implantation after choledochocholedochostomy as well as to discuss management of biliary complications. PATIENTS AND METHODS: We performed a retrospective review of 104 liver transplantations from August 2001 to February 2006, including 51 patients who underwent choledochocholedochostomy with a T-tube (group A) and 53, without a T-tube (group B). We compared the clinical characteristics, operative methods, biliary complications, morbidity, mortality, and management of complications. RESULTS: Between the two groups, there were no significant differences in clinical characteristics, including sex, age, and indication for liver transplantation (hepatitis B virus, hepatitis C virus, alcoholic liver cirrhosis, or hepatocellular carcinoma), Child-Pugh classification, Model for End-stage Liver Disease score, and operative macroscopic/microscopic findings. Additionally, there was no significant difference in biliary complications. Among these 104 patients, 14 (13.5%) developed biliary complications: seven anastomotic strictures, two intrahepatic duct strictures, two anastomotic stricture combined intrahepatic duct stricture, one bile leakage, one bile leakage combined with anastomotic stricture, and one external biliary compression. Nine patients with anastomotic stricture underwent endoscopy with a stent, which was successful only in two patients. The other six patients underwent choledochojejunostomy with excellent results. CONCLUSIONS: This study showed choledochocholedochostomy with or without a T-tube after liver transplantation did not influence the biliary complications. The biliary complications of anastomotic stricture after liver transplantation can be managed by endoscopy with a stent. If endoscopy fails, surgical intervention should be considered immediately.     

肝移植术后胆道并发症的内镜诊断和治疗(附250例次临床资料分析)

目的 总结经内镜逆行胰胆管造影（endoscopic retrograde cholangiopancreatography,ERCP）诊断和内镜治疗肝移植术后胆道并发症的经验。方法 回顾性分析139例原位肝移植术后合并胆道并发症行ERCP资料,通过ERCP发现10种胆道并发症,发生部位包括移植肝、吻合口和受体胆管、十二指肠乳头等,其中常见的并发症为胆管、吻合口狭窄（102/139,73.4%）,胆管炎（94/139,67.6%）,胆总管和肝内胆管胆泥、胆结石形成（75/139,54.0%）,十二指肠乳头功能紊乱（20/139,14.4%）,胆漏（17/139,12.2%）,T管相关的并发症（4/139,2.9%）等。少见的有十二指肠乳头狭窄（1/139,0.7%）,介入治疗相关的并发症（2/139,1.4%）,胆道出血（3/139,2.2%）,胆管过长、扭曲（4/139,2.9%）等。治疗方法：EST（112/139,80.6%）,扩张管和气囊扩张器扩张（157/250,62.8%）,塑料内支架（139/250,55.6%）,鼻胆管引流、冲洗（87/250,34.8%）,取石（27/250,10.8%）等。结果 本组139例共行250次ERCP,插管成功率达99.2%（248/250）,总治愈率达70.5%（98/139）,好转率为18.7%（26/139）,总有效率为89.2%（124/139）,中转手术9例（9/139,6.5%）,无效4例（4/139,2.9%）,放弃或失访2例。术后并发症主要包括：胆道感染37例,ENBD管滑脱26例,胆泥、胆结石形成18例。结论 内镜是诊断和治疗肝移植术后胆道并发症的主要方法。