内镜逆行胰胆管造影术治疗肝移植术后并发胆管结石受者临床分析

目的探讨肝移植术后并发胆管结石受者行内镜逆行胰胆管造影术(ERCP)治疗的安全性和有效性。 方法回顾性分析南京军区福州总医院肝胆外科2005年1月至2015年12月肝移植术后并发胆管结石受者的临床资料。24例受者胆管结石确诊主要依据T管造影、MRCP或ERCP。确诊胆管结石受者均采用ERCP下行球囊扩张联合胆道塑料支架置入治疗，术中采用地西泮镇静，同时密切监测生命体征。观察肝移植术后并发胆管结石受者结石类型、狭窄情况、ERCP治疗情况及其治疗前后肝功能指标变化。采用Wilcoxon符号秩和检验比较ERCP治疗前后受者血清总胆红素(TBil)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)、ALT和AST水平变化。P<0.05为差异有统计学意义。 结果24例受者中胆总管结石20例(包括单纯胆总管结石11例、胆总管结石合并胆管狭窄9例)，肝内、外胆管结石4例。肝移植至并发胆管结石平均间隔时间(604±215)d。19例发生在术后12～66个月，余5例发生在术后3个月内。11例胆总管结石受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架引流治疗，治疗有效。9例胆总管结石合并胆管狭窄受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架＋鼻胆管引流治疗，其中8例治疗有效；1例因重度胆管狭窄，反复内镜取石不能取尽，继发感染再次行肝移植。4例肝内、外胆管结石受者均采用柱状球囊扩张＋取石篮取石＋左、右肝管置入内支架＋鼻胆管引流治疗，治疗有效。受者内镜治疗后血清TBil、ALP和GGT分别为31、179和247 mmol/L，均低于内镜治疗前水平(43、273和385 mmol/L)，差异均有统计学意义(z＝0.042、0.001、0.004，P均<0.05)。截至2017年12月，24例受者随访时间为1～2年，4例因原发性肝癌复发分别于肝移植术后9、5、34、25个月死亡，1例因上消化道出血于肝移植术后34个月死亡，1例因重度胆管狭窄行二次肝移植并于2014年4月因肝脓肿继发感染性休克死亡，1例因感染性休克于肝移植术后33个月死亡，其余17例随访期间未见结石再发。 结论内镜下行球囊扩张联合塑料支架置入治疗原位肝移植术后并发胆管结石安全、有效，可作为目前原位肝移植术后并发胆管结石的首选治疗方案。

Endoscopic treatment of biliary stones in patients with orthotopic liver transplantation

ObjectiveTo investigate the safety and efficacy of endoscopic retrograde cholangio-pancreatography (ERCP) in the treatment of recipients with biliary stones after liver transplantation. MethodsClinical data of 24 patients undergoing ERCP treatment for duct stones after liver transplantation in the Fuzhou General Hospital of People′s Liberation Army between January 2005 and December 2015 were analyzed retrospectively. Recipients who with biliary stones were all diagnosed with T-tube cholangiography, magnetic resonance cholangiopancreatography or ERCP. Recipients who were confirmed were all treated with balloon dilatation plus balloon dilatation placement. Diazepam was used for sedation during operation and vital signs were supervised at the same time. Indexes including types of biliary stones, narrow situation, ERCP treatment condition and liver function indexes before and after transplantation were all observed. The Wilcoxon signed-rank test was used to compare with serum TBil, ALP, GGT, ALT and AST levels before and after ERCP treatment. ResultsTwenty of common bile duct stones in 24 patients (including 11 patients of common bile duct stones, 9 patients of common bile duct stones and bile duct stenosis), and 4 patients of intrahepatic and extrahepatic bile duct stones. The median time from liver transplantation to bile duct stones diagnosis was (604±215) d. 19 patients developed between 12 to 66 months after liver transplantation, and the remaining 5 patients developed within 3 months after liver transplantation. Eleven patients of common bile duct stones were successfully removed with endoscopic balloon dilation combined with stenting, 9 patients of common bile duct stones complicated with bile duct stenosis were treated with endoscopic balloon dilation, stone basket stone removal, combined with stenting and internal bile duct drainage. Among them, 8 patients of nine were successfully removed; 1 patient was re-transplanted with liver transplantation due to severe biliary stricture and secondary infection. Four patients of intrahepatic and extra-biliary stones were treated with endoscopic balloon dilation, stone basket removal stone , left and right hepatic duct placement internal stent + bile duct drainage. TBil, ALP and GGT were 31, 179 and 247 mmol/L after endoscopic treatment. Both were lower than the pre-endoscopic treatment levels (43, 273, and 385 mmol/L). As of December 2017, 24 patients were followed up for 1 to 2 years, 4 patients died of primary liver cancer at 9, 5, 34 and 25 months after liver transplantation, and 1 patient had developed upper gastrointestinal bleeding and died at 34 months after liver transplantation, 1 patient underwent secondary liver transplantation due to severe biliary stenosis and died of septic shock due to liver abscess in April 2014, and 1 patient underwent septic shock after liver transplantation. No stones were found in the remaining 17 patients during the follow-up period. ConclusionsEndoscopic balloon dilation plus stent placement was safe and effective for recipients with biliary stones after liver transplantation.ERCP can be used as the first-line approach for biliary stones after orthotopic liver transplantation.