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。     

内镜逆行胰胆管造影在肝移植后胆系并发症诊断和治疗中的作用

目的：评价内镜逆行胰胆管造影(ERCP)在肝移植术后胆系并发症诊治中的临床价值。方法：11例肝移植术后并发胆系并发症，其中吻合口狭窄4例，吻合口及供肝肝总管均狭窄2例，胆漏2例，多发性硬化性胆管炎样狭窄2例，移植肝胆总管与受者胆总管分离1例，分别行ERCP检查及治疗。结果：4例吻合口狭窄者，放置胆管塑料支架，2例吻合口和供肝肝总管均狭窄者放置Wallstenl，金属支架，上述6例近期黄疸均消退；2例胆漏者中，1例放置胆道塑料内支架，另1例行乳头括约肌切开术，均于2周内胆漏愈合；2例移植肝多发性硬化性胆管炎样狭窄者，1例行乳头括约肌切开后取出少量坏死胆管上皮样组织，另1例未行内镜治疗；1例移植肝胆总管与受者胆总管分离者再次手术行胆管吻合术。结论：内镜逆行胰胆管造影可用于肝移植术后的常见胆系并发症的诊断与治疗，可获得较好的近期疗效。     

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.     

Transjugular intrahepatic portosystemic shunts: An update

Transjugular intrahepatic portosystemic shunts (TIPS) have been used in the treatment of complications of portal hypertension. TIPS is used for the control of acute variceal bleeding and for the prevention of vericeal rebleeding when pharmacologic therapy and endoscopic therapy have failed. Patients with refractory ascites with adequate hepatic reserve and renal function who fail to respond to large volume paracentesis may be reasonable candidates for TIPS. Promising indications for TIPS are Budd-Chiari syndrome uncontrolled by medical therapy, severe portal hypertensive gastropathy, refractory hepatic hydrothorax, and hepatorenal syndrome. TIPS cannot be recommended for preoperative portal decompression solely to facilitate liver transplantation. Special care should be taken to insure proper placement of the stent to avoid increasing the technical difficulty of the transplantation procedure. The major limiting factors for TIPS success are shunt dysfunction and hepatic encephalopathy. Because shunt stenosis is the most important cause of recurrent complications of portal hypertension, a surveillance program to monitor shunt patency is mandatory. The MELD score may be useful in predicting post-TIPS survival, and also in counseling patients and their families. (Liver Transpl 2003;9:207-217.)     

Nonoperative management of blunt extrahepatic biliary duct transection in the pediatric patient: case report and review of the literature

An 11-year-old boy sustained a grade IV liver injury and complete disruption of the left hepatic duct (LHD) secondary to a sledding accident. Although he became hemodynamically stable after initial resuscitation in the emergency department and the intensive care unit (ICU), serial paracentesis procedures were necessary to manage abdominal compartment syndrome (ACS). The fluid initially was serosanguinous but subsequently became bile stained. A bile leak was confirmed by a technetium 99m dimethyliminodiacetic acid (HIDA) scan and an endoscopic retrograde cholangiogram (ERCP). The LHD transection was treated with percutaneous drainage of the subhepatic space and a transampullary biliary stent. The leak sealed within 8 days, and follow-up ERCP as an outpatient showed no extravasation but could not visualize the LHD. Repeat computed tomography (CT) scan 3[frac12] months after injury showed the liver laceration to be healed with atrophy of the left lobe and no ductal dilatation. The patient has had a complete recovery, resumed all activities, and currently is 20 months after his injury with no sequelae.     

肝移植术中不留置T型管指征的探讨

目的 探讨肝移植术中不留置T型管,以降低与T管相关胆道并发症的发生率.方法 对2004年1月至2006年10月的肝移植患者进行前瞻性临床研究.在此期间内符合指征未留置T管的患者102例,观察本组患者胆道并发症的发生率.结果 本组患者均随访6个月以上.胆道并发症的发生率是4.9%(5/102),其中3例为肝内胆管多发性狭窄,均行再次肝移植;2例为肝总管非吻合口狭窄,经ERCP行球囊扩张并放置胆道内支撑管3个月后治愈.结论 对符合指征的肝移植患者术中不留置T管是安全的,可避免T管相关并发症,降低胆道总体并发症的发生率.     

胆道塑料支架置入术治疗高龄胆总管结石

目的 评价内镜下胆道塑料支架置入术治疗高龄胆总管结石患者的效果.方法 回顾性分析2008年1月至2010年12月于我院行内镜下胆道塑料支架置入术的41例高龄胆总管结石患者(70~93岁)的临床资料.结果 本组41例患者中均顺利完成内镜下胆道塑料支架置入术,术后5d复查肝功能较入院时明显好转,术后每3个月行ERCP检查,根据结石变化情况,决定行取石或更换塑料支架治疗.经平均2.5次内镜下治疗,82.9％ (34/41)患者结石取净.平均随访时间21个月(8~40个月),未发生与ERCP或留置支架相关的严重并发症.结论 内镜下胆道塑料支架置入术是治疗高龄胆总管结石患者安全、有效并且微创的方法.     

ERCP in the management of early versus late biliary leaks after liver transplantation

The role of endoscopy in the management of bile leaks following liver transplantation has been controversial. Bile leak after liver transplantation has an incidence of approximately 10% to 15%, and the choice of observation, laparotomy, or endoscopic retrograde pancreatography (ERCP), usually with sphincterotomy and/or placement of a bile duct stent, has depended on the transplant groups' experience and the availability of skilled endoscopists. We report our experience in the management of bile leaks following orthotopic liver transplantation. Between July 11, 1995, and January 22, 2003, there were 174 whole-liver-graft orthotopic liver transplant procedures performed at the University of Kentucky. In 158 of these, the initial bile duct management was by choledochocholedochostomy (duct-to-duct anastomosis) over a small-caliber T-tube. Bile leaks were diagnosed in 21 of 158 patients, with an incidence of 13.3%. Of the early leaks (<30 days post-transplantation), 2 were managed with observation alone, and 12 underwent ERCP. This revealed five anastomotic leaks requiring laparotomy. Of the seven leaks occurring later, six were managed by ERCP and one required laparotomy. With a median follow-up period of 18 months, 18 patients (85.7%) are alive with no further biliary tract problems. ERCP remains a useful adjunct in the management of post-liver transplant bile leaks. It is, however, less likely to be successful in the definitive management of early leaks.     

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。     

Decreasing mortality of bile leaks after elective hepatic surgery

BACKGROUND: Bile leak is a serious complication following major hepatic surgery. It is associated with significant mortality rates if reoperative management is attempted. We evaluated our experience with aggressive, nonoperative management of postoperative biliary complications. METHODS: All medical records of patients undergoing major liver resection, cryosurgery or radiofrequency ablation from September 1996 through March 1999 were reviewed. RESULTS: Seventy-four patients were identified, and 9 (12%) developed bile leaks. Biliary leaks were investigated with endoscopic retrograde cholangiopancreatography (ERCP) and treated with endoscopic stenting when possible. The bile leak was found to originate from the resected duct stump or ablated surface of the liver in all cases. Patients were treated with ERCP stent placement (5), computed tomography-guided percutaneous drainage (3), and hepaticojejunostomy "chimney" (1). Six of 9 patients had resolution of their bile leak with the mean time of removal of the drain of 4.7 months. There was only 1 death, and that patient died nearly 3 months after surgery from complications not directly related to the bile leak. CONCLUSIONS: Bile leak after liver resection can be managed nonoperatively in most cases with a combination of percutaneous drain placement and biliary stenting. Most bile leaks will close with time, although a drain may be required for many months.     

Hepatic artery thrombosis resulting in gas gangrene of the transplanted liver.

Early hepatic artery thrombosis after orthotopic liver transplantation results in massive injury to hepatocytes and the bile duct epithelium. In the fulminate form, impaired liver synthetic function is expressed by encephalopathy and coagulopathy. Ischemic bile duct injury is associated with the disruption of the biliary anastomosis, bile duct strictures, and intrahepatic bilomas. The inability of the liver macrophages to clear translocated portal blood intestinal pathogens results in persistent bacteremia and sepsis. The major radiologic finding is the radiographic evidence of gas gangrene of the liver graft. Early recognition and correct interpretation of the radiologic findings, immediate removal of the liver graft, and placement of the patient on venous-venous bypass or total hepatic devascularization while a new liver is being procured and retransplantation are the only hope for survival.     

External biliary fistulas selectively managed by endoscopic retrograde cholangiography with sphincterotomy and/or stent placement

External bile duct fistulas are inherent postoperative complications that usually appear after biliary tract surgery, traumatic bile duct injuries and liver surgery for hepatic hydatid disease or liver transplant. The management is highly individualized, while the success and long-term results of endoscopic and surgical techniques are conflicting. The study included 32 cases with external bile duct fistulas managed by endoscopic retrograde cholangiography (ERC) with sphincterotomy and/or stent placement, including "rendez-vous" procedures in 2 cases. The causes of the external fistula were represented by cholecystectomy with/without retained common bile duct stones or strictures (22 cases), cholecystectomy and drainage of a subphrenic abscess caused by severe acute pancreatitis (1 case) and surgical interventions for hepatic hydatid disease (9 cases). Due to the prospective protocol of the study we were able to apply an individualized endoscopic treatment: sphincterotomy with proper relief of the bile duct obstruction (stone extraction) or sphincterotomy with large-size (10 Fr) stent placement for large-sized bile duct defects. The results consisted in closure of the fistula in 3.5 +/- 1.7 days for the subgroup of patients with sphincterotomy alone. Among the patients with stent insertion, fistulas healed slower in 14 +/- 3.5 days. There were no complications after endoscopic treatment; however the stent could not be passed in one patient that required subsequent surgery. In conclusion, endoscopic intervention is the treatment of choice for small external biliary fistulas complicating biliary tract surgery or liver surgery for hepatic hydatid disease. When the fistula is large, the placement of a 10 Fr endoprosthesis becomes necessary, while failure of endoscopic treatment leads to surgery with hepatico-jejunal anastomosis.     

浅析经颈静脉肝内门体静脉分流术治疗门静脉高压并发症

目的评估经颈静脉肝内门体静脉分流术(TIPS)治疗肝硬化门静脉高压并发症的安全性和有效性。方法自2013年12月至2014年6月,收集31例接受TIPS治疗的肝硬化门静脉高压症的临床资料。术前均接受肝脏CT增强扫描和血管三维重建,了解肝静脉与门静脉的解剖结构关系,以便确定穿刺门静脉分支的靶点,术中,28例栓塞曲张的食管胃底静脉,28例置入巴德公司的一个裸支架加一个Fluency覆膜支架,2例置入单个Fluency覆膜支架。结果 31例患者中30例TIPS操作成功,其中穿刺门静脉右支26例,穿刺门静脉左支4例,成功率为96.8%(30/31);1例因门静脉海绵样变性未成功;无严重并发症发生,近期止血率为100%。结论 TIPS治疗肝硬化门静脉高压并发症是安全和有效的。     

The Role of Endoscopic Procedures in the Management of Postcholecystectomy and Posttraumatic Biliary Leak

Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool in the evaluation of the biliary system. It not only diagnoses the site of biliary leak following bile duct injury, but it also acts as a therapeutic modality to allow interventional pro-cedures such as sphincterotomy, nasobiliary drainage, or stent placement to be performed. The present study was carried out to evaluate the role of endoscopic management of biliary leak, following either liver trauma or cholecystectomy. Of a total 21 patients with bile leak following liver trauma and biliary surgery, 20 were managed by various endoscopic procedures. In the postcholecystectomy group, ERCP revealed a cystic duct leak in 9 patients and common bile duct injury in 6 patients. These complications were managed by sphincterotomy alone in 2 patients, by nasobiliary drainage alone in 4 patients, by sphincterotomy and nasobiliary drainage in 8 patients, and by sphincterotomy and stent placement in 1 patient. Posttraumatic biliary fistula was successfully managed by performing sphincterotomy followed by the placement of nasobiliary drainage in all of five patients who had suffered trauma injury. Received: August 2, 1999 / Accepted: July 25, 2000     

Blunt Left Extrahepatic Bile Duct Injury: Case Report and Literature Review

Background  Extrahepatic biliary tract injuries following blunt abdominal trauma are very rare and pose a diagnostic and therapeutic challenge. Case Report  We report a case of blunt liver injury with left extrahepatic duct transection following a motor vehicle collision. Technetium 99m dimethyliminodiacetic acid scan confirmed a bile leak and endoscopic retrograde cholangiopancreatography (ERCP) diagnosed the injury of the left extrahepatic duct. Management was initially conservative, consisting of external drainage along with trials of stent placement. Ultimately, partial left hepatectomy was required to definitively treat the injury. Conclusion  In the setting of suspected biliary tract injury, early ERCP is essential to localize a leak and guide management decisions. In the event of a confirmed bile leak, a trial of nonoperative management consisting of endoscopic ductal decompression along with percutaneous drainage may initially be warranted although is not always successful.     

Laparoscopic endobiliary stenting significantly improves success of postoperative endoscopic retrograde cholangiopancreatography in low-volume centers

Background: Occult common bile duct stones (CBDS) discovered during laparoscopic cholecystectomy with intraoperative cholangiography are most often managed by postoperative endoscopic retrograde cholangiopancreatography (ERCP). Expert endoscopists at high-volume centers achieve common bile duct cannulation in nearly all patients undergoing ERCP, but cannulation rates of less than 80% have been observed in low-volume centers. As many as 20% of patients with CBDS referred for postoperative ERCP in low-volume centers may require repeated attempts at ERCP, referral to a high-volume center, percutaneous transhepatic techniques, or reoperation for clearance of CBDS when postoperative ERCP fails. Methods: Laparoscopic cholecystectomy with intraoperative cholangiography performed in 511 consecutive patients over 80 months at a community hospital showed occult CBDS in 66 patients (12.9%). Laparoscopic endobiliary stent placement was successful in 65 patients (98.5%). As part of an earlier study, 16 patients underwent laparoscopic common bile duct exploration with clearance of CBDS before stent placement. Laparoscopic endobiliary stent placement failed in one patient for whom CBDS were cleared with intraoperative ERCP. Results: Initial postoperative ERCP was successful in clearing CBDS in all 65 patients (100%) with laparoscopically placed stents. During the same period, 611 patients underwent ERCP for various indications including CBDS (43%). Selective cannulation was achieved in 78% of all patients during initial ERCP. Conclusions: Laparoscopic endobiliary stent placement is an effective adjunct to the management of occult CBDS. Laparoscopic endobiliary stenting ensures selective cannulation during postoperative ERCP and eliminates the need for repeated attempts at ERCP, referral to specialty centers, use of transhepatic techniques, or reoperation for retained CBDS. Laparoscopic endobiliary stent placement for treatment of occult CBDS significantly improves the success of postoperative ERCP in low-volume centers and eliminates the morbidity and expense of repeated procedures.     

Transhepatic biliary catheterization before graft implant in living donor liver transplantation

AIM: Despite the evolution in surgical technique, the biliary anastomosis remains the technical Achilles' heel of liver transplantation, especially in living donor liver transplantation. Interventional radiology or endoscopic procedures constitute the most common options to treat complications from the biliary anastomosis. We report a novel technique to prevent biliary complications following the transplant. METHODS: During the donor procedure a wire guide was introduced in the severed duct, left or right, in retrograde fashion. The liver surface was then perforated and the wire guide exposed. A 4F catheter was then attached to the wire guide and pulled into the bile duct passing through the end-to-end duct-to-duct anastomosis or hepaticojejunostomy. RESULTS: This technique was performed in six living donor grafts: one right lobe, two left lobes, and three left lateral segments. All patients had no complications from the stent placement, biliary strictures, or leaks. One developed a hepatic artery thrombosis on the posttransplant day 14 with no major biliary complications.     

Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.

OBJECTIVE: The authors demonstrate the feasibility of converting failed transjugular intrahepatic portosystemic shunt (TIPS) to distal splenorenal shunt (DSRS) in patients with good hepatic reserve for long-term control of variceal bleeding. SUMMARY BACKGROUND DATA: TIPS is an effective method for decompressing the portal venous system and controlling bleeding from esophageal and gastric varices. TIPS insufficiency is, however, a common problem, and treatment alternatives in patients with an occluded TIPS are limited because most have already failed endoscopic therapy. METHODS: The records of five patients who underwent conversion from TIPS to DSRS because of TIPS failure or complication in the past 36 months were reviewed. RESULTS: Four patients had ethanol-induced cirrhosis and one patient had hepatitis C virus cirrhosis. Three patients were Child-Pugh class A and two were class B. All patients had excellent liver function, with galactose elimination capacities ranging from 388 to 540 mg/min (normal 500 +/- 100 mg/min). The patients had TIPS placed for acute (2) or sclerotherapy-resistant (3) variceal hemorrhage. All five TIPS stenosed 3 to 23 months after placement, with recurrent variceal hemorrhage and failed TIPS revision. One patient had stent migration to the superior mesenteric vein that was removed at the time of DSRS. All five patients underwent successful DSRS, and none have had recurrent hemorrhage 18 to 36 months after surgery. CONCLUSIONS: TIPS provides inadequate long-term therapy for some Child-Pugh A or B patients with recurrent variceal hemorrhage. TIPS failure in patients with good liver function can be salvaged by DSRS in many cases.     

Endoscopic management of postcholecystectomy bile duct strictures

BACKGROUND: Review of 1.6 million cholecystectomies, from 1992 to 1999, demonstrated a 0.5% incidence of bile duct injury, despite increasing experience with laparoscopy. The incidence has not decreased after the "learning curve." The management of major bile duct injuries has traditionally been by hepaticojejunostomy. Endoscopy has been increasingly used to treat these injuries. This study reviews the senior author's endoscopic treatment of bile duct injuries. STUDY DESIGN: This is a retrospective study, from 1991 to 2006, examining data on 292 patients who were referred for postcholecystectomy problems; 199 had cholecystectomy-related injuries and 93 had other pathologies. Sixty-seven patients had bile duct injuries (Amsterdam Academic Medical Center Classification, types B, C, and D). Nineteen patients underwent bilioenteric bypass for complete bile duct occlusion or transection. In the remaining 48, endoscopic retrograde cholangiopancreatography (ERCP) evaluation and treatment were possible. Our protocol called for biliary stenting for 11 to 14 months, with stent changes at 3-month intervals. Short- and longterm results were evaluated by clinical, radiologic, and laboratory studies. RESULTS: Forty-six patients were selected for endoscopic management by balloon dilation and biliary stent placement. The mean +/- SD duration of endoscopic stenting was 12+/-9.8 months and followup was 30+/-24 months after stent removal. During the followup period, 10 of 46 patients (22%) had recurrent stricture: 6 (13%) responded to endoscopic biliary stenting and 4 (9%) required hepaticojejunostomy. Complications included pancreatitis (8%). There were no deaths in the endoscopic group. CONCLUSIONS: ERCP intervention is a safe, effective, minimally invasive treatment for bile duct strictures after cholecystectomy and can be an alternative to hepaticojejunostomy.     

胆总管巨大结石胆道塑料内支架"搅动溶石"作用临床研究

目的 评价胆道塑料内支架置入对胆总管巨大结石的搅动溶石作用.方法 常规方法行ERCP,对45例胆总管巨大结石病人(8例结石伴下端胆管狭窄、5例结石伴乳头过小),在导丝引导下放置8.5 Fr胆道塑料内支架治疗.结果 3个月后第2次ERCP检查时发现,10例结石消失;22例结石直径变小1/2以上或成碎片状经网篮或气囊扩张顺利取出;13例结石无明显变化,行更换塑料内支架治疗并每月腹部B型超声随访,一旦发现结石明显变小,即再次行ERCP+取石.经平均2.4次内镜下联合治疗,95.6%(43/45)病人结石取净.期间未发生与ERCP或放置胆道塑料内支架相关的严重并发症.结论 放置胆道塑料内支架是治疗胆总管巨大结石简便、有效方法,尤其适用于高危老年胆总管结石病人.