肝移植术后并发症与介入治疗四、门静脉并发症

肝移植术后门静脉供血障碍性并发症主要为门静脉狭窄和门静脉血栓形成,虽然发生率不高,但临床危害大,一经确诊,需积极处理。彩色多普勒血流显像可作为检测门静脉血流的首选方法,对确诊有功能意义的狭窄还需依赖血管造影。对于门静脉狭窄行球囊扩张术以及支架置入术可有效降低门脉压力,而门静脉血栓形成的病例可用药物溶栓、机械碎栓和支架置放术相结合进行治疗,必要时可行TIPS降低门脉压力。     

Management of venous outflow complications after liver transplantation

Liver transplantation can be complicated by stenosis of the hepatic venous or inferior vena cava outflow. Venous outflow stenosis occurs at rates of 1 to 6% depending on the type of anastomosis. Stenoses can develop acutely as a result of technical problems or can present much later after the transplant due to intimal hyperplasia or perianastomotic fibrosis. Common clinical presentations include hepatic dysfunction, liver engorgement, ascites, abdominal pain, and occasionally variceal bleeding. Treatment can generally be accomplished via a transjugular approach, but percutaneous transhepatic access may be needed when the anastomosis cannot be catheterized from the jugular access. Angioplasty can achieve technical success in restoring anastomotic patency in close to 100% of cases, but restenosis is frequent. Repeat angioplasties may be needed. In adults and pediatric patients with adult sized hepatic veins, stenting may be a better option. Resolution of clinical signs and symptoms is seen in 73 to 100% of cases. Major complications are uncommon, with stent migration being one of the more difficult complications to manage.     

Biliary complications after orthotopic liver transplantation

Liver transplantation has made many advances since its inception in the early 1970s. Despite volumes of basic science and clinical research related to liver transplantation, biliary complications continue to present the interventional radiologist with challenging cases in all transplant centers. Biliary complications can range from minor complications such as contained bile leaks to severe complications such as biliary necrosis resulting from hepatic artery thrombosis. Minor complications may require minimal or no intervention, whereas the more severe complications can require urgent surgery. To treat biliary complications such as anastomotic strictures, nonanastomotic strictures, biliary leaks, sludge or biliary necrosis, an accurate diagnosis must first be obtained. One must also be aware of how these complications can impair both allograft and transplant patient survival. With this information one can then plan a treatment knowing the potential success rates of specific treatments. Using proper technique with this information at hand can greatly increase the success rate in treating the spectrum of biliary complications. Interventional radiology serves a critical role in diagnosis and treatment of these liver transplant biliary complications and is important to the success of all transplant programs.     

门静脉血栓形成的外科策略及其对原位肝移植效果的影响

 目的 观察门静脉血栓形成(portal vein thrombosis, PVT)患者原位肝移植(orthotopic liver transplantation, OLT)术中的外科策略,评价外科措施对OLT肝移植效果的影响.方法 我院2002-02至2007-02间836例成人OLT患者中有71例术前合并门静脉血栓(PVT组).回顾性分析所有患者的临床资料,观察PVT组的外科处理策略,评价PVT对肝移植手术风险和治疗效果的影响.结果 71例PVT患者分别接受栓塞段门静脉切除术(18例)、门静脉内血栓切除术(46例)、间置静脉架桥术或曲张静脉吻合术(7例).PVT组手术时间(min)和无肝期时间(min) 明显长于对照组(分别为792.47±162.29和516.18±186.30, P=0.0072;77.53±24.76和48.55±31.20, P=0.033),而两组间术中输血量、平均住ICU时间、住院时间差异无统计学意义(P＞0.05).PVT组术后再栓塞率显著高于对照组 (分别为9.86%和1.44%,P=0.0002).除90 d时PVT组门静脉血流(cm/s)较高(41.43±17.19 和19.85±11.39, P=0.0047)外,两组间各随访时段中移植物功能和PVF没有显著性差异.PVT组围术期病死率略高于对照组,而1、3、5年生存率稍低于对照组,但差异均无统计学意义.结论 术前PVT可能会增加肝移植手术复杂程度,但并不影响肝移植效果.     

Hepatopetal collaterals after portal vein thrombosis following liver transplantation

Two liver transplant patients with hepatopetal collaterals after portal vein thrombosis are described. Angiographically, the appearance is similar to cavernous transformation of the portal vein. The demonstration of hepatopetal collaterals is diagnosic of portal vein occlusion from whatever cause. After portal vein occlusion, collaterals develop from preexisting periportal vessels which undergo compensatory enlargement and reconstitute the intraheptic portal vessels. In liver transplant patients, the collateral communications must arise de novo, since all potential collateral pathways are severed at the time of transplantation.     

Portal vein stenosis and occlusion stenting after liver transplantation in two adults

We report two cases of percutaneous transhepatic stenting of the portal vein to treat stenosis and occlusion disclosed 5 and 18 months, respectively, after orthotopic liver transplantation in two adult patients. If long-term patency is satisfactory, this technique should allow long-term management of portal vein stenosis and occlusion without the use of thrombolysis.     

肝移植术后血管与胆管并发症介入治疗初探

目的：评价血管造影和胆管造影诊治肝移植术后血管及胆管并发症的价值。方法：46例原位肝移植术后B超提示血流速度不畅或频谱异常，下肢水肿或黄疸的患者16例，进行腹腔动脉造影10例次，下腔静脉造影并球囊扩张或支架置入6例次，经皮肝穿刺门静脉造影并支架置入2例次，经皮肝穿刺胆管造影并引流4例次。结果：肝动脉血栓形成2例，1例经溶栓治疗后部分开通；肝动脉狭窄4例，1例球囊扩张后狭窄减轻；所有下腔静脉和门静脉阻塞或狭窄行球囊扩张及置放支撑架后临床症状好转，4例胆管狭窄和吻合口瘘者行经皮肝穿刺胆管造影引流（PTCD）治疗后黄疸减轻。结论；对肝移植术后出现的血管和胆管并发症，血管造影和胆管造影不仅可明确诊断，而且能同时工取得较好的近期疗效。     

肝移植术后血管和胆系并发症的MRI诊断价值

目的探讨磁共振血管造影(MRA)和MR胰胆管成像(MRCP)对诊断肝移植术后血管及胆管并发症的价值。方法7例原位肝移植术后患者均用磁共振(MR)快速自旋回波(TSE)序列及快速小角度激发梯度回波(FLASH)序列常规扫描、MRCP、钆喷替酸葡甲胺(Gd-DTPA)动态增强3DMRA检查，分析各序列图像特点。结果术后正常2例，主要表现少量腹水，积血和轻度淋巴结增大。血管并发症4例：肝动脉过长迂曲1例，肝动脉供体端瘤样轻度扩张2例；门静脉轻度狭窄2例，位于吻合口；肝静脉末梢分支杵状扩张2例。胆系并发症3例：吻合口胆管狭窄3例；在吻合口以外的胆管狭窄2例，位于肝门及肝内；胆总管在吻合口扭曲2例；胆囊管残端黏液囊肿2例；胆漏1例。结论MRA和胆管造影作为1种非侵袭性影像检查方法，可准确、快速诊断肝移植术后出现的血管和胆管并发症，对指导临床诊断及治疗具有重要意义。     

Management of hepatic artery steno-occlusive complications after liver transplantation

Steno-occlusive disease (arterial obstructive disease) of the transplant hepatic artery is a collective term that can be used to include hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks. The latter 2 can be referred to collectively as arterial anatomical defects. This chapter details the angiographic techniques and definitions required to make an accurate angiographic diagnosis of these arterial transplant complications. In addition, the chapter focuses on detailed technical aspects of the endoluminal management of these arterial complications. The chapter discusses the role and technical results of endoluminal management of these arterial complications and, when possible, the lesion morphologies most amenable to endoluminal management.     

肝移植术后胆道并发症的多层螺旋CT诊断

目的 评价MSCT在诊断肝移植术后胆道并发症中的价值.方法 83例原位肝移植术后患者因临床和生化检查可疑胆道并发症行MSCT增强检查.胆道并发症的确诊依据为直接胆道造影69例、移植肝病理11例、肝管空肠吻合术3例.分析CT诊断胆道并发症的能力,计算其敏感度、特异度、准确度、刚性预测值和阴性预测值,并用x2检验比较胆管吻合口狭窄和非吻合口狭窄的CT特征.结果 83例中,62例(74.7%)证实有胆道并发症,其中胆管吻合口狭窄32例,非吻合口狭窄21例,胆管结石16例(12例合并胆管狭窄),胆总管吻合口漏5例,胆汁瘤4例(合并胆管狭窄)、胆源性肝脓肿2例(合并胆管狭窄).CT诊断胆管狭窄的敏感度、特异度、准确度、阳性预测值、阴性预测值分别为90.6%、86.7%、89.2%、92.3%和83.9%.CT对胆管结石、胆总管吻合口漏、胆汁瘤、胆源性肝脓肿均能正确诊断,无漏诊和误诊.非吻合口狭窄表现为胆管不均匀扩张的发生率(71.4%,15/21)显著高于吻合口狭窄者(25.0%,8/32;P<0.01),而肝外胆管扩张(33.3%,7/21)和胆管均匀扩张(14.3%,3/21)的发生率均显著低于吻合口狭窄者(84.4%,27/32和68.8%,22/32;P<0.01).非吻合口狭窄肝动脉缺血的发生率(66.7%,14/21)明显高于吻合口狭窄者(15.6%,5/32;P<0.01).结论 MSCT对诊断肝移植术后胆道并发症具有重要价值,还可初步诊断胆管狭窄类型;肝动脉缺血是胆管非吻合口狭窄的重要原因.     

Interventional radiology in the management of complications after liver transplantation

The arrival of new surgical transplantation techniques, such as split living donor or auxiliary liver transplantation, have increased the incidence of vascular and biliary complications. The causes, symptoms, and diagnostic modalities of arterial, portal caval, and biliary complications are detailed. Interventional techniques, such as balloon angioplasty and stent placement in the arterial and portal tree, as well as biliary interventional techniques, are discussed.     

64层螺旋CT结合后处理技术对肝移植术后并发症的评估

目的:探讨64层螺旋CT结合后处理技术在肝移植术后评估的应用价值.方法:选取50例(男40例、女10例)肝移植术后患者,行64层螺旋CT平扫、四期增强扫描及CTA检查,由两位放射科医师对图像进行评估,内容包括肝实质、血管、胆道情况及有无转移.将结果与彩超及临床随访行对照分析.结果:CT检查示:肝动脉并发症3例、门脉并发...     

不同途径肝内微囊移植对肝功能及肝血流影响的对比研究

目的 探求经门静脉及肝动脉途径肝内移植微囊对肝功能及门脉血流的影响.方法 将海藻酸钠在无菌条件下制作成为直径50～500μm的微囊.将健康雄性犬20只随机分为V组和A组,V组为经门静脉移植组,再分为V1、V2组,A组为经肝动脉移植组,再分为A1、A2组;每组动物5只;V1、V2、A1、A2组分别移植微囊16 000个/...     

肝移植术后早期胆道并发症65例诊治体会

目的探讨肝移植术后早期胆道并发症的诊断和治疗。方法回顾性分析了我院2006年5月～2008年3月以来成功实施的65例肝移植的临床资料。其中尸肝移植54例，亲体肝移植11例，女性占16．92％（11／65），男性占83．08％（54／65）。结果本组65例肝移植患者其中有8例3个月内出现胆道早期并发症，发生率为12．31％（8／65），分别为胆漏3例，胆汁瘤1例，肝内胆汁湖1例，胆泥形成1例，胆道狭窄2例。女性患者早期胆道并发症发生率为9．09％（1／11），男性患者早期胆道并发症发生率为12．96％（7／54）。8例患者中，留置T管引流1例，未留置T管引流7例。治愈6例，好转2例，死亡0例（0％）。其中3例术后3d内出现单纯胆漏，通过留置的腹腔引流管得到及时的诊断，同时应用留置的腹腔引流管持续引流4周～2月后得到治愈。5例经B超、MRCP、ERCP得到诊断；1例胆汁瘤和1例肝内胆汁湖通过B超引导下穿刺引流而得到治愈；1例胆泥形成通过ERCP进行胆道冲洗后好转出院；2例通过ERCP进行球囊扩张或者放置支架后好转出院。结论肝移植术后早期胆道并发症的诊断主要手段是留置的腹腔引流管、B超、MRCP、ERCP等：肝移植术中留置的腹腔引流管对于肝移植术后早期胆漏的治疗起着特殊的作用：B超引导下穿刺引流是治疗胆汁瘤、胆汁湖的重要手段；ERCP下胆道冲洗对胆泥形成非常有效．ERCP下球囊扩张或者放置胆道支架对胆道狭窄的治疗很有效。     

肝移植术后结核感染的诊断与治疗

目的总结肝移植术后结核感染的发生率、临床表现和诊治方法。方法回顾分析246例肝移植患者中术后发生结核感染的3例的临床表现、化验检查结果、影像学资料及诊断和抗结核治疗经过。结果肝移植术后结核感染的发生率为1.2%(3/246)。3例中1例为血行播散型肺结核合并结核性胸膜炎;1例为结核性胸膜炎合并肝脏结核,经抗结核治疗痊愈,未再复发;1例术前有结核空洞,术后合并多种细菌感染和真菌感染,死于肺部感染。3例患者的临床表现均不典型,从症状出现到确诊平均历时30d;血清免疫指标均为阴性,PPD试验仅1例阳性;抗结核治疗安全有效,取得了满意疗效。应用抗结核药后免疫抑制剂血药浓度下降,可通过增加免疫抑制剂剂量后可纠正。无一例患者因抗结核药物的肝毒性而需中断治疗。结论肝移植术后结核感染在临床表现、诊断及治疗上有其特殊性,早期诊断、合理治疗预后较好。     

肝移植术后并发症与介入治疗六、胆道并发症的介入治疗

肝移植(LT)已成为终末期肝脏疾病和部分肝脏恶性肿瘤的有效疗法.胆道并发症(BC)是LT后常见的并发症及死亡原因.采用引流、球囊扩张、支架植入等多种介入手段,处理BC已经获得广泛认同,但是引起LT后BC发生的因素很多,了解BC的发病机制、病理、分类和诊断有助于合理制订治疗策略,提高LT并发症的处理水平和临床成功率.     

肝移植术后并发症与介入治疗七、其他

肝移植术后除了常见的肝动脉、门静脉、肝静脉和胆道并发症外,本文归纳了其他少见的并发症,这些不常见的并发症多数以个案或短篇报道的方式出现在以往的文献中,部分此类并发症也可以采用介入方法进行治疗.另外,介入医师应该了解在不同病因下的肝移植术后并发症的发生情况,有助于全面认识肝移植术后并发症.     

Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation

Backgrounds and aims

Accurate assessment of graft bile duct is important to plan surgical procedure. Magnetic resonance cholangiopancreatography (MRCP) has become an important diagnostic procedure in evaluation of pancreaticobiliary ductal abnormalities and has been reported as highly accurate. We aim to estimate the efficacy of preoperative MRCP on depicting biliary anatomy in living donor liver transplantation (LDLT), and to determine whether inaccurate preoperative imaging assessment would increase the biliary complications after LDLT.

Methods

The data of 118 cases LDLT were recorded. Information from preoperative MRCP was assessed using intraoperative cholangiography (IOC) as the gold standard. The possible risk factors of recipient biliary complications were analyzed.

Results

Of 118 donors, 84 had normal anatomy (type A) and 34 had anatomic variants (19 cases of type B, 9 cases of type C, 1 case of type E, 2 cases of type F and 3 cases of type I) confirmed by IOC. MRCP correctly predicted all 84 normal cases and 17 of 34 variant cases, and showed an accuracy of 85.6% (101/118). The incidence of biliary complications was comparable between cases with accurate and inaccurate classification of biliary tree from MRCP, and between cases with normal and variant anatomy of bile duct. While cases with graft duct opening ≤5 mm showed a significant higher incidence of total biliary complications (21.1% vs. 6.6%, P = 0.028) and biliary stricture (10.5% vs. 1.6%, P = 0.041) compared with cases with large duct opening >5 mm.

Conclusion

MRCP could correctly predict normal but not variant biliary anatomy. Inaccurate assessment of biliary anatomy from MRCP not increases the rate of biliary complications, while small-sized graft duct may cause an increase in biliary complications particularly biliary stricture after LDLT.     

经颈静脉肝穿刺门静脉途径门静脉及肠系膜上静脉血栓溶栓治疗6例报告

目的 评价经颈静脉经肝穿刺门静脉(TIPSS)途径门静脉及肠系膜上静脉血栓溶栓治疗的安全性和治疗效果。方法 对6例诊断为门静脉(PV)和肠系膜静脉(SMV)广泛血栓形成的患者进行了经TIPSS途径介入溶栓治疗。患者主要症状有腹痛、腹胀、厌食等。腹部体检有压痛,均无明确腹肌紧张和反跳痛。经B超、增强CT检查和直接PV-SIV造影确诊为本病。溶栓方法：穿刺PV分支成功后插入导管做PV-SMV造影,确定诊断及了解栓塞范围,抽吸及捣碎血栓,间断将尿激酶经多侧孔导管注入PV和SMV清除大部分血栓后,保留多侧孔导管于SMV内持续溶栓3～13天。术后药物抗凝治疗6个月左右。此间,密切监测出凝血时间及影像学变化。结果 介入治疗后,大部分血栓被清除,PV和SMV有血流通过,腹痛、腹胀和腹泻症状逐步缓解。经留置于SMV的导管造影显示,PV和SMV主干及主要分支血流通畅,3例门静脉的肝内少数分支有残留血栓,但无明显症状。随访4个月至3年,除1例死于外科手术并发症外,其余5例患者健在,无血栓复发证据及上消化道出血发生。结论 经TIPSS途径介入溶栓治疗急性PV和SMV血栓形成是安全有效的,近期及中远期疗效均好。     

Assessment of portal venous system patency in the liver transplant candidate: a prospective study comparing ultrasound,microbubble-enhanced colour Doppler ultrasound,with arteriography and surgery

AIM: To determine the role of microbubble-enhanced colour Doppler ultrasound (CDUS) in assessing portal venous patency prior to liver transplantation. MATERIALS AND METHODS: Over a 2-year period, all patients with chronic liver disease undergoing routine pre-transplant CDUS examination in whom the portal venous system was inadequately demonstrated were recruited to the study. CDUS was performed in 368 patients and 33 patients (9%) were recruited. A repeat CDUS examination following an intravenous bolus injection of the microbubble contrast agent Levovist (Schering Healthcare AG, Berlin, Germany) was performed. Diagnostic confidence was recorded on a free linear analogue scale for both examinations. Findings were compared with indirect portography and surgery. RESULTS: Of the 33 patients with sub-optimal baseline examinations, improvement in portal vein visualization was achieved in 31 patients (94%). Median diagnostic confidence increased from 50% (interquartile range 30-60) to 90% (interquartile range 75-98) (P < 0.001) following administration of Levovist. Overall accuracy of portal vein assessment using microbubble-enhanced CDUS in 15 patients in whom a definitive diagnosis was made within 2 months was 87%. CONCLUSION: Microbubble-enhanced CDUS is a simple, inexpensive adjunct to standard pre liver transplant screening of the portal vein. It is particularly helpful in patients with end-stage cirrhosis who are at high risk of portal vein thrombosis and in whom the conventional examination is sub-optimal.