原位肝移植术后胆道并发症治疗经验

目的总结原位肝移植术后胆道并发症的治疗经验。方法1999年2月至2004年2月,我中心采用胆总管-胆总管端端吻合术施行原位肝移植236例,96例采用置“T”管引流的胆管间断吻合;39例采用未置“T”管的胆管间断吻合技术;101例采用未置“T”管、前壁间断后壁连续的胆管吻合。结果全组术后32例(13·3%)发生胆道并发症,其中胆管狭窄24例(10·0%),胆漏6例(2·5%),胆管结石2例(0·8%)。3组胆道并发症发生率分别为17·7%、15·4%和7·9%,其中肝门部/肝内胆管狭窄发生率分别为8·3%,2·6%和1·0%。第3组胆道并发症发生率和胆管狭窄发生率显著降低(P<0·05)。20例胆管狭窄患者接受放射和/或内镜介入治疗,其中单纯吻合口狭窄治愈率90%,肝门部/肝内胆管狭窄治愈率60%。结论弃用“T”管的胆管前壁间断后壁连续的吻合方式能显著减少胆道并发症;非缺血相关性胆管吻合口狭窄和单纯肝门部胆管狭窄应首选介入治疗。     

损伤控制性手术原则在严重肝外伤治疗中的应用

目的：探讨损伤控制性手术原则（DCS）在肝外伤治疗中的应用价值。
方法：回顾性分析168例III级以上严重肝外伤患者临床资料,按是否实施损伤控制性手术原则分为两组,比较两组在平均手术时间、并发症、病死率以及住院时间方面的差异。
结果：DCS组的住院时间长于一期手术对照组 [（24.5±3.2）d vs.（16.4±4.1）d]（P<0.05）,但其平均手术时间、术后并发症发生率及病死率较对照组明显降低[（102±27）min vs.（224±35）min;26.3% vs. 38.4%;15.8% vs. 30.1%）]（均P<0.05）。
结论：损伤控制性手术原则在肝外伤治疗中对患者是有益的,可降低患者术后并发症及病死率。     

Management of biliary tract complications following liver transplantation.

BACKGROUND: A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2-year period. METHODS: A review was made of patient data collected prospectively, and confirmed by retrospective casenote review. RESULTS: A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end-to-end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T-tubes had complications: three leaks at T-tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T-tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor-recipient bile duct mismatch; severe cellular rejection: and prolonged postoperative hypotension. Acute rejection, steroid-resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re-transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30-180 days) compared with 33.5 days (range: 22-70 days) for patients without. Of patients with end-to-end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery. CONCLUSION: A total of 50% of patients with end-to-end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.     

Predisposing factors for biliary complications following liver transplantation

INTRODUCTION: Biliary complications remain a major cause of morbidity and mortality in patients following liver transplantation. We sought to identify possible risk factors predisposing to biliary complications after OLT using duct-to-duct biliary reconstruction. MATERIALS AND METHODS: We retrospectively reviewed 5 years of prospectively collected donor and recipient data between April 1999 and April 2004. We evaluated the presence of biliary complications, donor and recipient age, cold ischemia time, hepatic artery thrombosis, non-heart-beating donor (NHBD), and graft steatosis (>30%). The results were compared with a control group of OLT patients without biliary complications. RESULTS: Among 173 OLT recipients, biliary complications occurred in 28 patients (16.2%), of whom 12 were leaks, 15 strictures, and 1 a nonanastomotic intrahepatic stricture. The mortality following biliary complications was 11%, compared to 6% in the control group. CONCLUSION: Biliary complications remain a persistent problem in OLT. Analysis of risk factors identified hepatic artery thrombosis and steatosis as predisposing factors. With greater experience, NHBD livers may also prove to be at greater risk of biliary complications.     

严重肝外伤行损伤控制性手术患者的护理

目的探讨严重肝外伤行损伤控制性手术的护理方法.方法 对32例严重肝外伤行损伤控制性手术患者予监测生命体征,积极复温,观察代谢性酸中毒、凝血功能异常和腹部体征,预防腹腔间隔室综合征,做好患者再次手术的术前准备及术后护理,并注重心理护理等.结果 29例痊愈(90.6%),3例死亡(9.4%);术后未发生低体温,2例重度代谢...     

损伤控制外科理念在严重腹部创伤中的应用价值

目的探讨损伤控制外科（DCS）理念在严重腹部创伤中的应用价值。方法回顾性分析46例按DCS原则进行救治和58例未按DCS原则进行救治的严重腹部创伤患者的临床资料。DCS救治分为简单快速手术、复苏治疗和再次确定性手术3个步骤实施。比较两组患者围手术期死亡率和并发症发生率。结果DCS组和非DCS组患者围手术期死亡率分别为15．2％（7／46）和34．5％（20／58）,差异有统计学意义（Х^2=4．954,P=0．026）;围手术期总并发症（包括围手术期死亡病例）发生率分别为37．0％（17／46）和67．2％（39／58）,差异有统计学意义（Х^2=9．468,P=0．002）。结论按照DCS理念对严重腹部创伤患者进行救治,可明显降低围手术期死亡率和并发症发生率,疗效满意,值得推广。     

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.     

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。     

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.     

损伤控制性手术在严重肝脏外伤中的应用价值

目的 探讨损伤控制性手术在严重肝脏外伤救治中的应用价值.方法 回顾性分析我院2000年1月到2011年11月间45例严重肝脏外伤手术病例,其中按AAST分级Ⅲ级15例,Ⅳ级21例,Ⅴ级9例;合并其他器官损伤38例;行损伤控制性肝脏手术19例,一期确定性手术26例,对比分析损伤控制性手术与一期确定性手术在住院时间,并发症发生率,死亡率等指标的差异.结果 住院时间和术后并发症发生率两组差异无统计学意义(P>0.05),而损伤控制性手术组的死亡率较一期确定性手术组明显降低,差异有统计学意义(P<0.05).结论 严重肝脏外伤治疗选择损伤控制性手术,能有效改善患者预后.     

损伤控制外科理念在严重肝外伤诊治中的指导作用

"损伤控制性外科"(damage control surgery,DCS)是Rotondo等[1]在20世纪90年代提出的理念,其含义有两个方面:一方面是控制继续损害机体的原有创伤,如出血和污染;另一方面是对手术操作所带来的二次打击进行有效控制,如施行损伤控制性手术、使用微创技术等.     

Management of biliary tract complications after orthotopic liver transplantation

INTRODUCTION: Despite improved survival, biliary complications remain a significant cause of morbidity following orthotopic liver transplantation. The aim of this study was to review the incidence, treatment and optimum management pathway of biliary complications at the Scottish Liver Transplant Unit. MATERIALS AND METHODS: All patient data were collected prospectively onto a database at the Scottish Liver Transplant Unit with review of hospital records for validation. RESULTS: A total of 379 consecutive orthotopic liver transplants were performed in 333 adult patients between November 1992 and September 2001. Biliary complications occurred in 55 grafts (51 patients) (14.6%) and their incidence decreased with time. Biliary complications occurred in 29 (10.9%) of the 265 choledocho-choledochostomies compared with 14 (25%) of the 56 with T-tubes. Twenty-eight biliary leaks occurred, 22 of which were anastomotic. Seventeen anastomotic leaks were successfully treated non-operatively. Eight patients with biliary leaks subsequently developed an anastomotic stricture. Of the 30 anastomotic strictures, stent insertion was successful in resolving six of 14 (42%) early anastomotic strictures compared with one of 12 (8%) late anastomotic strictures (p = 0.0479). Six (38%) of the 16 early anastomotic strictures required surgery for complete resolution, compared with 12 (86%) of the 14 late anastomotic strictures (p = 0.0106). CONCLUSION: The incidence of biliary complications has decreased with time. The abandonment of choledocho-choledochostomy over a T-tube has been justified. A combination of conservative, endoscopic, and radiological management has been effective in treating biliary leaks and early anastomotic stricture. However endoscopic or radiological stenting was ineffective in the management of late anastomotic strictures, which were best treated by surgical intervention.     

A case of post-reperfusion syndrome following surgery for liver trauma

We report the case of a young trauma patient who needed tightperihepatic surgical packing to control bleeding from a rupturedliver. He developed severe cardiovascular and respiratory decompensationon removal of the surgical packs as a result of the post-reperfusionsyndrome. He underwent a total hepatectomy and, 35 h later,orthotopic liver transplantation. The pathophysiology of post-reperfusionsyndrome is discussed, and its importance to anaesthetists inthe non-transplant setting is emphasized.     

肝脏移植术后胆道并发症的防治

目的探讨原位肝移植术后胆道并发症的防治方法。方法回顾性分析我院2002年6月至2006年9月完成的160例肝移植资料,其中行胆管-空肠Roux-en-Y吻合术10例、胆管-胆管端端吻合术150例。术后超声、CT、MRI、胆道造影和血清学检查了解移植肝形态、血流动力学及肝功能。98例随访2～48个月。结果发生胆道并发症24例（18%）,其中因肝动脉狭窄或栓塞引起的胆漏、胆道狭窄和肝内局限性坏死7例（5例经溶栓及内支架介入治疗后恢复、2例因肝功能衰竭并感染死亡）;胆道狭窄8例（6例经再次手术和ERCP及PTCD胆道内、外支撑等介入治疗恢复、2例胆管消融并发胆管炎死亡）;胆漏7例（6例经再次手术或超声引导下穿刺置管引流治愈、1例保守治愈）;胆道铸型2例（均经再次手术治愈）。结论供肝的质量和完整的动脉采集及胆道黏膜的保护,精细的动脉和胆管吻合是预防肝移植术后胆道并发症的关键。肝动脉溶栓、ERCP及PTCD胆道内支撑等是治疗胆道并发症的有效手段。     

肝移植术后胆道并发症的防治

目的 探讨原位肝移植术后胆道并发症的预防与治疗.方法 对1995年5月至2006年12月中国医科大学附属第一医院183例肝移植患者术后胆道并发症的发生情况进行回顾性分析.结果 共发生胆道并发症15例,发生率为8.2%,其中近期并发症占6.0%(11例),远期并发症占2.2%(4例),未发生与肝动脉血栓形成有关的胆道并发症.15例中13例治愈,其中4例行经皮肝穿胆道造影(PTC)并留置支架管,8例行内镜逆行胰胆管造影(ERCP)并进行胆道冲洗及留置支架管,1例吻合口狭窄患者在外院行ERCP未成功而改行胆管空肠吻合术,均获治愈.2例因近期发生胆汁漏而行胆管-空肠Roux-en-Y吻合者最后均死于真菌感染,胆道并发症相关死亡率为1.1%.结论 采用腹腔器官联合快速切取技术可缩短供肝冷、热缺血时间,防止变异胆管和血管损伤,降低胆道并发症.肝移植术中注意保护胆总管的血运是减少胆道并发症的关键.PTC和ERCP结合留置支架管是非缺血型胆道并发症的主要治疗手段.     

Surgical management of biliary complications following living donor liver transplantation

Khalaf H, Alawi K, Alsuhaibani H, Hegab B, Kamel Y, Azzam A, Albahili H, Alsofayan M, Al Sebayel M. Surgical management of biliary complications following living donor liver transplantation.
Clin Transplant 2011: 25: 504–510. © 2010 John Wiley & Sons A/S. Abstract: Background: Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. Methods: Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. Results: Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non‐surgical procedures, three (11.5%) died from BC‐related sepsis, one (3.8%) died from BC‐unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow‐up period of 4.5 yr (0.1–6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). Conclusions: In our experience, BCs after LDLT were frequently resistant to non‐surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.     

The effect of smoking on biliary complications following liver transplantation

We sought to estimate the effect of smoking on the biliary complication rate following orthotopic liver transplantation. We retrospectively evaluated the records of liver transplant recipients at our center from July 1, 1999 to October 26, 2007. Using Cox proportional hazards models, we estimated the time to the earliest biliary complication (leak or stricture) based on smoking exposure, as active, former, or lifetime nonsmoker, adjusting for other clinical factors. Overall, 409 liver transplant recipients were evaluated. The overall biliary complication rate was 37.7% (n = 154). Biliary complications included 66 anastomotic leaks, 60 anastomotic strictures, and 28 nonanastomotic lesions. ERCP was the primary diagnostic modality (n = 112). 18.1% of liver transplant recipients were active smokers (n = 74) and 42.8% were former smokers (n = 175). Active smokers were at greatest risk for biliary complications on unadjusted analysis (P = 0.022). After multivariable adjustment, active smokers had a 92% higher rate of biliary complication rates compared with lifetime nonsmokers (HR 1.92, 95% CI 1.07–3.43), but no difference was noted in the rate of complication resolution. Smoking clearly portends a significant risk of biliary complications following liver transplantation. Smoking status should be clearly defined when evaluating transplant candidacy and in counseling patients with cirrhosis.