肝移植术后胆道并发症介入治疗疗效分析

目的评价肝移植(LT)术后胆道并发症(BC)的介入治疗疗效,为临床提供参考。资料与方法回顾分析1999年7月至2009年11月北京朝阳医院介入放射科收治的41例LT术后BC患者的临床及随访资料;BC根据临床表现、实验室检查和影像学表现综合诊断,部分患者行肝穿刺活检;疗效根据患者治疗前、后临床表现及黄疸相关指标综合评判,采用SPSS 18.0软件对黄疸指标进行统计分析,P<0.05认为差异具有统计学意义。结果 41例患者BC包括弥漫性肝内胆管狭窄(32/41)、局限性胆管狭窄(16/41)、胆漏、胆汁瘤(3/41)、胆泥淤积(2/41)、胆管结石(1/41)、肝外胆管迂曲延长(2/41)。全部患者术后近期(1个月内)黄疸明显缓解,黄疸指标显著下降(P<0.05);多数患者中远期黄疸复发,但予以介入干预后均再获缓解。结论胆管狭窄是LT术后最常见的BC,经皮穿刺胆汁引流适用于各型BC,球囊扩张成形对局限性胆管狭窄效果良好。早期诊断并及时采取适当的介入治疗有助于患者顺利渡过LT危险期,随后适时的介入治疗对延长患者生存期、提高生活质量亦是不可或缺的治疗方法。     

肝移植术后胆道并发症的介入诊疗

目的 探讨介入手段在诊断和治疗肝移植术后胆道并发症的应用,分析移植术后T管留置的价值.方法 回顾性分析55例肝移植术后胆道并发症患者的介入诊治资料,分析有无T管所需采取的介入治疗方式.结果 保留T管的28例患者经造影证实胆道并发症存在后需进行介入治疗的17例,仅需通过原T管引流治疗的11例,而仅需进行球囊扩张后仍以T管引流的3例,需行经皮经肝胆道引流(PTBD)治疗(和辅以球囊扩张)的14例;无T管的27例患者全部进行经皮经肝胆管造影(PTC)诊断发现梗阻病变并予以介入治疗.共发现8例同时存在血管并发症并予以相应处理.所有患者在介入治疗后黄疸均明显消退,技术成功率100%,短期(1个月)缓解率100%.结论 对于肝移植术后胆道并发症患者,介入治疗安全、可靠,可重复性好,具有不可替代的作用;术后留置T管可为部分患者提供针对胆道梗阻进行造影诊断与引流治疗的途径,但大部分患者仍需介入手段干预,才能达到满意的治疗效果.     

Liver transplantation: diagnostic imaging in the preoperative assessment]

The correct selection of patients for liver transplantation, which is essential for surgical success, requires thorough radiological evaluation. The authors present their experience on 94 pretransplant adult patients that underwent a total of 251 diagnostic exams (Doppler US, CT, angiography and cholangiography) and interventional radiology maneuvers (biopsy, chemoembolization, biliary drainage). Three sclerosing cholangitis, 3 Budd-Chiari syndromes and 20 hepatocellular carcinomas in cirrhotic patients were identified; venous collaterals were present in 62.7% of the cases, 12.8%, of which had important spontaneous porto-systemic shunts; 6 patients had portal thrombosis; 20 arterial variations were found. Interventional maneuvers were useful and free of complications. US, CT and angiographic findings of each patient were compared. Integrating informations from different exams allowed a significant increase in the accuracy of diagnostic conclusions. Thanks to interventional maneuvers 5 patients could be selected for transplantation (hepatic arterial lipiodolization stopped the growth of 4 hepatic neoplasms; 2 infected fluid collections were sterilized by percutaneous US-guided drainage and topic therapy.     

肝移植术后胆道并发症ERCP表现及内窥镜介入治疗

目的探讨肝移植术后胆道并发症的原因及影像学表现,并对部分并发症进行内窥镜介入治疗,以提高肝移植的成功率。方法通过十二指肠镜逆行胰胆管造影(ERCP)检查对肝移植术后胆道异常改变11例资料进行回顾性分析,并根据检查结果做相应的内窥镜下介入治疗。结果通过ERCP检查,对11例肝移植术后患者出现梗阻性黄疸原因得到明确诊断,其中,胆道胆泥形成2例,胆管吻合口狭窄6例,胆道腹腔漏3例。并对2例胆道胆泥进行了乳头括约肌切开(EST) 网蓝胆泥取出术;5例吻合口狭窄行气囊扩张或塑料内支架内引流(ERBD)及2例胆道腹腔漏行鼻胆管引流治疗(ENBD),治疗效果确切,经有针对性的预防和治疗后,除2例胆道腹腔漏分别于肝移植术后6月及11月病死和1例因胆管吻合口处完全阻塞未能放置内支架引流管,导致肝内胆汁淤积症并肝硬化及肝功能失代偿病死外,其余患者均痊愈出院,现仍长期存活,总生存率为72.7%。结论肝移植术后一旦怀疑胆道并发症时应及时行ERCP检查,并根据检查结果做内窥镜介入治疗。胆道并发症的及时发现和处理将可能使患者较快痊愈。     

Percutaneous Access of the Modified Hutson Loop for Retrograde Cholangiography,Endoscopy, and Biliary Interventions

PurposeThe purpose of this study was to present the institutional experience of performing endoscopy, cholangiography, and biliary interventions through the modified Hutson loop by interventional radiology.Materials and MethodsA total of 61 of 64 modified Hutson loop access procedures were successful. This single-center retrospective study included 61 successful procedures of biliary interventions using existing modified Hutson loops (surgically affixed subcutaneous jejunal limb adjacent to biliary anastomosis or anastomoses) for diagnostic or therapeutic purposes in 21 patients. Seventeen of 21 patients (81%) had undergone liver transplantation. Indications included biliary strictures (n = 18) and biliary leaks (n = 3). The clinical success and complications were evaluated.ResultsThere were 3 of 26 modified Hutson loop retrograde biliary intervention failures (12%) before introduction of endoscopy and no failures (0 of 38 [0%]) subsequently (P = .06). Endoscopy or cholangioscopy was performed in 19 procedures by interventional radiologists. Retrograde biliary interventions included diagnostic cholangiography (n = 26), cholangioplasty (n = 25), stent placement (n = 29), stent retrieval (n = 25), and biliary drainage catheter placement (n = 5). No procedure-related mortality occurred. There was 1 major complication (duodenal perforation) (1.6%) and 12 minor complications (19%). In the 9 patients undergoing therapeutic interventions for biliary strictures, there was a significant decrease in median alkaline phosphatase (288.5 to 174.5 U/L; P = .03). There was a trend toward decrease in median bilirubin levels (1.7 to 1 mg/dL; P = .06) at 1 month post-intervention.ConclusionsThe modified Hutson loop provided interventional radiologists a safe and effective alternative access to manage biliary complications in patients with biliary-enteric anastomoses. Introduction of the endoscope in interventional radiology has improved the success rate of these procedures.     

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.     

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。     

The radiologist’s role in managing paediatric liver transplantation: personal experience with 40 patients

PURPOSE: The aim of our study was to evaluate the radiologist's role in managing paediatric orthotopic liver transplantation (OLT) through a retrospective review of our experience in diagnosing and treating post-OLT complications. MATERIALS AND METHODS: Forty children (mean age 4.6 years) underwent 44 OLTs over 71 months. The follow-up period (mean 724 days) was divided into three phases: hospital stay, up to three months after discharge and subsequent period. The number and type of radiological examinations, radiologically detectable complications and interventional procedures were analysed. RESULTS: Most examinations were carried out with ultrasound (US) (859/931 of all radiological studies performed during the first two phases, 92.3%). Colour-Doppler US enabled early detection and treatment of all vascular complications (9/40, 22.5% of patients; 13 complications in nine patients, eight arterial and five portal complications; 1.4 for each patient with complications). Computed tomography (CT) or angiography was very rarely employed. US also detected biliary complications (11 patients, 27.5%: three cases of segmental ducts excluded from the anastomosis, four cases of stenosis of the biliodigestive anastomosis, one lithiasis, three stenoses associated with lithiasis), which were successfully managed in 75% of the cases treated with interventional radiology procedures (percutaneous bilioplasty and/or lithotripsy). At the time of writing this paper, the patient survival rate was 100%, and the organ survival rate was 91% (40/44). There were four re-transplantations: three due to hepatic artery thrombosis and one to biliary stenosis with lithiasis. CONCLUSIONS: The radiologist's role is fundamental for early sonographic diagnosis of post-OLT complications in children. Vascular complications are often associated in a single patient, and early treatment may improve the prognosis. Interventional radiology represents a safe and effective treatment for many biliary complications.     

经皮肝穿胆道引流术治疗肝移植术后胆道并发症

目的 评价介入方法治疗肝移植术后胆管并发症的价值.方法 回顾性分析1999年10月-2005年10月肝移植术后发生的6例胆道并发症的相关资料,其中胆总管狭窄2例、胆总管狭窄并胆瘘1例、胆瘘1例、胆汁瘤2例.结果 术后出现胆道并发症患者,经皮肝穿胆道引流治疗5例,放置胆道支架1例.手术均取得成功,患者的临床症状有所好转.结论 介入方法治疗肝移植术后胆管并发症可减少再手术创伤,提高生存率与生存质量,具有良好的近期效果.     

Combined Surgical and Transhepatic Rendezvous Procedure for Relieving Anastomotic Biliary Obstruction in Children with Liver Transplants

Four children (3 boys and 1 girl, age 1.4–9.4 y) presented 2–70 months after liver transplantation (mean 26 months) with high-grade narrowing at the surgical anastomosis that could not be crossed at percutaneous transhepatic cholangiography. Each patient was treated with a combined surgical and interventional radiology “rendezvous” procedure. Biliary drainage catheters were left in place for an average of 6 months after the procedure. At a mean 7.5 months after biliary drainage catheter removal, all children were catheter-free without clinical or biochemical evidence of biliary stricture recurrence.     

原位肝移植术后胆道狭窄的介入治疗

目的:探讨经T型管及其窦道和经皮肝穿刺胆道引流治疗原位肝移植术后胆道狭窄的可行性及其疗效.方法:对252例原位肝移植术后出现胆道狭窄的26例患者分别行胆道气囊扩张术、胆道引流术和胆道支架置入术.结果:3例胆道狭窄合并胆瘘患者和3例单纯吻合口狭窄患者,经气囊扩张术和胆道引流后痊愈.6例肝内外胆管多发狭窄患者,气囊反复扩张胆道狭窄段后,5例狭窄纠正而获得痊愈;1例气囊扩张治疗后出现肝内血肿,再次行肝移植.12例肝内外胆管多发狭窄合并胆泥的患者,经反复球囊导管扩张后,10例狭窄明显减轻,黄疸缓解;1例置入胆道支架,后因支架管阻塞而再次肝移植;1例治疗后狭窄仍存在,黄疸无缓解而再次肝移植.2例T型管引流口段狭窄行经皮肝穿刺胆道引流术后,狭窄明显减轻,黄疸缓解.结论:经T型管及其窦道和经皮肝穿刺胆道引流是治疗原位肝移植术后胆道狭窄的良好方法.     

Percutaneous Biliary Interventions: Inside and Outside the Box: Role of Interventional Radiology in the Management of Acute Cholangitis

Acute cholangitis presents with a wide severity spectrum and can rapidly deteriorate from local infection to multiorgan failure and fatal sepsis. The pathophysiology, diagnosis, and general management principles will be discussed in this review article. The focus of this article will be on the role of biliary drainage performed by interventional radiology to manage acute cholangitis. There are specific scenarios where percutaneous drainage should be preferred over endoscopic drainage. Percutaneous transhepatic and transjejunal biliary drainage are both options available to interventional radiology. Additionally, interventional radiology is now able to manage these patients beyond providing acute biliary drainage including cholangioplasty, stenting, and percutaneous cholangioscopy/biopsy.     

Biliary complications after liver transplantation in patients with preexisting sclerosing cholangitis

To determine if biliary complications after liver transplantation are more frequent in patients with preexisting sclerosing cholangitis and to clarify the role of interventional procedures in this setting, the authors reviewed all 40 adult cases in which liver transplantation was performed at their institution over a 3 1/2-year period. Biliary complications, particularly strictures at the choledochojejunostomy and debris in the intrahepatic and common ducts, were seen in six of ten liver transplant patients (60%) with preexisting sclerosing cholangitis; this is six times the frequency of biliary complications seen in other adult recipients (10%). Biliary complications were definitively diagnosed and managed with interventional radiologic procedures. Obstruction due to anastomotic strictures required treatment with balloon dilation in all six of the affected patients. Obstructive biliary complications occur in many liver recipients with preexisting sclerosing cholangitis. These complications require aggressive radiologic assessment and intervention but to date have not adversely affected survival.     

介入治疗原发性肝癌移植术后复发的价值

目的探讨原发性肝癌肝移植术后复发患者的临床表现及介入治疗价值。 方法2004年3月～2011年6月14例肝移植术后复发的肝癌患者行综合介入治疗,包括肝动脉化疗栓塞32次、肝动脉泵置泵1例、经皮肝穿刺胆道引流1例、经内镜逆行性胰胆管造影术1例,高强度聚焦超声1例。 结果肝癌复发灶呈肝内多发、肝外广泛转移的特点,多为富血供肿瘤,合并血管及胆管并发症者各2例;接受介入治疗后至今存活2例,12例从接受肝移植治疗到死亡平均生存16.1个月。 结论原发性肝癌肝移植术后采用介入治疗可有效抑制肝癌术后复发灶及转移灶的生长,消除移植术并发症对患者的危害,延长患者的生存时间并提高生活质量。     

The role of interventional radiology in biliary complications after orthotopic liver transplantation: a single-center experience

This study evaluated interventional radiological experience in the management of biliary complications of OLT at the National Cancer Institute of Milan. Seventeen patients who had undergone orthotopic liver transplantation in various hospital were referred to our unit with biliary complications. Group I consisted of 8 patients with anastomotic biliary fistula who came to our attention a short time after transplantation. Group II consisted of 9 patients with anastomotic strictures who came to our attention in a longer period. Two different interventional radiological approaches were used: (a) percutaneous transhepatic biliary drainage (PTBD) in the presence of fistulas in patients of group I; and (b) percutaneous transhepatic biliary drainage combined with dilatation of the strictures with a balloon catheter in patients of group II. On the whole resolution of the biliary complications was achieved in 13 of the 17 cases treated (76.5%), 5 of 8 in group I and 8 of 9 in group II. No secondary stenosis after PTBD were observed in group I, whereas two patients of group II needed a second dilatation. Percutaneous biliary drainage is indicated as a valid treatment in the management of biliary complications, either to allow closure of the fistula either to perform balloon dilatation of stenosis.     

Magnetic resonance cholangiography in the assessment and management of biliary complications after OLT

Despite advances in patient and graft management, biliary complications (BC) still represent a challenge both in the early and delayed period after orthotopic liver transplantation (OLT). Because of unspecific clinical presentation, imaging is often mandatory in order to diagnose BC. Among imaging modalities, magnetic resonance cholangiography (MRC) has gained widespread acceptance as a tool to represent the reconstructed biliary tree noninvasively, using both the conventional technique (based on heavily T2-weighted sequences) and contrast-enhanced MRC (based on the acquisition of T1-weighted sequences after the administration of hepatobiliary contrast agents). On this basis, MRC is generally indicated to: (1) avoid unnecessary procedures of direct cholangiography in patients with a negative examination and/or identify alternative complications; and (2) provide a road map for interventional procedures or surgery. As illustrated in the review, MRC is accurate in the diagnosis of different types of biliary complications, including anastomotic strictures, non-anastomotic strictures, leakage and stones.     

Biliary Complications in Living Donor Liver Transplantation: Imaging Findings and the Roles of Interventional Procedures

Purpose To describe the incidence, types, and findings of biliary complications in living donor liver transplantation (LDLT) and to determine the roles of interventional procedures. Materials and methods Twenty-four biliary complications among 161 LDLT patients (24/161, 14.9%) were identified. These complications were divided into two groups according to the initial manifestation time, i.e., “early” (<60 days) or “late”. The CT and cholangiographic findings were reviewed regarding the presence of a stricture or leak and the location, and length, shape, and degree of the stricture. Both groups were categorized into three subgroups: leak, stricture, and both. The type of interventional procedures used and their roles were determined. Results Early complications were identified in 14 of the 24 patients (58%) and late complications in 11 (46%). One patient showed both early and late complications. Biliary stricture was detected in 10 patients, leak in 10, and both in 5. By cholangiography, all strictures were irregular and short (mean length 15 ± 6 mm) at the anastomotic site and complete obstruction was observed in 2 patients with late stricture. Twenty-three of the 24 patients were treated using percutaneous and/or endoscopic drainage procedures with or without balloon dilatation. Seventeen (74%) showed a good response, but reoperations were inevitable in 6 (26%). All patients except those with complete obstruction showed a favorable outcome after interventional management. Conclusion Biliary leaks and strictures are predominant complications in LDLT. Most show good responses to interventional treatment. However, complete obstruction needs additional operative management.     

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.     

肝移植术后血管胆道并发症的介入治疗

目的:评价介入治疗对肝移植后胆道、血管并发症的价值。材料和方法:18例肝移植患者接受了介入治疗。其中肝动脉狭窄8例,行肝动脉造影及溶栓治疗;下腔静脉及肝静脉狭窄2例,行内支架置入术;胆瘘及胆道狭窄8例,行PTCD治疗。结果:胆道并发症8例,PTCD治疗后症状消失;肝动脉狭窄8例,溶栓后肝动脉完全开放6例,1例血流部分开放,1例肝动脉血流未恢复再次肝移植治疗;下腔静脉及肝静脉狭窄2例内支架置入术后下腔静脉梗阻及肝肿大症状消失。结论:介入治疗是治疗肝移植后胆道血管并发症的有效方法。