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.     

肝门部胆道引流管折叠技术在肝移植后胆道非吻合口狭窄治疗中的应用

目的 介绍全新设计经皮经肝胆道引流管肝门部胆管折叠技术,以单一入路实现双侧胆道支撑引流;研究该技术在治疗原位肝移植后肝门部非吻合口胆道狭窄中的疗效和安全性.方法 2000年7月至2010年7月收治10例原位肝移植后非吻合口胆道狭窄患者.胆道狭窄处予球囊扩张,胆道引流管置入后,在肝门部胆管内折叠成Y形,实现左、右肝管并肝总管三向支撑引流.分析其技术成功率、临床疗效、并发症率及复发率等.结果 技术成功率为10/10.9例临床症状缓解,生化指标恢复正常,影像学检查有明显改善.26个月(中位数)的随访中,未见复发.2例有轻微并发症.1例治疗失败,行第2次肝移植后死亡.结论 经皮经肝胆道引流管肝门部胆管汇合部折叠技术在技术上是可行的;在原位肝移植后非吻合口肝门部胆道狭窄治疗中的初步应用结果表明,其技术成功率、疗效、安全性均令人满意.     

原位肝移植术后肝动脉狭窄导致缺血型胆管损伤的治疗

目的 探讨原位肝移植术后肝动脉狭窄导致缺血型胆管损伤的治疗方法及预后.方法 回顾性分析我院2004年6月至2008年6月,11例肝移植术后肝动脉狭窄导致胆管损伤,接受肝动脉支架成形联合内镜逆行胰胆管造影术(ERCP)和(或)经皮经肝胆管引流(PTCD)处理患者的临床资料.结果11例患者成功植入12枚冠脉支架,5例单独采用胆道ERCP引流,3例采用PTCD,3例ERCP疗效欠佳后改用PTCD.随访4个月至4年,6例死于感染,其中5例1年内死亡,3例再次接受移植,2例生存至今.结论 肝移植术后肝动脉狭窄导致缺血型胆管损伤总体疗效欠佳.肝动脉支架联合胆道长期引流可延长移植物存活期,为再次肝移植提供机会.     

经桡动脉置入冠脉支架治疗肝移植术后迂曲型肝动脉狭窄

目的 评价经左侧桡动脉置入冠状动脉(冠脉)支架治疗肝移植术后迂曲型肝动脉狭窄的可行性和疗效.方法 2006年6月至2008年4月我科收治的6例肝移植术后迂曲型肝动脉狭窄患者.狭窄发病于肝移植术后6～110 d,平均47 d.2例患者因右侧股动脉入路置入支架失败改用左侧桡动脉入路,4例患者参考术前CTA直接经左侧桡动脉入路置入支架.合并肝动脉血栓的1例患者置入支架前使用尿激酶50万u溶栓治疗.合并肝内胆道扩张的2例患者同时行胆道穿刺引流术.结果 6例患者支架置入均成功,1例合并肝动脉血栓患者溶栓成功,2例合并肝内胆道扩张患者胆道穿刺引流成功.术后随访36～148 d,中位时间76 d.随访期间彩色多普勒超声检查未见支架狭窄,6例置入支架均通畅,各项肝功能指标好转.结论 经桡动脉置入冠脉支架能够有效治疗肝移植术后迂曲型肝动脉狭窄.     

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。     

肝移植术后胆道狭窄经皮肝穿刺胆管造影的并发症及其预防

目的观察经皮肝穿刺胆道介入治疗原位肝移植术后胆道狭窄发生并发症的频次和类型。资料与方法对292例原位肝移植术后出现胆道狭窄的30例患者分别行胆道球囊扩张术、胆道引流术和胆道支架置入术,观察术中反应、术后临床经过、相关实验室检查、B超和复查胆道造影表现。结果 3例(10.0%)胆道狭窄合并胆瘘患者和3例(10.0%)单纯吻合口狭窄患者行气囊扩张术和胆道引流后痊愈。8例(26.7%)肝内外胆管多发狭窄患者气囊反复扩张胆道狭窄段后,7例狭窄纠正而获得痊愈。14例(46.7%)肝内外胆管多发狭窄合并胆泥患者中12例(40.0%)狭窄明显减轻,黄疸缓解;2例(6.7%)T形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。30例患者(100.0%)术中均感疼痛,其中12例(40.0%)疼痛剧烈。2例(6.7%)术中发生出血,其中1例再次行肝移植。27例(90.0%)术后胆管仍再狭窄,需反复多次成形。2例(6.7%)治疗后狭窄持续存在而再次行肝移植,其中1例曾置入胆道支架,另1例直接行二次肝移植。结论疼痛、再狭窄是经皮肝穿刺胆道介入治疗肝移植术后胆道狭窄的常见并发症,术中预防大出血是降低风险的关键。     

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.     

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。     

肝门部胆管癌高位多支复杂胆道梗阻的介入引流方法探讨

目的：探讨肝门部胆管癌引起的高位多支复杂类型梗阻性黄疸的介入引流方法和临床疗效。 方法：选取因肝门部胆管癌引起的多支复杂类型梗阻性黄疸患者38例,其中男28例,女10例。Bismuth-Corlett分型Ⅱ型6例,Ⅲ型18例,Ⅳ型14例。根据胆道梗阻的部位、范围、各分支梗阻情况及胆道扩张的程度,对不同类型患者的引流方案进行个体化设计。其中30例单纯采取了引流管引流,并根据需要对引流管临时剪孔,每例放置1~3条胆道外引流管。8例Ⅳ型肝门部胆管癌根据左右肝管分支角度不同分别采取了不同的方法进行胆道双支架置入。 结果：全部病例介入引流手术过程顺利,除2例合并少量胆道出血外,无其他严重并发症发生。术后患者黄疸明显减轻或消退,皮肤瘙痒和胆管炎等症状逐渐消失。术后1~2周,血清胆红素水平由术前的（242.69±27）μmol/L降至（58.32±5.6）μmol/L,差异有统计学意义（t=9.73,P<0.05）,收到了较好的近期治疗效果。8例行胆道双支架置入患者中有3例分别于术后4~6个月发生支架再阻塞,黄疸复发,再次行经皮肝穿刺胆道引流治疗。 结论：肝门部胆管癌高位胆道梗阻病变复杂,通过引流管剪孔,可在保证引流效果的前提下尽量减少引流管的个数,减少了创伤,方便了术后生活和引流管护理,是对普通胆道外引流管的改良。双支架置入对肝门部Bismuth-Corlett Ⅳ型胆管癌近期疗效可靠,根据左右肝管分叉角度采取不同的双支架置入术式方法可行。     

介入治疗T管引流术后胆道再狭窄的初步探讨

目的 评价介入治疗外科T管引流后胆道再狭窄的疗效、安全性、可行性.方法 回顾性分析2014年6月-2016年3月收治的T管术后胆道再狭窄的25例患者资料,其中胆管癌6例,胆囊癌3例,胆系结石13例,肝癌2例,胃癌外科术后1例.25例中合并胰胆管合流异常4例.经原T管途径行介入治疗22例,经T管造影后再行PTCD治疗3例.所有患者中,行球囊扩张配合胆道引流者21例,行胆道金属支架植入者4例.良性狭窄患者引流管保留2～3个月后给予拔除.患者经门诊或电话随访3～24个月,通过引流管造影评价疗效.结果 介入手术均顺利,无相关并发症发生,技术成功率100％.15例良性胆道狭窄患者经原T管窦道途径行球囊扩张成形术,留置胆道10.2～12 F内外引流管,拔除原T管.随访发现1例胆管癌吻合口狭窄患者术后8个月死于肺部感染.10例恶性狭窄中,3例胆道梗阻位于T管上方,均行PTCD术;其中2例肝癌侵犯胆道患者,癌栓范围较大,行内外引流管植入;黄疸消退后分别于术后1个月、2.2个月死于肝衰竭;1例胆囊癌侵犯胆道行支架植入,术后2.5个月死于肿瘤进展.7例胆道梗阻位于T管下方,经T管窦道途径植入内外引流管4例,植入金属支架3例.其中2例胆囊癌患者分别于术后3.8个月、5个月死于肿瘤进展;5例胆管癌患者中2例术后3个月出现支架再狭窄,给予PTCD处理.3例于术后3.6个月、5.2个月、9个月死于肿瘤进展、多脏器功能衰竭.结论 介入治疗外科T管引流后胆道再狭窄疗效确切,安全可行,可明显改善患者生活质量.     

Percutaneous transhepatic endobiliary drainage of hepatic hydatid cyst with rupture into the biliary system: an unusual route for drainage

The most common and serious complication of hydatid cyst of the liver is rupture into the biliary tract causing obstructive jaundice, cholangitis and abscess. The traditional treatment of biliary-cystic fistula is surgery and recently endoscopic sphincterotomy. We report a case of complex heterogeneous cyst rupture into the biliary tract causing biliary obstruction in which the obstruction and cyst were treated successfully by percutaneous transhepatic endobiliary drainage. Our case is the second report of percutaneous transbiliary internal drainage of hydatid cyst with rupture into the biliary duct in which the puncture and drainage were not performed through the cyst cavity.     

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 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.     

Single-wall puncture: a new technique for percutaneous transhepatic biliary drainage

OBJECTIVE: The purpose of our study is to evaluate the safety and utility of a new single-wall puncture technique for percutaneous transhepatic biliary drainage in comparison with the conventional double-wall puncture technique. CONCLUSION: Our results suggest that the single-wall puncture technique is a useful method for percutaneous transhepatic biliary drainage and may be safer than the conventional double-wall puncture technique.     

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.     

The role of sonography and transhepatic cholangiography in the diagnosis of biliary complications after liver transplantation

We retrospectively reviewed the results of real-time sonography in 41 patients in whom biliary complications after liver transplantation were documented by percutaneous transhepatic cholangiography. Abnormalities included bile duct stricture (26 cases), occluded internal biliary stent (six cases), common duct redundancy with resultant functional biliary obstruction (three cases), bile leak (three cases), choledocholithiasis (two cases), and an abscess in a cystic duct remnant (one case). Sonography was abnormal in 22 of the 41 cases (sensitivity, 54%). Bile duct dilatation was the positive sonographic finding in 19 (86%) of the 22 abnormal examinations. In the remaining 19 patients, sonography was normal. Sonography is not a reliable test for the early detection of biliary abnormalities after liver transplantation. Percutaneous transhepatic cholangiography should be performed in patients with suspected biliary complications after liver transplantation.     

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。