肝移植术后慢性排斥反应的临床与病理分析

目的 探讨原位肝移植术后慢性排斥反应的病理组织学特点、临床表现以及诊治经验.方法 回顾性分析2004年1月至2006年12月收治的516例原位肝移植患者的临床病理资料;对肝移植术后发生慢性排斥反应患者的病理组织学改变、临床表现、诊治方案加以分析.结果 516例肝移植患者中,发生慢性排斥反应12例(2.3%,12/516),其中早期慢性排斥反应7例,晚期慢性排斥反应5例.其主要组织学特征是移植肝组织内的胆管严重减少或缺失和累及中等动脉的闭塞性动脉炎;其中早期慢性排斥反应可表现为小叶间胆管的细胞变性和其数量进行性减少以及形成小叶中央坏死性炎症.12例慢性排斥反应患者中,7例早期慢性排斥反应患者经激素冲击治疗和调整免疫抑制药物后病情得到控制(包括2例接受抗CD3抗体治疗,2例接受抗胸腺细胞球蛋白治疗)且近期疗效满意;5例晚期慢性排斥反应患者肝功能迁延不愈最终至肝功能衰竭而行再次肝移植,其中2例伴术后严重腹腔内感染而死亡,1例死于术后多脏器功能衰竭,另外2例再移植病例获临床治愈.本组慢性排斥反应发生的时间为术后4～26个月;与慢性排斥相关的病死率为25.0%(3/12).结论 肝移植术后发生慢性排斥反应的患者缺乏典型的症状和体征,其病理改变可以有重叠和复合存在;移植肝连续穿刺活检和再次移植术后病理仍是目前诊断慢性排斥反应的"金标准".如能及时发现早期慢性排斥反应并积极进行合理的治疗,病情则具有潜在的可逆性;晚期阶段慢性排斥反应所致的移植肝功能衰竭需要再次肝移植治疗.     

高位胆管梗阻的外科治疗原则对降低再手术率的意义

良性高位胆管狭窄、梗阻多为肝胆管结石和胆管损伤的继发病变。有的病例虽经再次或多次手术仍反复发作胆管炎、梗阻性黄疸。如不及时、有效解除梗阻 ,最终导致慢性淤胆性肝脏改变、肝功毁损或梗阻性化脓性胆管炎 ,预后不良。良性高位胆管狭窄梗阻的原因主要是肝胆管结石、反复胆管炎继发胆管狭窄 ,其次为高位胆管损伤所致。我们曾统计一组单纯肝门胆管良性狭窄 73例的原因 ;肝胆管结石占 6 5 8% (48/ 73) ,高位胆管损伤 2 6 % (19/ 73) ,胆囊结石Ｍｉｒｉｚｚｉ征 5 5 % (4/ 73) ,不明原因的瘢痕性狭窄 2 7% (2 / 73)。实际上高位胆管梗…     

肝移植术后常见病变的病理诊断与分级指南(Ⅱ)

全国肝胆肿瘤及移植病理协作组(以下简称"协作组")曾于2007年6月在上海召开的首届肝移植病理学术研讨会上,讨论制订了《肝移植术后常见病变的病理诊断与分级指南(Ⅰ)》,着重对供肝脂肪变、缺血再灌注损伤、急性和慢性排斥反应以及胆管并发症等制订了相应的病理诊断和组织学分级指南~([1]),并制订了肝移植病理申请单模板,作为肝移植病理诊断和报告模式的参考依据.     

肝移植术后常见病变的病理诊断与分级指南(Ⅱ)

<正>全国肝胆肿瘤及移植病理协作组(以下简称协作组)曾于2007年6月在上海召开的首届肝移植病理学术研讨会上,讨论制订了《肝移植术后常见病变的病理诊断与分级指南(I)》,着重对供肝脂肪变、缺血/再灌注损伤、急性和慢性排斥反应以及胆管并发症等制订了相应的病理诊断和组织学分级指南[1],并制订了肝移植病理申请单模板(下载网址:http://www.ipathology.org.cn),作为肝移植病理诊断和报告模式的参考依据。在此基础上,     

肝移植术后常见病变的病理诊断与分级指南(Ⅰ)

中华医学会病理学分会全国肝胆肿瘤及移植病理协作组于2007年6月22-24日在上海召开了首届"全国肝脏移植病理诊断学术研讨会",根据目前肝移植临床病理诊断工作中存在的实际问题,重点对肝移植病理诊断的基本规范、供肝脂肪变的分级、缺血再灌注损伤的分级、急性和慢性排斥反应的Banff评分、中央静脉周围炎的分级、胆管并发症的病理诊断以及程序性肝穿刺等问题进行了专题研讨,制定相应的病理工作规范和组织学分级指南以及肝移植病理检查申请单,供临床病理诊断时参考使用.     

肝移植术后常见病变的病理诊断与分级指南(Ⅰ)

中华医学会病理学分会全国肝胆肿瘤及移植病理协作组于2007年6月22-24日在上海召开了首届"全国肝脏移植病理诊断学术研讨会",国内主要肝移植中心的病理专家和学者根据目前肝移植临床病理诊断工作中存在的实际问题,重点对肝移植病理诊断的基本规范、供肝脂肪变的分级、缺血再灌注损伤的分级、急性和慢性排斥反应的Banff评分、中央静脉周围炎的分级、胆管并发症的病理诊断以及程序性肝穿刺等问题进行了专题研讨,制定相应的病理工作规范和组织学分级指南以及肝移植病理检查申请单,供临床病理诊断时参考使用.     

肝胆管结石临床诊断与治疗研究进展

肝胆管结石是难治性常见病 ,术前合并症多 ,术后有“三高”(即残石率高、再次手术率高、复发率高 )的特点〔1〕。近年来 ,随着对肝胆管结石研究的深入及设备条件的改善和技术经验的积累 ,肝胆管结石的诊疗效果有了显著改善 ,结石残留率及复发率已有下降。本文就其临床诊断与治疗研究现状作一综述。一、肝胆管结石临床诊断研究进展1.关于肝胆管结石的临床病理特点 :从肝内胆管结石肝切除的病理标本进行组织学和血管灌注扫描电镜观察 ,可见结石病变部位的肝内门静脉小分支破坏、闭塞、汇管区纤维化等是肝脏病变的基本特征 ,这种病变呈严格的节…     

肝移植术后胆管狭窄发病机制的研究进展

肝移植术后胆管并发症是目前导致肝移植失败的主要原因,其中胆管狭窄的发病机制复杂,其机制研究是移植界热点问题,本文结合近年来该方面研究进展,认为其发病机制与肝动脉血栓形成、胆管血运的破坏、供肝胆管早期的充分冲洗、供肝的冷热缺血时间、排斥反应、巨细胞病毒感染ABO血型不符、受体原发性硬化性胆管炎等因素有关.     

再次肝移植22例的指征与疗效分析

目的 分析我院再次肝移植患者的手术指征和移植效果.方法 2001年6月至2004年11月,22例患者因各种原因行再次肝移植.原因分别为：胆道并发症10例,肝动脉血栓形成4例,其中1例合并胆漏,慢性排斥反应4例,急性排斥反应2例,原发性移植肝无功能2例.并对再次肝移植患者进行随访.结果 在22例再次移植患者中,存活12例,死亡10例,住院期间死亡率为45%（10/22）.死亡病例术后生存时间3～35 d,平均12.6 d.死于脓毒败血症7例;手术出血性休克2例;脑血管意外1例.在存活者中,并发症发生率为25%（3/12）,其中胆道并发症2例,伤口裂开1例,院内感染11例,感染率为92%（11/12）.随访2～28个月,中位随访时间18个月.存活3～31个月,中位生存时间为16个月.结论 再次肝移植主要指征为胆道并发症、肝动脉栓塞、慢性及急性排斥反应,原发性移植肝无功能.导致再次肝移植死亡原因主要为脓毒败血症.     

肝胆管结石症取石后胆管壁病变及其转归

目的 探讨肝胆管结石患者在结石祛除后胆管壁病变的变化和转归。方法 回顾性分析遂宁市中心医院肝胆外科从2016年1月1日至2019年12月31日24例肝胆管结石患者的胆道镜图片资料。选取每位患者其中一支有铸型结石的胆管为目标胆管,观察目标胆管在取石完成后即刻的管壁病变情况包括：黏膜充血及脱失、管壁硬化、黏膜下血管网萎缩、胆管狭窄、胆管扩张、黏膜新生物等,并在随访期内对以上黏膜病变的转归进行观察记录,评价是否有好转、不变、恶化。结果 24支目标胆管在取石后95.8%存在黏膜充血及脱失;54.1%存在胆管硬化病变;100%存在黏膜下血管网萎缩,黏膜显现苍白;33.3%存在胆管狭窄;83.3%存在胆管扩张;16.6%的胆管可见乳头样新生物。经3～165周的观察发现：100%的黏膜水肿和脱失可以在1～3周内好转;15.3%的胆管硬化病变稍有好转;黏膜下血管网均未见明显恢复;胆管扩张持续存在;75%胆管狭窄恶化。有2例患者的扩张胆管内发现“草笼”状结构的絮状物。结论 肝胆管结石取净后,急性炎症性黏膜病变在短期内有明显好转,但慢性硬化性胆管的管壁病变依然存在甚至会有加重趋势,这可能是导致患者结石复发和胆管癌变的病理基础。     

Pediatric liver retransplantation: indications and outcome

INTRODUCTION: Liver transplantation is the only treatment for end-stage liver disease. Not all patients have a favorable outcome. Graft failure secondary to primary nonfunction, vascular complications, or chronic rejection among other problems may lead to retransplantation. Retransplantation represents 8% to 29% of liver transplantations in the pediatric population. The aim of this study was to present our experience with retransplanted children by analyzing the indications and the results. METHODS: All patients were prospectively included in our database, including 125 children. We included the indications for retransplantation, complications, and mortality. Kaplan-Meier curves were used for survival analysis. RESULTS: Since 1994, 125 patients were transplanted and 25 were retransplanted (20%), including 5 who received a third graft. Primary nonfunction represented 30% of the indications for retransplantation and hepatic artery thrombosis, 20%. Six of 25 patients who received a first retransplantation and 2 of 5 who received a second retransplantation died. The most frequent cause of death was multiorgans failure. The survivals at 1 and 5 years were 82% and 76% for children receiving a first retransplantation, and 60% at 1 and 5 years for those who received a second retransplantation. CONCLUSIONS: Organ failure after liver transplantation was a common event in pediatric transplantation. Survival was similar between patients transplanted once and those who received one retransplantation. Survival decreased among patients who received a third graft but was maintained at 60%, which is better than most published results for first retransplanted patients. Retransplantation is a valid option with good results for selected pediatric cases.     

Vanishing bile-duct syndrome following liver transplantation--is it reversible?

Loss of bile ducts is a characteristic feature of chronic rejection in the liver allograft (also known as irreversible rejection and vanishing bile-duct syndrome). Typically, this occurs as a progressive lesion resulting in irreversible damage and graft failure requiring retransplantation. In this study, we describe 6 patients who developed a transient loss of bile ducts following liver transplantation. This occurred in a series of 138 patients who underwent the first 160 liver transplant operations in the Birmingham Liver Transplant Programme (incidence = 4.4% of patients, 3.7% of grafts). Forty needle biopsies were obtained from the 6 patients between 6 and 1303 days after transplantation. Thirteen specimens, taken between 8 and 1253 days posttransplant (median 98 days) showed an absence of bile ducts in more than 50% of portal tracts. Other histologic features of chronic rejection, inflammatory bile-duct lesions, perivenular cholestasis, and hepatocyte dropout were also seen in these biopsies, and severe cholestasis was present biochemically (median serum bilirubin level 240 mumol/L). The histologic and biochemical changes were thought to be compatible with a diagnosis of chronic/irreversible rejection, but the decision to carry out retransplantation was deferred on the basis of stable and, subsequently, improving biochemistry. Follow-up biopsies showed recovery of duct loss and other histologic abnormalities. All 6 patients are currently alive and well with good graft function. It is concluded that a transient, reversible bile-duct loss can occur after liver transplantation and that cases with this condition are indistinguishable from those who subsequently develop irreversible graft damage. In view of the risks associated with additional immunosuppression and/or retransplantation, caution is advocated in the interpretation of ductopenia in posttransplant liver biopsies. We suggest that the term "early chronic rejection" might be appropriate to describe cases in which a definite diagnosis of irreversible graft damage cannot be made.     

肝移植术后高胆红素血症的鉴别诊断

目的 探讨肝移植术后高胆红素血症的发生规律和特点,提高鉴别诊断和治疗的正确率,方法 总结5例肝移植术后高胆红素血症的发生频度、诊断和治疗效果,分析导致高胆红素血症的各种可能因素,提出鉴别诊断的要点。结果 5例肝移植共经历了11次高胆红素血症,其中急性排斥反应3例,肝内胆汁淤滞2例,胆总管内支撑物堵塞、CsA毒性反应以及肝动脉血栓形成各1例,均及时诊断并治愈,肝外胆道进行性狭窄、慢性排斥反应、供肝原发性无功能、以及乙肝复发各1例次,由于未能及时诊断导致治疗失败。结论 高胆红素血症是肝移植术后常见并发症,原因和机理错综复杂。了解肝移植术后恢复过程的规律,根据胆红素升高的时间,辅助检查结果以及病理学所及时作出正确诊断,是治疗成功的关键。     

再次肝移植的原因与预后分析

目的探讨再次肝移植的原因和预后。方法回顾性分析2003年11月26日至2012年5月26日期间笔者所在医院行再次肝移植215例患者的临床资料,分析其再次肝移植的原因与预后。结果笔者所在医院完成再次肝移植215例,其中行2次肝移植200例,3次肝移植14例,4次肝移植1例。第2次肝移植的主要原因为胆道并发症（53.5%,115/215）,其次为肝移植物原发性无功能或功能低下（8.4%,18/215）;第3次肝移植的原因主要为胆道并发症（5/14）,其次为肝癌复发（2/14）。早期（肝移植术后1个月内）与后期（肝移植术后1个月后）第2次肝移植移植物生存率比较差异有统计学意义（P=0.005）,后期第2次肝移植移植物生存率较高。第3次肝移植移植物生存率低于第2次肝移植（P=0.043）。与胆道并发症者比较,肝癌复发者（P=0.001）和肝移植物原发性无功能或功能低下者（P=0.033）移植物生存率较低,慢性移植肝失功能者移植物生存率较高（P=0.037）。结论胆道并发症为再次肝移植的最主要原因。移植后早期行再次肝移植的效果不佳,其主要原因是围手术期的死亡增加。因肝癌复发而行再次肝移植患者移植物的预后不理想,而慢性移植肝失功能患者移植物的预后最佳。     

再次肝移植的原因与手术时机的选择

目的 探讨再次肝移值的原因与手术时机的选择。方法 本移植中心1999年7月至2004年12月共实施的164例肝移植中，再次肝移植6例，其中因缺血再灌注损伤致肝内胆管多发狭窄3例，肝动脉狭窄和血栓1例，乙肝复发1例，肝静脉流出道梗阻1例。再移植率为3．65％，再次肝移植均采用改良背驮式肝移植技术。结果 6例再次肝移植术后临床症状改善4例，无明显改善2例。术后腹腔出血2例，胆漏1例，腹腔细菌感染1例，霉菌感染2例，术后4月内死于细菌和霉菌感染2例，保守治疗治愈4例。结论 供肝缺血再灌注损伤致肝内胆管狭窄或消失是国内再次肝移植的主要原因，对于各种治疗均无法改善移植肝肝功能，肝功能进行性恶化，应该尽早行再次肝移植。     

Intrahepatic biliary strictures after liver transplantation

Biliary complication has been one of the most common complications after liver transplantation. Nonanastomotic strictures and dilatations involving the intrahepatic biliary tree have been recognized as biliary complications. These lesions were reported to be associated with hepatic artery thrombosis; prolonged preservation time; ABO-incompatible organs; and immunological injury, including injuries to vascular endothelial cells (chronic rejection) and the bile duct (primary sclerosing cholangitis). However, the etiology of these lesions appeared to be mostly related to ischemic injury. Anatomical research on the arterial supply of the bile duct has provided further insights into bile duct blood supply and its surgical implications. The biliary tract is supplied with arterial blood by a vasculature called the peribiliary vascular plexus. Any injury to the peribiliary vascular plexus may contribute to ischemic death of the biliary system mucosa. At many points, the process of liver transplantation exposes the endothelial cells and peribiliary vascular plexus to ischemic injury. The majority of intrahepatic biliary strictures (IHBS) are diffuse or bilateral. A percutaneous or an endoscopic approach has been used as the initial treatment. However, a low threshold for surgical intervention (retransplantation) should be adopted, because these patients demonstrate high mortality. The aim of this article is to review the anatomy, etiology, clinical picture, diagnosis, management, and prognosis of IHBS after liver transplantation.     

再次肝移植手术方式分析

目的探讨再次肝移植手术方法。方法回顾分析20例再次肝移植的临床资料和手术方式。结果20例再次肝移植均无术中死亡。5例(25%)于术后早期死于感染性休克、多器官功能衰竭、急性心肌梗塞和颅内出血等并发症。15例(75%)至今存活,其中1例术后出现胆管吻合口狭窄,经ERCP扩张后痊愈;1例拔除T管后出现胆漏,经保守治疗后痊愈。结论再次肝移植情况复杂,应熟练掌握和灵活运用各种常见手术方式,认真细致的进行血管和胆道的重建,以防止术后并发症的发生,提高再次肝移植的疗效。     

Biliary tract complications after liver transplantation in a single center

Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to determine the incidence of biliary complications and analyze methods of treatment. From 1993 to 2004, 14 cases (10%) among 140 patients who had undergone liver transplantation developed biliary complications, third to respiratory and neurologic complications. In addition to biliary leakage in six cases, obstruction/stenosis occurred in three cases. One case of biliary fistula and one vanishing bile duct syndrome were observed. There was no death or need for retransplantation; all cases were treated surgically without recurrence. Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory and safe in selected cases.