肝脏移植受体手术与外科相关并发症防治

目的总结防治肝移植受体手术后外科相关并发症的方法与经验。方法回顾性分析2000年1月-2006年12月32例行肝移植患者临床资料,其中肝豆状核变性3例,慢性重症肝炎3例,晚期肝硬化12例（其中淤胆性肝硬化2例）,原发性肝癌合并肝硬化12例,肝门部胆管癌合并肝硬化2例。结果所有手术均获成功,术中平均出血量3 600（1 000-10 000）ml,手术时间平均5.2（4-9）h。围手术期死亡3例,分别死于术后出血、急性肾衰和移植肝无功能。术后腹腔出血4例,胆漏4例,胆管狭窄2例,无血管并发症。结论肝移植受体手术创伤大,术中应仔细操作,严密止血,高质量完成各种管道的重建,可大大减少各种外科相关并发症。     

The Effect of Recipient-Specific Surgical Issues on Outcome of Liver Transplantation in Biliary Atresia

Biliary atresia (BA), the most common reason for orthotopic liver transplantation (OLT) in children, is often accompanied by unique and challenging anatomical variations. This study examines the effect of surgical-specific issues related to the presence of complex vascular anatomic variants on the outcome of OLT for BA. The study group comprised 944 patients who were enrolled in the Studies of Pediatric Liver Transplantation (SPLIT) registry and underwent OLT for BA over an 11-year period. 63 (6.7%) patients met the study definition of complex vascular anomalies (CVA). Patient survival, but not graft survival, was significantly lower in the CVA group, (83 vs. 93 % at 1-year post-OLT). The CVA group had a significantly higher incidence of all reoperations, total biliary tract complications, biliary leaks and bowel perforation. The most frequent cause of death was infection, and death from bacterial infection was more common in the CVA group. Pretransplant portal vein thrombosis and a preduodenal portal vein were significant predictors of patient survival but not graft survival. This study demonstrates that surgical and technical factors have an effect on the outcome of BA patients undergoing OLT. However, OLT in these complex patients is technically achievable with an acceptable patient and graft survival.     

Long-Term Outcome of Adult-to-Adult Living Donor Liver Transplantation for Post-Kasai Biliary Atresia

Our objective was to analyze problems in the perioperative management and long-term outcome of living donor liver transplantation (LDLT) for biliary atresia (BA). Many reports have described the effectiveness of liver transplantation (LT) for BA, particularly in pediatric cases, but little information is available regarding LT in adults (> or =16 years old). Between June 1990 and December 2004, 464 patients with BA underwent LDLT at Kyoto University Hospital, of whom 47 (10.1%) were older than 16 years. In this study, we compared the outcomes between adult (> or =16 years old) and pediatric (<16 years old) patients. The incidence of post-transplant intestinal perforation, intra-abdominal bleeding necessitating repeat laparotomy and biliary leakage was significantly higher (p < 0.0001, <0.001 and <0.001, respectively) in adults. Overall cumulative 1-, 5- and 10-year survival rates in pediatric patients were significantly higher (p < 0.005) than in adults. Two independent prognostic determinants of survival were identified: a MELD score over 20 and post-transplant complications requiring repeat laparotomy. Outcome of LDLT in adult BA patients was poorer than in pediatric patients. It seems likely that LT will be the radical treatment of choice for BA and that LDLT should be considered proactively at the earliest possible stage.     

Living-Donor Liver Transplantation in the United States: Identifying Donors at Risk for Perioperative Complications

Donor safety has been scrutinized by both the medical community and the media. Variability exists in reported donor complications and associated risk factors are ill defined. Use of administrative data can overcome the bias of single-center studies and explore variables associated with untoward events. A retrospective cohort study identifying living liver donors in two large healthcare registries yielded 433 right and left lobe donors from 13 centers between 2001 and 2005. Perioperative complications were identified using International Classification of Diseases, 9th Revision (ICD-9) coding data and classified according to the Clavien system. Logistic regression models identified factors associated with complications. There was one perioperative death (0.23%). The overall complication rate was 29.1% and major complication rate defined by a Clavien grade >or=3 was 3.5%. Center living-donor volume (OR = 0.97, 95% CI = 0.95-0.99) and the ratio of living-donors to all donors (living and deceased) (OR = 0.94, 95% CI = 0.92-0.96) were associated with a lower risk of all complications. Donor age >50 years (OR = 4.25, 95% CI = 1.22-14.87) was associated with a higher risk of major complications. Living liver donation is currently performed with a low risk of major morbidity. Use of administrative data represents an important tool to facilitate a better understanding of donor risk factors.     

Biliary Complications After Liver Transplantation: Old Problems and New Challenges

Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.     

Roux-en-Y Choledochojejunostomy Versus Duct-to-Duct Biliary Anastomosis in Liver Transplantation for Primary Sclerosing Cholangitis: A Meta-Analysis

Background

Roux-en-Y choledochojejunostomy and duct-to-duct anastomosis are potential methods for biliary reconstruction in liver transplantation (LT) for recipients with primary sclerosing cholangitis (PSC). However, there is controversy over which method yields superior outcomes. The purpose of this study was to evaluate the outcomes of duct-to-duct versus Roux-en-Y biliary anastomosis in patients undergoing LT for PSC.

Methods

Studies comparing Roux-en-Y versus duct-to-duct anastomosis during LT for PSC were identified based on systematic searches of 9 electronic databases and multiple sources of gray literature.

Results

The search identified 496 citations, including 7 retrospective series, and 692 patients met eligibility criteria. The use of duct-to-duct anastomosis was not associated with a significant difference in clinical outcomes, including 1-year recipient survival rates (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.65–1.60; P = .95), 1-year graft survival rates (OR, 1.11; 95% CI, 0.72–1.71; P = .64), risk of biliary leaks (OR, 1.23; 95% CI, 0.59–2.59; P = .33), risk of biliary strictures (OR, 1.99; 95% CI, 0.98–4.06; P = .06), or rate of recurrence of PSC (OR, 0.94; 95% CI, 0.19–4.78; P = .94).

Conclusions

There were no significant differences in 1-year recipient survival, 1-year graft survival, risk of biliary complications, and PSC recurrence between Roux-en-Y and duct-to-duct biliary anastomosis in LT for PSC.     

肝移植术后心血管系统并发症的防治

目的总结肝移植术后常见的心血管系统并发症及其可能的原因和防治方法. 方法回顾性分析1998年1月至2003年12月间286例成人肝移植病例术后近期发生的心血管系统并发症192例. 结果 192例(67.1%)患者发生心血管系统并发症,其中术后高血压173例(60.5%), 心衰21例(7.3%),心肌缺血性疾病(包括心绞痛和心肌梗塞)16例(5.6%),肺动脉高压9例(3.1%).与心血管并发症相关的死亡率为11.2%(32/286).术后早期高血压与多种因素有关,晚期高血压则是由于长期服用免疫抑制药物所造成;心衰同肝移植术中输血量有明显关系(χ2=20.27, P<0.01);除术前即存在冠心病史外,术后凝血功能紊乱可能是发生心肌缺血的主要原因. 结论心血管系统并发症是肝移植术后常见的和严重的并发症之一,并有较高的死亡率.合适的病例选择,维持出入量及凝血机制的平衡是降低术后心血管并发症的关键.     

原位肝移植术后胆道并发症的预防和治疗(附43例肝移植报告)

目的：探讨原位肝移植术后胆道并发症的防治。方法：回顾性分析2001年10月至2003年3月的43例原位肝移植的临床资料。结果：本组43例行原位肝移植术的病人中，6例发生了胆道并发症，发生率为13．95％；计胆道狭窄3例，拔T管时胆漏2例，胆总管漏1例。前25例用UW液冲洗胆道，有5例发生胆道并发症．发生率为20．00％．后18例先用林格液彻底冲洗胆道，再用UW液灌注保存，仅1例发生胆道并发症，发生率为5．56％。留置T管的18例病人中3例发生胆道并发症，未放T管的25例中也有3例发生胆道并发症，发生率分别为16．67％和12．00％。6例胆道并发症病人中仅1例实施再次手术，1例死于严重的肺部感染，其余经PTCD充分引流、放射介入和(或)内镜气囊扩张并放置支架等治疗，均取得了满意疗效。结论：在切取供体早期用林格液彻底冲洗胆道系统，是降低胆道并发症的一种有效方法；是否放置T管取决于胆道两端口径的匹配情况和手术医生吻合技术的熟练程度，T管至少宜放置4个月；而胆道并发症的治疗大多可经非手术治愈。     

肝移植术后胆道并发症的防治体会

目的：报告本院１９９６年１２月～２００２年１月施行的１７例肝移植术后胆道并发症的诊治体会,探讨其发生的主要原因及防治方法。方法：终末期肝病合并症肝功能衰竭（部分合并肾功能衰竭）１７例。男∶女,８∶９;年龄３２～６５岁;原发病：原发性胆汁性肝硬化６例,肝炎后肝硬化４例,酒精性肝硬化一例,Ｗｉｌｓｏｎ＇ｓ病２例,多囊肝合并多囊肾２例,原发性肝癌一例,遗传性毛细血管增生症一例;肝功能状态：均为Ｃｈｉｌｄ　Ｃ。结果：１７例病人中１４例获得长期存活,生活质量良好,３例术后短期生存。２例术后发生胆道梗阻并发症,均经再次手术治愈。结论：肝移植术后胆道并发症的诊断主要依靠Ｂ超、胆道造影等影像学方法。针对病因,确保胆道系统的血供,是预防肝移植术后胆道并发症的主要手段。在治疗上应视具体情况,争取切除梗阻部位、重建胆流通道。     

Liver Transplantation Across Rh Blood Group Barriers Increases the Risk of Biliary Complications

Background Cold ischemia time and the presence of postoperative hepatic arterial thrombosis have been associated with biliary complications (BC) after liver transplantation. An ABO-incompatible blood group has also been suggested as a factor for predisposal towards BC. However, the influence of Rh nonidentity has not been studied previously. Materials Three hundred fifty six liver transplants were performed from 1995 to 2000 at our hospital. BC incidence and risk factors were studied in 345 patients. Results Seventy patients (20%) presented BC after liver transplantation. Bile leakage (24/45%) and stenotic anastomosis (21/30%) were the most frequent complications. Presence of BC in Rh-nonidentical graft–host cases (23/76, 30%) was higher than in Rh-identical grafts (47/269, 17%) (P = 0.01). BC was also more frequent in grafts with arterial thrombosis (9/25, 36% vs 60/319, 19%; P = 0.03) and grafts with cold ischemia time longer than 430 min (26/174, 15% vs 44/171, 26%; P = 0.01). Multivariate logistic regression confirmed that Rh graft–host nonidentical blood groups [RR = 2(1.1–3.6); P = 0.02], arterial thrombosis [RR = 2.6(1.1–6.4); P = 0.02] and cold ischemia time longer than 430 min [RR = 1.8(1–3.2); P = 0.02] were risk factors for presenting BC. Conclusion Liver transplantation using Rh graft–host nonidentical blood groups leads to a greater incidence of BC.     

弓形刀腔内电切治疗肝移植术后胆管吻合口狭窄

目的探讨弓形刀腔内电切(IEI)能否降低传统内镜下气囊扩张(BD)和塑料支架置入(PS)治疗肝移植术后胆管吻合口狭窄(PTAS)的复发率。方法对笔者所在单位2007年1月至2011年10月期间采用BD+PS或IEI+BD+PS两种方式治疗的27例PTAS患者的临床资料进行回顾性分析。结果采用BD+PS治疗的11例PTAS患者中有9例(81.8%)成功,其中5例复发(55.6%);采用IEI+BD+PS治疗的16例PTAS患者中有14例(87.5%)成功,其中3例复发(21.4%)。置入的塑料支架总直径平均值IEI+BD+PS组大于BD+PS组〔(12±3.2)Fr比(8±1.3)Fr,P=0.039〕;8例复发者均再次通过IEI+BD+PS治疗成功。并发症包括胰腺炎5例(18.5%),胆管炎8例(29.6%),出血1例(3.7%),均通过内科保守治疗治愈;未出现与IEI直接相关的并发症如出血或穿孔等。内镜治疗后平均随访时间为22个月(1～49个月)。结论弓形刀腔内电切能降低气囊扩张和塑料支架置入治疗PTAS的复发率,是对传统内镜疗法的安全和有效的补充.     

Outcomes Analysis for 280 Patients with Cholangiocarcinoma Treated with Liver Transplantation Over an 18-year Period

Cholangiocarcinoma is an aggressive malignancy with 5-year survival rates <15%. Selected patients present with localized but unresectable disease and are candidates for orthotopic liver transplantation (OLT). The purpose of this study was to evaluate a multi-institutional experience with liver transplantation for this malignancy. Two hundred eighty patients with cholangiocarcinoma treated with OLT from 1987 to 2005 were identified in The United Network for Organ Sharing database. Patient and allograft survivals were calculated and the potential prognostic value of multiple clinicopathologic variables was assessed. At a median follow-up interval of 452 days (range: 0–6,166 days), 1- and 5-year patient survivals were 74 and 38%, respectively, with 49 actual 5-year survivors and 21 actual 10-year survivors. Posttransplant 1- and 5-year allograft survivals were 69 and 36%, respectively. Study variables associated with improved survivals included diagnosis of cholangiocarcinoma pre-OLT [5-year overall survival (OS): 68 vs. 20% for patients with incidental diagnoses at the time of OLT, p < 0.001] and OLT after 1993 (5-year OS: 45 vs. 30% pre-1994, p < 0.01). In contrast, the diagnosis of concomitant primary sclerosing cholangitis did not impact survivals (5-year OS: 41 vs. 50% without primary sclerosing cholangitis, p = 0.402). Selected cholangiocarcinoma patients treated with OLT experience a survival benefit. Diagnosis of cancer prior to OLT allows for better staging and pre-OLT therapy that may translate into improved outcomes. These data support the continued development of multimodality cholangiocarcinoma treatment protocols that include OLT. Presented at the 7th Annual American Hepato-Pancreato-Biliary Association Meeting, April 21, 2007, Las Vegas, NV.     

Variation in Biliary Complication Rates Following Liver Transplantation: Implications for Cost and Outcome

Although biliary complications (BCs) have a significant impact on the outcome of liver transplantation (LT), variation in BC rates among transplant centers has not been previously analyzed. BC rate, LT outcome and spending were assessed using linked Scientific Registry of Transplant Recipients and Medicare claims (n = 16 286 LTs). Transplant centers were assigned to BC quartiles based upon risk‐adjusted observed to expected (O:E) ratio of BC separately for donation after brain death (DBD) and donation after cardiac death (DCD) donors. The median incidence of BC was 300% greater in the highest versus lowest DBD quartiles (19.0% vs. 5.9%) and varied 250% between DCD quartiles (20.3%–8.4%). Donor and recipient characteristics suggest that high BC centers actually used lower donor risk index organs, fewer split livers and fewer imports (p < 0.001 for all). Transplant at a center in the highest O:E quartile was associated with increased posttransplant mortality (adjusted hazard ratio [aHR] 2.53, p = 0.007) in DCD transplant and increased graft loss (aHR 1.21, p = 0.02) in DBD transplant. Medicare spending was $22 895 (p < 0.0001) higher at centers in highest versus lowest BC quartile. In summary, BC rates vary widely among transplant centers and higher rates are a marker for an increased risk of death, graft failure and health‐care spending.     

Who Pays for Biliary Complications Following Liver Transplant? A Business Case for Quality Improvement

We use biliary complication following liver transplantation to quantify the financial implications of surgical complications and make a case for surgical improvement initiatives as a sound financial investment. We reviewed the medical and financial records of all liver transplant patients at the UMHS between July 1, 2002 and June 30, 2005 (N = 256). The association of donor, transplant, recipient and financial data points was assessed using both univariable (Student's t-test, a chi-square and logistic regression) and multivariable (logistic regression) methods. UMHS made a profit of $6822 +/- 39087 on patients without a biliary complication while taking a loss of $5742 +/- 58242 on patients with a biliary complication (p = 0.04). Reimbursement by the payer was $5562 higher in patients with a biliary complication compared to patients without a biliary complication (p = 0.001). Using multivariable logistic regression analysis, the two independent risk factors for a negative margin included private insurance (compared to public) (OR 1.88, CI 1.10-3.24, p = 0.022) and biliary leak (OR = 2.09, CI 1.06-4.13, p = 0.034). These findings underscore the important impact of surgical complications on transplant finances. Medical centers have a financial interest in transplant surgical quality improvement, but payers have the most to gain with improved surgical outcomes.     

The Diagnostic Conundrum and Liver Transplantation Outcome for Combined Hepatocellular‐Cholangiocarcinoma

Combined hepatocellular‐cholangiocarcinoma (cHCC‐CC) is a rare primary liver malignancy with mixed hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) histological features. It is almost impossible to obtain an accurate, preoperative noninvasive diagnosis of cHCC‐CC with tumor markers or cross‐sectional abdominal imaging due to the mixed histological features. Despite these difficulties, accurate cHCC‐CC diagnosis remains an important goal with prognostic significance. In our study, we retrospectively reviewed the tumor markers: AFP and CA 19‐9, and cross‐sectional liver imaging, in light of liver explant findings, to identify and characterize cHCC‐CC features followed by liver transplantation (LT) outcome analysis. The results from this 12 patient cohort failed to identify characteristic features for cHCC‐CC. None of the imaging features helped to identify the cHCC‐CC tumor and they mimicked either HCC or CC, depending on the degree of glandular differentiation expressed histologically. In our cHCC‐CC LT recipients, the 1‐, 3‐ and 5‐year cumulative survival probabilities were 79%, 66% and 16%, respectively with a 5‐year survival comparable to or better than LT for intrahepatic CC but poorer than LT for HCC following the Milan criteria. Conceivably explained by its cholangiocarcinoma component the LT outcome for this rare and hard to diagnose tumor appears poor.     

Surgical Techniques and Long-Term Outcomes of Living Donor Liver Transplantation for Budd-Chiari Syndrome

We have developed the surgical techniques of living donor liver transplantation (LDLT) for Budd-Chiari syndrome (BCS) and evaluated long-term outcomes including specific complications. BCS is characterized by hepatic outflow obstruction. Liver transplantation from living donors poses a unique challenge as liver replacement therapy does not replace the retrohepatic segment of inferior vena cava (IVC). We have performed 1105 LDLTs in 1055 patients from January 1990 to March 2005. Of these, nine patients (eight males and one female) underwent LDLT for BCS. Five out of nine patients underwent LDLT as a primary procedure and four patients had received other treatments before transplantation. Eight patients presented with chronic and one with fulminant liver failure. Predisposing factors were identified in three patients. IVC reconstruction without patch plasty was performed on four patients. Five patients needed cavoplasty using a replacement vein graft. Of the nine patients, seven are alive at a median follow-up of 58 months (range 1 month to 15.2 years) with two patients developing recurrent hepatic vein stenosis which were treated successfully with metallic stent placement. Two patients died: one from multiorgan failure and the other from pulmonary embolism secondary to disease recurrence. LDLT for BCS is highly effective by using modified cavoplasty and provides good long-term survival which may be obtained by life-long anticoagulant treatment and nonsurgical interventions.     

30例原位肝移植手术临床分析

目的总结原位肝移植手术的临床经验,探讨提高肝移植手术效果的措施。方法回顾分析2003年12月~2006年3月30例原位肝移植患者的临床资料,均采用同种异体(尸体供肝)原位全肝移植,其中经典式24例,背驮式6例。结果30例手术全部成功,供肝热缺血时间平均4.5 m in,冷缺血时间5 h。围术期死亡3例。与手术相关主要并发症有:腹腔内出血4例,门静脉狭窄2例,胆道吻合口狭窄1例、胰漏1例、胸腔积液5例。27例获随访3~30个月,1例术后3月死于胆道铸型综合征并感染,肝癌复发2例。结论确保供肝质量是肝移植成功的前提,良好的血管和胆管重建技术是肝移植手术成功的关键,专业化的围手术期处理可有效地减少并发症的发生。     

Biliary Strictures in 130 Consecutive Right Lobe Living Donor Liver Transplant Recipients: Results of a Western Center

Biliary strictures remain the most challenging aspect of adult right lobe living donor liver transplantation (RLDLT). Between 04/2000 and 10/2005, 130 consecutive RLDLTs were performed in our center and followed prospectively. Median follow-up was 23 months (range 3-67) and 1-year graft and patient survival was 85% and 87%, respectively. Overall incidence of biliary leaks (n = 19) or strictures (n = 22) was 32% (41/128) in 33 patients (26%). A duct-to-duct (D-D) or Roux-en-Y (R-Y) anastomosis were performed equally (n = 64 each) with no difference in stricture rate (p = 0.31). The use of ductoplasty increased the number of grafts with a single duct for anastomosis and reduced the biliary complication rate compared to grafts >/=2 ducts (17% vs. 46%; p = 0.02). Independent risk factors for strictures included older donor age and previous history of a bile leak. All strictures were managed nonsurgically initially but four patients ultimately required conversion from D-D to R-Y. Ninety-six percent (123/128) of patients are currently free of any biliary complications. D-D anastomosis is safe after RLDLT and provides access for future endoscopic therapy in cases of leak or stricture. When presented with multiple bile ducts, ductoplasty should be considered to reduce the potential chance of stricture.