肝移植术后胆道并发症的预防

目的　探讨如何预防肝移植术后胆道并发症的发生。方法　对 1993年 4月至 2 0 0 1年10月我科实施的 12 0例肝移植病人临床资料进行回顾性分析。结果　共有 10例病人通过胆道造影确诊为肝移植术后胆道并发症 ,8例治愈 ,1例好转 ,1例死亡。胆道并发症发生率为 8 3 % (10 / 12 0 ) ,与胆道并发症相关的死亡率为 0 8% ,与T管相关的胆道并发症发生率为 4 3 % (5 / 116) ,与肝动脉供血相关的胆道并发症发生率为 1 7% (2 / 12 0 )。热缺血时间 >3min、冷缺血时间 >8h组胆道并发症发生率明显升高 (P <0 0 5 )。结论　胆道保存性损伤是引起肝移植术后胆道并发症的重要原因。缩短供肝的热、冷缺血时间和确保供肝胆管系统的血供可减少胆道并发症的发生。改进T管置管方法可显著降低与T管相关的胆道并发症发生率     

肝移植术后胆道并发症的治疗

目的 探讨处理原位肝移植术后胆道并发症的有效方法.方法 叫顺性分析2001年1 1月至2012年3月南京军区福州总医院收治的316例原位肝移植（其中1例施行二次肝移植）患者的临床资料.供肝获取时采用HTK＋ UW液冷灌注,UW液保存,切取供肝后UW液灌洗胆道.尸体肝移植中采用经典原位肝移植或背驮式肝移植,活体肝移植采用左半肝移植或右半肝移植.胆道重建方式采用胆管空肠Roux-en-Y吻合或胆管胆管对端吻合.2006年前选用普通T管引流,2006年后选用6F小儿吸痰管或硬膜外导管进行T管引流,术后3～6个月予以拔除.术中常规放置经胃空肠造瘘管,术后早期开始肠内营养.术后常规采用他克莫司＋麦考酚吗乙酯＋肾上腺皮质激素3联免疫抑制治疗方案或他克莫司＋麦考酚吗乙酯＋西罗莫司＋激素4联免疫抑制治疗方案.通过移植随访中心随访2年,了解患者胆道并发症情况、预后和进行用药指导.2006年前50例患者与2006年及之后267例患者胆汁漏发生率的比较采用x2检验.结果 患者供肝热缺血时间为2 ～6 min,冷缺血时间为3～10 h.尸体肝移植患者中,经典肝移植291例次,背驮式肝移植24例次;胆管空肠Roux-en-Y吻合5例次,胆管胆管端端吻合310例次.活体肝移植患者中,左半肝移植和右半肝移植各1例,均采用胆管胆管端端吻合.术后采用3联免疫抑制治疗方案311例,4联免疫抑制治疗方案5例.316例原位肝移植患者中,38例发生胆道并发症.胆道并发症分类：胆汁漏18例,缺血性胆道损伤引起的肝内外胆管狭窄6例,单纯吻合口狭窄6例,保存性损伤所致汇管区小胆管炎症、胆汁淤积4例,胆管结石合并胆管炎2例,单纯胆道感染2例.2006年以前患者胆汁漏发生率为14.00％ （7/50）,高于2006年及以后患者的4.12％ （11/267）,两者比较,差异有统计学意义（x2=7.676,P＜0.05）.38例胆道并发症患者中,治愈及好转35例,死亡3例.18例胆汁漏患者中,15例采用保守治疗后痊愈;3例采用手术治疗（其中1例经通畅引流,加强抗感染、营养支持等处理后好转,但于术后1个月突发腹腔大出血,手术探查发现肝动脉破裂出血,最终死于失血性休克所致MODS;2例行腹腔引流术,1例治愈,1例合并腹腔感染,最终死亡）.6例缺血性胆管损伤引起的肝内外胆管狭窄患者中,1例行二次肝移植后取得良好效果,5例经保守或行ERCP或经PTCD导管球囊扩张术治疗后好转.6例单纯吻合口狭窄患者中,3例经保守或行ERCP或经内镜下柱状气囊扩张、取石、支架置入治疗后好转;1例因肝癌复发放弃治疗后死亡;1例予手术探查,行吻合口成形＋T管引流术效果良好;1例手术探查切除复发肿瘤,行胆肠吻合后痊愈.4例保存性损伤所致汇管区小胆管炎症、胆汁淤积患者采取保肝、减轻黄疸等保守治疗后痊愈.2例胆管结石合并胆管炎患者,1例行ERCP支架置入痊愈;1例经保守治疗后TBil有所下降,未予进一步处理.2例单纯胆道感染患者均经抗感染等保守治疗痊愈.结论 多数患者胆道并发症可经非手术治疗取得满意疗效;而对非手术治疗效果不佳的患者,再次行胆道探查术是较为确实可靠的治疗手段;对于部分严重缺血性胆道损伤导致移植肝失功能的患者,二次肝移植是唯一的选择.     

Risk factors for biliary complications after liver transplantation

HYPOTHESIS: Biliary complications after liver transplantation can be predicted from perioperative factors. DESIGN: Retrospective analysis of data collected prospectively. SETTING: Tertiary referral center. PATIENTS: From October 5, 1991, through June 22, 2002, 230 patients received 241 consecutive orthotopic liver transplants. Patients were divided into those with (group 1) and those without (group 2) biliary complications. MAIN OUTCOME MEASURES: Postoperative outcomes, biliary leakage, and anastomotic stricture. RESULTS: The overall biliary complication rate was 20.7%, including bile leakage rate of 7.1% and anastomotic stricture rate of 16.2%. By means of univariate analysis, risk factors associated with biliary complications were preoperative serum bilirubin level (P = .003), international normalized ratio (P = .04), the use of stent or T-tube splinting of the anastomosis (P = .02), and the use of live-donor liver graft (P = .03). Stepwise logistic regression analysis demonstrated that the preoperative serum bilirubin level (relative risk [RR], 1.00), use of stent or T-tube splinting of the anastomosis (RR, 2.10), and use of live-donor liver graft (RR, 2.01) were independent risk factors predicting biliary complications after liver transplantation. Graft survival rates at 1, 3, and 5 years were 89.5%, 84.7%, and 79.7%, respectively, in group 1 and 84.7%, 78.4%, and 75.1%, respectively, in group 2 (P>.05). Patient survival rates at 1, 3, and 5 years were 89.1%, 86.5%, and 86.5%, respectively, in group 1, and 86.1%, 82.8%, and 81.0%, respectively, in group 2 (P>.05). CONCLUSIONS: Preoperative serum bilirubin level and the use of stent or T-tube splinting of the anastomosis and live-donor liver grafts were independent risk factors for biliary complications after liver transplantation. We postulated that high preoperative serum bilirubin level reflected severe liver disease and difficult hemostasis, leading to inadvertent injury to the anastomosis during graft rotation or manipulation for hemostasis. The use of a stent or a T tube predisposes to more complications. Further technical refinement is necessary for biliary reconstruction in live-donor liver transplantation.     

Management of biliary complications after liver transplantation.

Biliary tract complications after liver transplantation are common, and the evaluation of newer treatment options compared with standard surgical treatment is important. In 62 liver transplants performed in 55 adult patients, the biliary tract was reconstructed with choledochocholedochostomy (CC) in 52 (84%) and Roux-en-Y choledochojejunostomy (RYCJ) in 10 (16%). Seventeen biliary tract complications occurred in 16 patients (29%). The incidence of complications was the same after CC and RYCJ. Eight complications (47%) occurred within the first month and nine (53%) thereafter. Only 6 of 17 (35%) biliary tract complications required operation. One patient died of a biliary tract complication. No other allografts were lost due to biliary tract complications. Four patients transplanted at other centers were also treated, for a total of 21 biliary tract complications. Overall, there were nine bile leaks, eight bile duct strictures, two Roux loop hemorrhages, one choledocholithiasis, and one ampullary dyskinesia. Temporary or permanent stents were used successfully in seven of eight strictures. Five bile leaks were managed without operation. Nonsurgical management is appropriate for a selected majority of patients with late bile leaks, biliary tract strictures, or choledocholithiasis after liver transplantation.     

肝移植术后胆道并发症病因分析

目的探讨原位肝移植术后胆道并发症的病因.方法回顾性分析235例尸体供肝和36例活体供肝原位肝移植的临床资料,总结术后胆道并发症的病因.结果36例活体肝移植受体术后胆道并发症的发生率为5.6%,235例尸体供肝肝移植受体术后胆道并发症的发生率为19.1%;肝内胆道狭窄和胆道铸型结石形成等严重胆道并发症在活体肝移植中未发生.讨论缺血时间尤其热缺血时间是导致严重胆道并发症的最主要的原因,所留取的受体胆道长度也是影响胆道并发症的一个主要因素.     

原位肝移植术后胆管并发症的预防与处理

目的 探讨原位肝移植术后胆管并发症的原因及防治。方法 2000年5月至2002年1月38例原位肝移植的临床资料进行回顾性研究。结果 本组38例病人术后共发生胆管并发症9例（9/38，24%）。其中单纯胆瘘4例，胆管空肠吻合口狭窄，肝内胆管结石，胆管狭窄合并胆泥形成，胆瘘继发胆管狭窄，胆管狭窄合并肝内胆汁瘤各1例。此9例中2例死于严重感染，7例痊愈。结论 原位肝移植术后胆管并发症病因复杂，后果严重。首先应该注重预防，并做到早期诊断。逆行性胰胆管造影术（endoscopic retrograde cholangiopanreatography,ERCP）和经皮经肝胆管造影术（percutaneous tran-shepatic cholangiography,PTC）等辅助性介入治疗手段应受到重视。     

肝移植术后胆道并发症的发生原因与对策

肝移植术后胆道并发症发生率高达10％～34％，严重影响肝移植受者生存时间及生活质量，是肝移植后居第2位的主要并发症。随着对该并发症的进一步认识和外科技术的提高，外科技术原因造成的吻合口、引流管相关并发症发生率呈下降趋势，而非外科技术原因造成的胆道并发症变则成了主要类型。因此，被称为“阿基里斯之踵再现”。     

Long-term biliary complications after liver surgery leading to liver transplantation

Chronic biliary obstruction with repeated bouts of cholangitis adversely affects quality of life and may lead to secondary biliary cirrhosis with liver failure. We reviewed our experience with chronic biliary complications after surgical treatment of various diseases that at the end needed a liver transplantation. Twelve patients with previous biliary surgery developed secondary biliary cholangitis, secondary biliary cirrhosis, or both. Seven had surgery for liver hydatid disease by Echinococcus granulosus, another four had complicated biliary surgery unrelated to hydatid disease, and one had a history of a traffic accident with liver trauma and hepatectomy with chronic biliary fistula. The repeated cholangitis attacks and in two cases of hydatid disease the development of biliary-bronchial fistulas made these patients' lives miserable. All had had previous surgical procedures that made the transplantation procedure more difficult. Nevertheless, patient survival and graft actuarial survival after liver replacement were 75.0% and 69.2%, respectively, at 5 years.     

改进供肝处理方法减少肝移植术后早期胆道并发症

目的改进供肝处理方法，以减少肝移植术后的胆道并发症。方法供肝处理进行如下改进：（1）肝门游离仅达胃十二指肠动脉下缘，不游离其上方的肝蒂结构；（2）修整供肝时暂不结扎胃十二指肠动脉本身的断端；（3）修整供肝时暂不切除胆囊，待供肝植入、肝动脉重建后切除。共行99例肝移植，患者的原发病，58％为良性肝病，42％为肝癌。供肝热缺血和冷缺血时间分别控制在5min和16h以内。胆道重建方式均为胆总管-胆总管端端吻合，其中5例放置T管。观察术后早期胆道并发症的发生情况。结果4例（4％，4／99）肝移植术后发生胆道并发症，其中1例术后10d发现胆道吻合口漏；1例术后5个月胆道内有胆树形成；1例为胆道吻合口狭窄；1例为左肝管狭窄。改进前的肝移植术后早期胆道并发症发生率为11．6％（5／43）。结论通过改进供肝的处理方法，可最大限度地保留供肝胆道血液供应，显著减少术后胆道并发症。     

通过Meta分析探讨T管对肝移植后胆道并发症的影响

目的 尝试通过Meta分析的方法对肝脏移植中T管的应用与胆道并发症发生率的关系进行分析,并与同期回顾分析结果对照.方法 于www.ncbi.nlm.nih.gov网站进行检索,以"T-tube"AND"liver transplantation"为主题词,文章类型限定为"RCT",严格限定纳入文章的分组,诊断方法,胆道并发症类型,及所需统计数据的完整.采用RevMan4.2Review Manager进行随机效应模型的Meta分析.结果 T管组与未放置T管组胆道并发症未发现统计学差异.与同期对照研究比较认为.虽然认为无T管胆道吻合有较低的胆道并发症的文章较多,肝移植中不留置T管的方法未发现突出的优势.结论 选择性的针对术中情况,分别采用两种方法,应该是肝移植发展的趋势.     

原位肝移植术后动脉并发症的诊断与治疗

目的 探讨肝移植术后动脉并发症的早期诊断与治疗方法。方法 回顾性分析本院180例次原位肝移植术后动脉并发症的监测、诊断与处理。结果 动脉并发症发生率为5．0％(9／180)，其中肝动脉血栓形成(HAT)5例，肝动脉狭窄(HAS)3例，腹腔动脉狭窄1例。8例动脉造影证实，1例尸检证实。彩色多普勒超声(CDI)的诊断敏感度和特异度分别为88．9％和95．9％；术中超声(IOUS)的敏感度、特异度，阳性预测值和阴性预测值分别为100％，96．0％，66．7％和100％。3例患者接受介入治疗、3例接受再血管化手术、2例分别接受再次肝移植和非手术治疗。3例治愈，6例死亡。结论CD1是监测动脉并发症的首选方法；IOUS有助于术中的早期诊断。HAS和HAT治疗应首选再血管化或再次肝移植；介入溶栓的疗效不佳；个别患者可尝试非手术治疗。     

肝移植术后胆道并发症的介入治疗

目的探讨介入治疗在肝移植术后胆道并发症治疗方面的作用。方法回顾性分析本中心2004年4月至2006年10月采用介入方法治疗的37例肝移植术后胆道并发症患者的I临床资料。结果本中心肝移植术后胆道并发症的发生率为7．2％（30／417）。介入治疗的近期治愈率为54．1％（20／37），近期治愈患者中需反复治疗的比率是40％（8／20），围手术期病死率为5．4％（2／37），总病死率为16．2％（6／37）。吻合口漏、胆道坏死导致的胆漏、吻合口狭窄、非吻合口狭窄、胆泥和胆石形成的介入治疗治愈率分别为57．1％（4／7）、0（0／4）、100％（8／8）、16．7％（2／12）、100％（6／6）。结论介入治疗是肝移植术后胆道并发症的重要治疗方法。疗效与胆道并发症的类型相关，吻合口狭窄、胆泥和胆石形成以及吻合口漏的介入治疗效果良好；胆道坏死导致的胆漏及非吻合口狭窄的介入治疗效果较差，应把握好时机进行再次肝移植。     

Portal vein complications after liver transplantation for biliary atresia

The objective of this report is to review portal complications (PC) after pediatric liver transplantation (LT) for biliary atresia (BA) in the Bicetre surgical series. From January 1, 1988, to February 28, 1995, 96 children with BA underwent 115 LTs Portal anastomosis was done on either the recipient portal vein (n = 85) or superior mesenteric vein (n = 11). No antiaggregative agents were administered postoperatively. Median follow-up was 50 months (range, 12 to 97). Nineteen PC (16.5%) occurred in 17 recipients: 16 portal thrombosis (PT) and 3 portal stenosis (PS). Fifteen instances of early PT occurred between days 0 and 17 (median, day 2). Emergency thrombectomy was performed in 9 cases (successful in 5). Three children underwent a secondary portosystemic shunt (successful in 2). Three PS were cured by either surgery or balloon dilatation. Four children died, 3 are alive with portal hypertension (PHT), and 10 are alive without PHT. Three- year patient actuarial survival is 82.4% in PC cases and 82% in others (NS). Significant risk factors of PC are young age and weight at the time of LT, small portal vein, and emergency LT. Analysis of our own results and review of the literature suggest that prevention of PC depends primarily on appropriate surgical technique. Reduction of postoperative hypercoagulability may also play an important role: a meta-analysis of 1,257 published pediatric LT show an overall risk of PT of 2.2% in teams using aspirin with or without dipyridamole compared with 7.8% when no antiaggregative agents are given (P = .0001). (Liver Transpl Surg 1997 Jul;3(4):351-8)     

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.     

肝移植术后胆道并发症的防治

目的探讨肝移植术后胆道并发症的防治措施。方法回顾性研究2002年4月至2007年2月我中心249例肝移植的临床资料。结果249例肝移植患者中,31例发生胆道并发症(12.45%),其中胆漏16例(早期14例、晚期2例),吻合口狭窄9例,非吻合口狭窄6例。并发胆漏患者中,3例经ERCP放置鼻胆管引流治愈,4例在B超引导下行腹腔穿刺置管引流治愈,7例轻度胆漏患者经延长腹腔引流管放置时间治愈,2例晚期胆漏患者充分引流后治愈。吻合口狭窄患者中,5例行PTCD球囊扩张术,4例行ERCP球囊扩张术,共有3例放置了胆道支架,现均存活良好。非吻合口狭窄患者中,2例二次肝移植后治愈,另4例行PTCD联合胆道镜治疗,2例治愈,2例恢复不佳。结论完善手术技术、缩短移植物冷热缺血时间及保护胆道血供是预防肝移植术后胆道并发症的重要措施,个体化治疗,多可取得良好疗效。