ԭλ����ֲ�����ؽ���������

目的 探讨肝脏移植胆道重建的外科技巧和影响胆道重建效果的因素。方法 对中山大学附属第一医院器官移植中心2004—2005年施行368例同种原位肝移植病人的临床资料进行分析总结。结果：368例肝移植病人中36例（9．8％）发生与胆道相关的并发症。23例经非手术治疗而愈；13例行开腹手术治疗，其中7例接受再次肝脏移植。5例因胆道并发症导致死亡，死亡原因为严重胆道感染和腹腔感染，病死率为13．9％。结论 保证供、受体胆管断端良好血液供应，正确选择胆道重建方式，精细的显微外科胆管吻合技术和确保胆管通畅性等，是提高胆道重建质量、降低胆道并发症发生率的重要因素。     

Biliary complications after liver transplantation

Abstract:  Biliary complications remain a substantial cause of morbidity following liver transplantation. They have been reported to occur in a rate of 10–15% of full-size transplantations and may be higher in living donor, split or reduced size liver transplantations. The most common biliary complications following liver transplantations are leaks and strictures. In both, the incidence varies with respect to type of graft and donor as well as the type of biliary anastomosis. The management of the biliary complications requires a multidisciplinary approach and has changed over the past decade, favoring endoscopic and radiological techniques. Surgical revision including retransplantation is reserved for patients in whom endoscopic and interventional modalities are unsuccessful.     

Biliary complications after paediatric liver transplantation: Birmingham's experience

Between 1983 and 1992, 112 children underwent liver transplantation. Of 138 grafts, 60 (43.4%) were whole livers, 77 (55.6%) were reduced livers, and 1 (0.7%) was a split liver. Biliary complications (BC) were defined as any abnormality, even minor, related to the biliary tract. Results were analysed with a minimum follow-up of 9 months. Some 36 grafts (26.1%) in 34 patients (30.4%) presented with BC: bile leaks (17 grafts), biliary obstructions or dilatations (16 grafts), and other complications (3 grafts). Management was mainly surgical with biliary reconstruction via a Roux-en-Y loop. Interventional radiology had an increasing role in recent years. BC were associated with a mortality of 1.8% (2/112), a graft loss rate of 4.3% (6/138), and significant morbidity. Among the various factors whose association with BC was studied, the date of transplantation, the use of reduced grafts and the use of gallbladder conduits appeared to be the main determining factors for BC. From multivariate analysis the use of reduced grafts emerged as the most important factor in reducing BC. We therefore conclude that BC are associated with significant morbidity, but general improvements in both surgical and medical management seem to account for better results in recent years.     

Outcomes of surgical repair of bile leaks and strictures after adult‐to‐adult living donor liver transplant

Melcher ML, Freise CE, Ascher NL, Roberts JP. Outcomes of surgical repair of bile leaks and strictures after adult‐to‐adult living donor liver transplant.
Clin Transplant 2010: 24: E230–E235. © 2010 John Wiley & Sons A/S. Abstract: We sought to determine factors that predict the successful surgical repair of biliary complications after adult living donor liver transplantation (ALDLT). Methods: Records of 82 consecutive ALDLT right lobe recipients were reviewed. Operations were performed on 19 recipients for biliary complications. Post‐operative biliary complications were analyzed. Fisher’s exact test was used to identify variables that correlated with successful surgical repair. Results: A total of 29 recipients had biliary complications, of which 19 had a surgical repair. The five recipients, operated on for a stricture without history of leaks, did not develop further complications. However, nine of 14 with a history of a leak developed further complications after surgical repair (p‐value = 0.044). All five who presented with a biliary complication more than 100 d after transplant had successful surgical repair; however, nine out of 13 who presented within 57 d had additional complications after repair. Conclusions: Operations for strictures after ALDLT are more successful than operations for leaks. Recipients with isolated biliary strictures after ALDLT can be managed surgically; however, recipients with history of a leak often require additional interventions after surgical repair.     

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.     

肝门胆管癌两种姑息性治疗方法并发症及适应证的比较

目的:比较经内镜逆行胆道支架置入术与经皮经肝穿刺胆道支架置入术对肝门胆管癌的近期治疗效果及适应证。方法:回顾性将肝门胆管癌患者60例按不同治疗方法分为经皮经肝穿刺胆道支架置入术组(35例)及经内镜逆行胆道支架置入术组(25例),比较经不同治疗方法后肝门胆管癌患者近期肝功能的恢复、相关并发症发生率及不同类型肝门胆管癌行不同治疗方法的成功率。结果:经内镜逆行胆道支架置入术同经皮经肝穿刺胆道支架置入术成功率分为80%和92%,在术后胆道出血及胰腺炎并发症方面,两种治疗方法存在明显差异(P0.05);Ⅳ型肝门胆管癌治疗成功率经皮经肝穿刺胆道支架置入术存在明显优势(P0.05);经内镜胆道支架置入术与经皮经肝穿刺胆道支架置入术在支架术后胰腺炎方面未见明显差异(P0.05)。两组治疗在减黄,肝功能恢复方面未见明显差异。结论:在并发症方面两种治疗方法各有优缺点,在Ⅳ型肝门胆管癌治疗中以经皮经肝穿刺胆道支架置入术为佳,Ⅰ型及Ⅱ型肝门胆管癌以内镜逆行胆道支架置入术治疗为佳,Ⅲ型肝门胆管癌根据具体情况而定。     

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.     

急性胆源性胰腺炎继发感染性胰腺坏死处理方式及时机

胆源性胰腺炎作为一种最常见且病因明确的急性胰腺炎，解除病因是其治疗的首要原则。但是对于合并感染性坏死、器官功能衰竭等较重的病情，如何解决胆道问题以及进行坏死组织清创成为一个较为复杂的问题。在病程早晚、感染坏死病灶复杂程度、胆道并发症及器官功能衰竭严重程度等多个因素得到综合评估的基础上制定符合个体化原则的治疗方案应是合理手段。多种微创清创技术及分步强化的清创策略（“step-up”策略）的应用虽然已逐渐被广泛认可，但仍有可能因为刻板分步、过度强调微创而造成治疗周期延长、并发症增加等不良后果。针对胆源性胰腺炎，一方面宜积极处理胆道问题为安全清创创造条件，另一方面宜根据局部病灶的复杂程度及器官功能状态妥善处理清创与彻底解决胆道并发症的关系，因此，必须制定一套完善合理的处置流程。     

胆道手术抗生素的预防应用

１９８６年１月～１９９２年１２月，对２２４例慢性结石性胆囊炎患者行胆囊切除．其中７８例胆囊内胆汁普通培养，１６．７％出现细菌，而２４１例急性胆管炎的胆汁细菌培养阳性率高达７４．３％．胆汁中细菌对抗生素的敏感度依次为头孢菌素族、氨基甙类和半合成青霉素．本研究资料表明，为了预防胆道手术后并发感染，短期和超短期的用药方式是合理的．     

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。     

肝移植术后早期非肝动脉栓塞性胆道缺血性损伤并发症的预防

目的：探讨肝移植术后早期非肝动脉栓塞性胆道缺血性损伤并发症的预防。方法：对60例同种原位背驮式肝移植病人术中、术后采用改善供肝血液循环的策略。结果：术后6个月内出现胆道并发症3例，发生率为5％（5／60），1例因拔T管时发生胆漏；1例经T管胆道造影导致胆道感染，胆泥形成；1例胆道吻合口渗漏。结论：肝移植术中、术后扩张血管、改善胆管微循环是预防术后早期非肝动脉栓塞性胆道缺血性损伤并发症的重要措施。     

内镜治疗术后胆管损伤的研究

目的 探讨内镜治疗手术后并发胆漏和继发性胆管狭窄的方法和效果.方法 胆漏患者均先行内镜下十二指肠乳头切开,行鼻胆管引流术,引流腹腔感染.待胆管、腹腔引流停止1～2周证实胆漏愈合后拔管,伴有胆管狭窄的患者在拔除鼻胆管后置入塑料内支架,持续扩张2～3个月.结果 26例胆漏患者鼻胆引流3～4周后胆漏处均闭合,17例胆管狭窄置入内支架者,14例支架取出后狭窄解除,4例合并肝总管狭窄者经重新置入双支架3个月后效果良好,1例左肝管狭窄伴结石者,再置入单支架,术后仍有胆管感染症状反复出现,另1例在一年后因反复感染出现肝脓疡,药物治疗无效作肝叶切除.结论 内镜治疗可列为手术后胆漏或继发胆管狭窄治疗的首选方法.     

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.     

Recurrent hepatitis C virus disease after liver transplantation and concurrent biliary tract complications: poor outcome

Recurrent hepatitis C virus (HCV) infection is particularly aggressive in the post-liver transplantation setting, with rapid progression of liver fibrosis. Biliary complications remain a significant cause of morbidity following liver transplantation. Post-cholecystectomy biliary strictures are associated with advanced hepatic fibrosis. The aim of this retrospective study was to determine whether the presence of biliary complications affects survival in liver transplant recipients with recurrent HCV disease. The files of liver transplant recipients (53.7% male; mean age 52.7+/-10.3 yr) were reviewed for incidence, type and treatment of biliary complications, and findings were compared between those who developed recurrent HCV disease (n=47, 83.9%) and those who did not (n=9). Twenty-one biliary complications developed in 12 patients with recurrent HCV (25.5%). Treatment with endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography with balloon dilatation and stent placement or surgical revision was successful in nine (75%). Three biliary complications developed in three patients with no recurrence (p=NS). There was no statistically significant association between recurrent HCV disease and biliary complications. However, among those with recurrent disease, the recurrence was severe in nine of 12 recipients with biliary complications (75%) but in only nine of 35 without biliary complications (26%) (p=0.001). Death was documented in eight patients with severe recurrence (44.4%), including three (37.5%) with biliary complications and two (7%) with non-severe recurrence, neither of whom had biliary complications (p=0.003). Antiviral treatment was successful in nine of 25 patients (36%) who received it. On multivariate analysis, biliary complications were a significant predictor of severe recurrence (OR 27.0, 95% confidence interval 2.07-351.4) (p=0.012). Fibrosis stage in the second biopsy was significantly correlated with serum alanine aminotransferase (p=0.01) and with duration of biliary obstruction (p=0.07). In conclusion, biliary complications of liver transplantation strongly affect outcome in patients with recurrent HCV disease despite attempts to relieve the biliary obstruction and to treat the recurrent HCV disease.