肝移植术后胆道并发症的内镜治疗

胆道并发症是影响肝移植受者和提高移植肝存活率的主要原因,目前常见的胆道并发症主要有胆管狭窄、胆漏、胆管结石、胆管炎、乳头肌功能紊乱等.现对我院肝移植术后出现胆道并发症的16例患者进行回顾性分析,总结内镜治疗肝移植术后胆道并发症的疗效,报道如下.     

肝移植与胆管并发症——原位肝移植后胆管并发症的治疗

背景：尽管原位肝移植的存活率有所改善，但胆管并发症仍然是导致其死亡的主要因素。本研究的目的是对苏格兰肝移植中心病例的发病率、治疗回顾性分析以寻求胆管并发症的最佳治疗途径。     

肝移植术后胆道并发症的内镜治疗

随着外科技术、麻醉和新型免疫抑制剂的发展，肝移植成功率已达到了一个较高的水准，但肝移植术后的胆道并发症仍然是肝移植的一大挑战，严重影响肝移植患者的生存率和生活质量。作为非手术治疗的主要形式，内镜治疗技术越来越多的用于肝移植术后胆道并发症的诊治。本文通过对13例内镜治疗的肝移植术后胆道并发症患者临床资料的回顾性分析，总结内镜治疗肝移植术后胆道并发症的经验。     

原位肝移植术后胆道并发症的内镜治疗

原位肝移植术后胆道并发症是肝移植后常见的并发症，胆道并发症临床上处理较棘手，再次手术创伤大，并发症多、死亡率高、重复性差。近几年，随着内镜技术的使用，使肝移植术后胆道并发症的治疗倾向于简单。我院共行9例同种异体原位肝移植术，3例术后发生胆道并发症，通过内镜治疗，取得近期满意疗效，结合文献复习，以探讨内镜治疗的价值，为临床提供参考。     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。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的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。     

原位肝移植术后胆管狭窄的诊断和治疗

胆管狭窄一直是胆道外科棘手的问题，肝移植术后也面临着同样的问题，手术解决较困难，而内镜技术的应用给胆管狭窄的诊治带来了新方法。[第一段]     

内镜治疗术后胆漏和继发胆管狭窄

目的 探讨内镜治疗手术后并发胆漏和继发胆管狭窄的方法及效果。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,继续保留原有胆道、腹腔引流。待胆道、腹腔引 流停止1-2周证实胆漏愈合后拔管,伴有胆道狭窄的患者在拔除鼻胆引流管后置入塑料内支架,持 续扩张2-3个月。结果 22例胆漏患者鼻胆引流3-4周后胆漏处均闭合,13例胆管狭窄置入内支 架者,10例支架取出后狭窄解除,2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,术后仍有胆道感染症状反复出现。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。     

一例肝移植患者胆管内支架术后再狭窄的内镜治疗

患者女性，23岁。16年前确认肝窦状核变性。肝功能Child-pugh C级。于2000年3月行同种异体肝移植术，脾切除术。术后3个月，患者逐渐出现全身皮肤黄染，粪便呈灰白色。[第一段]     

肝移植术后胆管狭窄的防治

34例同种异体原位肝移植术患者,术后发生胆管狭窄4例。均曾行内镜、鼻胆管引流、球囊扩张、内支架置入治疗;其中2例行二次肝移植术,1例行胆肠吻合术．1例持续行内镜治疗。该并发症重在预防,一旦发生可采用上述不同方法治疗。     

肝移植术后胆管狭窄内支架术一例

患者女性，19岁。12年前确诊肝豆状核变性。肝功能Child-pugh C级，行同种异体原位肝移植术，脾切除术。术后7周经胆道引流管造影见肝内外胆管显影清晰，无胆管扩张或狭窄，肝功能化验多项值均在正常范围，拔除引流管。术后3个月，患者逐渐出现周身黄染，大便灰白，肝功能检查；丙氨酸转氨酶260U/L，天冬氨酸转氨酶210U/L,γ-谷氨酰     

Current management of biliary complications after liver transplantation: Emphasis on endoscopic therapy

Biliary complications occur in 5-25% of patients after liver transplantation and represent a major source of morbidity in this group of individuals. The major risk factor for most of these complications is ischemia of the bile tree usually due to obstruction or vascular insufficiency of the hepatic artery. The most common complications include biliary strictures (anastomostic and nonanastomotic), bile leaks, and biliary filling defects. The initial diagnostic approach starts with a high index of suspicion along with an abdominal ultrasound and Doppler exam. Magnetic resonance imaging is highly sensitive and is usually reserved for confirmation. The vast majority of these complications can be successfully treated with endoscopic retrograde cholangiography, however if this procedure cannot be performed a percutaneous approach or surgery is recommended. Nonanastomotic strictures and living donor recipients present a less favorable response to endoscopic management. This review focuses on the current diagnostic and therapeutic approaches for the management of biliary complications after liver transplantation.     

Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature

Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation(LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.     

肝移植后胆道并发症的预防及其治疗

近年来肝移植技术日趋完善,但胆道并发症仍很常见.常见胆道并发症包括胆道狭窄、胆漏、胆管炎、胆道结石等,发生率为10%～15%[1],在有些移植中心甚至更高,严重影响肝移植的整体疗效.虽然胆道并发症一般并不影响患者生命,但约1%～3%的胆道并发症最终导致移植物功能的丧失[2].有效的预防,及时正确的诊断及处理,可以有效降低胆道并发症的发生率,并最大限度减少对移植物功能的影响.     

Management of biliary complications after liver transplantation

Biliary complications(BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.     

改良多点引流法治疗肝移植术后胆道并发症的价值

目的:探讨改良多点引流法对肝移植术后胆道并发症的影响。方法:研究对象为2018年5月—2020年5月上海中医药大学附属曙光医院肝移植术后因胆道并发症行经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）治疗的125例患者。按EXCEL产生随机数...     

肝移植术后胆道并发症的临床及病理分析

目的探讨原位肝移植术后胆道并发症的常见病理组织学及临床特点.方法回顾性分析1998年9月-2005年6月的肝移植术后胆道并发症患者173例（235例次）肝穿刺活组织检查的病理和临床资料.结果肝移植后胆道并发症发生于术后3～2 920 d,其中1～30 d、31～90 d、91～180 d、180 d以后的发生率分别为49.71%（86/173）、17.92%（31/173）、4.62%（8/173）、27.74%（48/173）.炎症类占72.25%（125/173）,行肝穿刺活组织检查171例次;梗阻类占27.74%（48/173）,行肝穿刺活组织检查64例次.病理表现以小叶间胆管上皮细胞变性及炎细胞浸润、汇管区炎症、小胆管增生、汇管区纤维化、小胆管及肝细胞胆汁淤积为主.上述病理表现在炎症和梗阻两类并发症患者中的检出率分别为100.00%（171/171）和100.00%（64/64）、100.00%（171/171）和96.87%（62/64）、9.36%（16/171）和73.44%（47/64）、3.51%（6/171）和79.69%（51/64）、50.29%（86/171）和87.50%（56/64）、63.16%（108/171）和93.75%（60/64）.结论原位肝移植术后胆道并发症以炎症类居多,多发生于术后30 d内,梗阻类多见于术后90 d,预后较差.肝穿刺活组织检查的病理组织学表现在胆道并发症的分类、程度评估及鉴别诊断中具有重要价值.     

Liver biochemistry profile, significance and endoscopic management of biliary tract complications post orthotopic liver transplantation

AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy. METHODS: Patients who developed biliary complications were analysed in detail for the clinical information,laboratory tests,treatment offered,response to it,follow up and outcomes. The profile of liver enzymes was determined. The safety,efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed. RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be > 3 times (388.1 ± 70.9 U/mL vs 168.5 ± 34.2 U/L,P = 0.007) and SAP > 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L,P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic strictures in 28 (40%). Sustained success was achieved in 26 (81%) patients. CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early,non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.     

Endoscopic treatment of biliary complications after liver transplantation

AIM： To evaluate the efficacy of endoscopic treatment in patients who undergo OLTx or LRLTx and develop biliary complications. METHODS： This is a prospective, observational study of patients who developed biliary complications, after OLTx and LRLTx, with duct-to-duct anastomosis performed between June 2003 and June 2007. Endoscopic Retrograde Cholangiopancreatography （ERCP） was considered unsuccessful when there was evidence of continuous bile leakage despite endoscopic stent placement, or persistence of stenosis after i year, despite multiple dilatation and stent placement. When the ERCP failed, a percutaneous trans-hepatic approach （PTC） or surgery was adopted. RESULTS： From June 2003 to June 2007, 261 adult patients were transplanted in our institute, 68 from living donors and 193 from cadaveric donors. In the OLTx group the rate of complications was 37.3%, while in the LRLTx group was 64.7%. The rate of ERCP failure was 19.4% in the OLTx group and 38.6% in LRLTx group. In OLTx group, i patient was retransplanted and 8 patients died. In the LRLTx group, 2 patients underwent OLTx and 8 patients died. The follow-up was 23.3±13.13 mo and 21.02± 14.10 mo, respectively.CONCLUSION： Albhough ERCP is quite an effective mode of managing post-transplant bile duct complications, a significant number of patients need other types of approach. Further prospective studies are necessary in order to establish whebher obher endoscopic protocols or new devices, could improve bhe current results.     

肝移植术后胆道并发症的磁共振评价

目的:探讨磁共振胰胆管成像(MRCP)联合MR断面图像在诊断肝移植术后胆道并发症中的应用价值.方法:对57例肝移植术后怀疑有胆道并发症的患者行MR检查,分析其表现,并与手术、胆道造影、肝脏活检和,临床随访结果进行对照.比较MRCP和MRCP联合MR断面图像对胆道并发症诊断的确诊率.结果:57例患者胆道并发症发生率64.9%(37/57).其中吻合口狭窄患者14例,非吻合口狭窄8例.孤立性胆道结石或胆泥淤积5例,胆管炎及胆管周围炎3例,胆汁湖/胆汁瘤3例,供体-受体胆总管不匹配3例,肝外胆管吻合后过长1例.对胆道并发症诊断的准确率,MRCP为75.7%(28/37),MRCP联合MRI断面图像为94.6%(35/37),两者差别有统计学意义(P<0.05).结论:MRCP联合MR断面图像能提高胆道并发症诊断的准确性.