Biliary complications after orthotopic liver transplantation: MRCP findings

Orthotopic liver transplantation is a widely accepted treatment for end-stage liver disease and selected cases of hepatocellular carcinoma. Despite surgical progresses, biliary complications after transplantation remain a serious cause of morbidity, mortality, and graft dysfunction or failure in recipients. Early complications occur within a few weeks after transplantation and are mainly represented by bile leakage. Late complications, which become evident from 3 months to years, include strictures, stones, intraductal debris or sludge formation, kinking and ampullary dysfunction. Donor-to-recipient common bile duct disproportion has been reported as a borderline condition. Diagnosis is challenging because of the low specificity of clinical and biologic findings. Sonography does not provide projectional images of the biliary tract or direct evaluation of the anastomoses. Moreover, direct cholangiographic procedures have an unacceptable rate of complications to be used in patients with low clinical suspicion. Magnetic resonance cholangiography is a safe and accurate tool, playing an increasing role in the diagnosis and management of biliary complications. Heavily T2-weighted images provide panoramic, detailed evaluation of the biliary tract, showing biliary complications as a variable combination of bile duct dilatation, strictures, filling defects, fluid collections and peculiar morphologic changes, as described in this paper.     

从胆道内镜角度分析和认识原位肝移植后的胆遭并发症

背景:胆道并发症是肝移植后患者常见的死亡原因,胆道内镜微创技术正逐步成为解决原位肝移植后胆道并发症的重要手段.目的:分析文献中关于肝移植后胆道并发症的阐述和论证,明确胆道内镜在胆管铸型并发症中的地位和作用.方法:以orthotopic liver transplantation, biliary complications, Biliary tract, endoscope technique 为检索词,检索Pubmed数据库(1980-01/2008-10);以肝移植,胆道并发症,胆管铸型,胆道镜为检索词,检索维普咨询数据库(1994/2009-01)、CNKI数据库(1994/2009-01).文献检索语种限制为英文和中文.纳入肝移植后胆管损伤导致胆管并发症相关的内容.排除肝移植胆道并发症以外的研究.结果与结论:计算机初检得到52篇文献,根据纳入排除标准,对30篇进行分析.胆道并发症是肝移植后患者常见死亡原因,由于早期识别困难及处理棘手,正越来越受到重视.治疗性ERCP和胆道镜技术,成为解决移植后胆道并发症的重要手段和首选方法.     

Neurological complications after liver transplantation

This was a single-centre, prospective study to assess the frequency of neurological complications and their impact on prolonged hospitalization in 137 liver transplant patients presenting between September 1997 and June 2010. Neurological complications were seen in 22 (16%) patients during their postoperative stay in the intensive care unit. Complications included new-onset, recurrent headache (five patients), generalized seizures (four patients), dysarthria (two patients), delirium with agitation (three patients), persistent flapping tremor (two patients), alteration in level of consciousness (three patients), central pontine myelinolysis (one patient), myopathy (one patient) and visual hallucinations (one patient). Seizures were associated with immunosuppressive drug toxicity (tacrolimus). Myopathy presenting as quadriplegia was diagnosed by muscle biopsy. The patient with central pontine myelinolysis lived in a persistent vegetative state for 2 years and died of pneumonia. In conclusion, neurological complications are frequently encountered after liver transplantation, and are an important cause of severe morbidity and prolonged intensive care unit and hospital stay.     

肝移植术后胆道并发症的内镜下诊治

目的初步探讨内镜在肝移植术后胆道并发症诊治中的临床应用价值。方法35例肝移植术后出现胆道并发症患者,共行ERCP124次,其中行ERCP次数最少为1次,最多为17次,平均为3.54次。根据患者的情况进行扩张、EST、取石、鼻胆管引流、内支架置入等治疗。结果13例为单纯的胆道吻合口狭窄,经胆道扩张后胆道梗阻症状解除,其中1例术后4个月因肝癌远处转移死亡;3例为单纯吻合口胆瘘,经EST及支撑管,胆瘘愈合;7例胆道狭窄合并胆瘘,经EST及胆道扩张后放入支撑管,胆瘘愈合;12例胆道狭窄合并狭窄上端胆总管及肝内胆管结石,经胆道扩张后取出部分结石。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度下降,临床症状明显改善,无严重并发症发生。结论内镜对于肝移植术后胆道并发症的诊断与治疗安全而有效,避免了患者再次外科手术。     

MRI诊断56例肝移植术后移植肝实质并发症

目的 探讨MRI对肝移植术后移植肝实质并发症的诊断价值。方法 56例肝移植术后患者均接受MR常规序列扫描(Fiesta、Dual-Echo、FSPGR、FS FSE RT、DWI)及LAVA薄层动态增强检查,分析各序列影像表现。结果 肝实质动脉期异常灌注15例;肝内肿瘤复发9例,伴下腔静脉、门静脉及肝静脉癌栓3例;肝局灶性缺血、坏死2例,胆源性肝脓肿2例,肝脏周围炎2例,灶性肝出血2例,局灶性脂肪肝2例,弥漫性脂肪肝1例,肝淤血1例,肝嗜酸性肉芽肿1例,未分化肉瘤1例。结论 MRI可准确反映移植肝实质各种并发症,在其临床诊断及治疗方案的制定中具有重要价值。     

血清中细胞因子的检测在预测肝移植术后并发症中的作用

目的探讨肝移植术后患者血清中IL-2、IL-6、IL-10、IL-15、VEGF、MCP-1的变化在预测肝移植术后并发症中的作用。方法以2004年6月-2007年1月在本院行肝移植术的79例病人为研究对象，采用ELISA方法检测肝移植患者术前及术后血清中1L-2、IL-6、IL-10、IL-15、VEGF、MCP-1的浓度，观察其变化规律。结果IL-2 GVHD组术前、术后均为0，GVHD组术前、术后均为0，与其它各组比较有统计学意义（P〈0．05），血管并发症组术前显著高于其它组（P〈0．05），术后各组均升高，重度感染死亡组升高明显，3／5患者〉400pg／ml；IL-6血管并发症组、重度感染死亡组术前较高，而GVHD组术前结果较低，重度感染死亡组术后升高明显（P〈0．05），5例患者均〉300pg／ml；其余各组术后均降低；IL-10除排异组、GVHD组降低外，其余各组均升高，其中血管并发症组、重度感染死亡组升高非常明显；IL-15排异组、血管并发症组、重度感染死亡组术后升高（P〈0．05）；MCP-1术前，对照组明显高于其它组（P〈0．05），术后对照组下降，重度感染死亡组升高明显，〉300pg／ml；VEGF二次各组术前、术后数据的测定值几乎均为0。结论IL-2对GVHD的发生有鉴别诊断意义；细胞因子的明显升高，可能预示有重度感染，并濒临死亡；血中细胞因子的检测在预测肝移植术后并发症中有一定的临床意义。     

肝移植术后胆系并发症的影像学研究

1材料与方法 回顾性分析2002～2006年资料完整的34例同种异体原位肝移植术后CT、MRI及ERCP扫描患者的影像学表现。其中男27例，女7例，年龄18～63岁，平均46岁，肝硬化14例，肝功衰竭5例，肝豆状核变性1例，中晚期肝癌12例，在我院行经典原位术式者24例，行背驮式者10例，所有供受者血型均相符，所有病例均为胆总管对端吻合。     

肝移植术后胆道并发症的超声诊断

目的探讨超声在肝移植术后胆道并发症诊断和治疗中的价值.方法 13例实施肝移植术后临床拟诊胆道并发症患者,以二维超声检查移植肝内外胆管及肝周情况,彩色多普勒超声评估肝动脉血流,并与其他影像学检查相对比.结果超声检出胆道梗阻者10例(其中2例行超声引导PTC);胆漏者3例(其中2例在超声引导下置管引流);有肝动脉血栓并发胆道梗阻者3例.结论超声在肝移植术后胆道并发症的诊治中有着重要应用价值.     

Vascular complications after liver transplantation: evaluation with Doppler US

Purpose To demonstrate the spectral and color Doppler ultrasonography (US) findings that would indicate vascular complications after liver transplantation and to report our single center results of vascular complications detected in liver transplant recipients. Materials and methods Our study was consisted of 326 patients who underwent liver transplantation procedures between November 1997 and May 2004. The records of all patients were reviewed retrospectively for the details of each patient’s post-transplant Doppler US examinations, visceral angiographic examinations, and/or surgical procedures. Doppler US findings were correlated with angiographic results or surgery. Sensitivity and specificity of Doppler US parameters for the diagnosis of vascular complications of the hepatic artery, portal vein, and hepatic veins were calculated. Results Vascular complications occurred in 47 patients (14%). Eight instances of vascular complications were detected intraoperatively by Doppler US at the time of transplantation. For hepatic artery complications, use of a Doppler US criteria resulted in a sensitivity and a specificity of 92% and 97%, respectively. Doppler US parameters also resulted in a sensitivity and a specificity of 100% in detecting portal vein complications, and resulted in a sensitivity of 99% and a specificity of 100% in detecting hepatic vein complications. Conclusion Although it is clear that Doppler US evaluation is an effective choice for diagnosing vascular complications after liver transplantation, we also observed that Doppler US examination plays an important role in detecting vascular complications intraoperatively and improving the patient’s chance for a successful outcome.     

超声造影在肝移植术后并发症中的应用

目的探讨超声造影在肝移植术后并发症中的应用价值。方法对26例彩色多普勒超声检查结果异常或可疑病变的肝移植患者进行超声造影。造影剂（Sono Vue）用量2．4ml，机械指数0．06～0．08，采用肘静脉或术中静脉留置管快速团注，14例患者注射1次，10例患者注射2次，2例患者注射3次，记时器与录像机同步记录。结果移植肝肝癌复发6例，移植肝门静脉癌栓2例、血栓4例，移植肝肝硬化再生结节3例，移植肝肝动脉扭曲、重叠、侧支循环形成2例，移植肝脂肪肝伴坏死1例；移植肝血肿1例，移植肝未见异常7例。21例得到手术病理、穿刺活检的证实，5例与其他影像学检查结果一致。结论超声造影可协助诊断肝移植术后主要并发症，尤其能鉴别门脉内的血栓和癌栓，鉴别肝癌复发与血肿和脂肪坏死。     

Management of complications after varicoportal anastomosis in liver transplantation

The presence of portal vein thrombosis is a potential limitation for liver transplantation. An intraoperative diagnosis is linked to extensive surgical treatment and massive postoperative complications and mortality. We present a surgical less risky method for the treatment of intraoperatively diagnosed portal and mesenteric vein thrombosis that served as salvage therapy for a patient who underwent liver transplantation in our centre. Postoperative complications were ascites and renal failure. Persistent ascites required repeated paracentesis during the first month after liver transplantation but medical treatment sufficed thereafter. Moderate renal failure as defined by the K/DOQI-guidelines improved gradually and dialysis was never indicated. Six months after transplantation, the patient had normal liver function and adequate renal function.     

肝移植术后胆管并发症的内镜治疗

目的 对原位肝移植术后胆管并发症患者的类型进行了回顾性总结,评价经内镜下逆行胰胆管造影(ERCP)疗效及安全性.方法 原位肝移植术后出现胆管并发症的11例患者共行ERCP57次.治疗方法包括十二指肠乳头括约肌切开(EST)、胆管支架置入、气囊或探条扩张、及鼻胆管引流(ENBD)等.结果 肝移植术后胆管并发症主要包括胆漏、胆管狭窄、胆泥和结石形成等,分别通过十二指肠乳头肌切开取石术、胆管狭窄扩张术及鼻胆管引流术等进行治疗.11例患者均行了胆管造影,其中9例(82%)显示吻合口狭窄,5例(45%)有胆泥形成,4例(36%)兼有吻合口狭窄及胆泥形成,1例(9%)为肝内胆管广泛狭窄,1例(9%)为肝内胆管稀疏及广泛狭窄伴胆泥形成.5/9例(56%)胆总管吻合口狭窄的患者通过扩张及支架置入得到了有效的治疗.4/5例(80%)胆泥形成患者通过胆管扩张、支架置入及鼻胆管引流等得以治愈.ERCP术后没有严重的相关并发症发生.结论 肝移植术后胆管并发症主要为吻合口狭窄及胆泥形成.乳头切开取石及支架置入对于这些是有效且安全的治疗方法;而对于肝内胆管广泛狭窄及胆管稀疏的患者ERCP治疗效果不佳,再次肝移植可能是唯一选择.     

肝移植术后肝动脉并发症的介入治疗

目的:对肝移植术后肝动脉并发症的早期诊断及介入治疗进行初步的探讨。方法:回顾性分析我院1999年9月~2005年2月进行的450例原位肝移植术后36例肝动脉并发症的诊断及介入治疗。其中肝动脉血栓形成5例,肝动脉狭窄28例,肝动静脉瘘1例,肝动脉狭窄伴吻合口破裂出血1例,假性动脉瘤形成1例。所有病例均经彩色多普勒及动脉造影证实。其中34例接受了介入治疗。结果:32例肝动脉并发症的介入治疗获得成功,未发生与介入治疗相关的并发症,术后肝功能有明显改善。2例肝动脉血栓形成接受血管内溶栓的患者死于肝功能衰竭。结论:介入方法对肝移植术后肝动脉并发症的早期诊断及治疗具有较大的应用价值。     

阻力指数对肝移植术后肝动脉并发症的诊断价值

目的评价肝动脉阻力指数在肝移植术后肝动脉并发症中的诊断价值。方法总结155例肝移植受者的超声和临床资料,将肝动脉阻力指数(RI)进行分类分析。结果首次检查和随诊中,共16例出现低阻力指数其中10例(10/16)发生动脉并发症;17例出现高阻力指数者和70例持续正常阻力指数者未发生动脉并发症;52例舒张期无血流,其中仅1例(1/52)发生动脉并发症。结论肝移植术后低阻力指数与早期肝动脉并发症有明显相关性,而高阻力指数和舒张期无血流与肝动脉并发症无明显相关。     

Perioperative risk factors for pulmonary complications after liver transplantation

Using monofactorial and multivariate logistic regression analyses, the correlation of perioperative risk factors with postoperative pulmonary complications (PPCs) within 1 month after orthotopic liver transplantation (OLT) was investigated. Data on 107 patients (median age 46.8 years, 72% male) with end-stage liver disease who received OLT were retrospectively analysed. The incidence of PPCs was 60.7%. Overall mortality was 13.1% and pulmonary causes accounted for 85.7% of deaths. Mortality was 18.5% and 4.8% for patients with and without pulmonary complications, respectively. Independent risk factors for PPCs were a preoperative model for end-stage liver disease (MELD) score > or =25, intraoperative fluid transfusion volume > 10 1 and intraoperative blood transfusion volume > 4 l. A fluid balance of < or = -300 ml for > or =2 days of the first 3 days after surgery was protective. Other variables studied did not predict PPCs. It was concluded that improving the patient's preoperative medical condition, restricting intraoperative transfusion volumes and maintaining a negative fluid balance in the first 3 days after operation may decrease PPCs.     

肝移植术后并发症的CT影像学研究

目的：系统性研究肝移植术后各种并发症的CT影像学表现。资料与方法：对2003～2005年3年之间资料完整的23例同种异体原位肝移植术后CT影像学表现进行回顾性研究。结果：所有肝移植术后患者均出现肝周积液、胸腔积液及右下肺肺炎及门静脉伴行影。肝梗死4例，局限性脾梗死1例，肝内血肿2例，腹膜后血肿1例，胆总管下段胆泥阻塞伴胆管扩张5例， 13例肝癌患者中肝移植术后单纯双肺转移3例，单纯移植肝转移1例， 多脏器转移8例，1例因术后循环衰竭而死亡。结论：双螺旋CT能清楚显示肝移植术后的并发症影像。     

肝移植后胆道并发症的超声诊断价值

背景：肝移植后胆道并发症可引起移植后肝失功,超声是移植肝胆道并发症的重要检查手段之一。目的：探讨超声对肝移植后胆道并发症的诊断价值。 方法：纳入92例肝移植患者,男81例,女11例,年龄21-67岁;其中同种异体原位肝移植90例,活体部分肝移植2例;胆道重建方式均为胆管-胆管端端吻合。回顾性分析肝移植后常规检查及彩色多普勒超声检查结果,着重分析患者有无胆漏、胆道狭窄、胆泥或胆石形成,部分患者于超声引导下穿刺引流。 结果与结论：92例患者中超声诊断肝移植后胆道并发症14例：胆漏5例;胆道狭窄4例,其中吻合口狭窄2例,非吻合口狭窄2例;4例胆泥形成;1例胆管结石。提示肝移植胆道并发症患者有特征性超声表现,超声对肝移植后胆道并发症的诊断有重要价值。     

原位肝移植术后并发症的彩色多普勒超声诊断

目的探讨彩色多普勒超声在原位肝移植术后并发症中的诊断价值。方法回顾分析彩色多普勒超声对32例原位肝移植患者术后并发症的诊断结果。结果彩色多普勒超声诊断原位肝移植术后并发症主要有胸腹腔积液、肝动脉血栓、肝癌复发、肝周及腹腔占位、胆管炎及移植肝排异等。结论彩色多普勒超声在肝移植术后并发症诊断中具有重要的实用价值。     

肝移植术后管腔重建相关并发症的介入治疗

目的：探讨介入技术治疗肝移植术后血管和胆管管腔重建相关性并发症的可行性。方法：肝移植术后共有16例相关并发症患者接受介入治疗,其中肝动脉狭窄4例,肝动脉血栓形成2例,门静脉狭窄并血栓形成1例,胆管吻合口狭窄9例。肝动脉狭窄行球囊扩张（PTA）或内支架治疗,肝动脉血栓形成行导管接触性溶栓治疗,门静脉狭窄并血栓形成行溶栓、支架置入及分流道栓塞治疗,胆管吻合口狭窄行PTA或支架置入治疗。结果：16例患者均获技术成功,治疗均有效,有效率为100%。4例肝动脉狭窄1例单纯PTA有效,3例行支架置入术后有效,血流恢复。2例肝动脉血栓形成术后血栓消失,血流恢复通畅。1例门静脉并发症治疗后血流恢复,灌注增加。9例胆管吻合口狭窄2例行PTA有效,7例置入支架后有效。随访0.5～17个月无复发,5例死于原发病进展或系统并发症,与该并发症或介入治疗无关。结论：介入技术成功率高、并发症少,是治疗肝移植管腔重建相关并发症的有效方法。     

胆管周围血管丛损伤与肝移植术后胆道并发症

背景:随着肝移植术后单纯胆管吻合所导致的胆道并发症明显下降,目前需要重视的是各种因素引起的胆管动脉血供受损所产生的缺血性胆管损害.目的:总结了胆道的解剖结构与胆管周围血管丛生理形态、肝移植对胆管周围血管丛的损伤及其导致胆道并发症的机制、以及如何预防胆管周围血管丛损伤.方法:应用计算机检索PubMed和CNKI 数据库、万方、维普数据库中2010-12以前与肝移植和胆管周围血管丛相关内容的文章,在标题和摘要中以"肝移植,胆管周围血管丛,胆道并发症,胆管微循环,缺血再灌注损伤"或"liver transplantation,peribiliary vascular plexus,biliary complications,microcirculation of bile duct,ischemia-reperfusion injury"为检索词进行检索.初检得到228篇文献,根据纳入标准选择23篇文章进行综述.结果与结论:胆管的血供主要是由肝动脉通过胆管周围血管丛提供的,肝动脉的大部分终末分支形成胆管周围血管丛,承担胆管的血供和营养.在肝移植过程中胆管树潜在性遭受很多因素的损害,而大多数因素均是直接或间接地作用于胆管周围血管丛进而导致移植术后胆道并发症的发生.