肝移植术后缺血性胆道病变的介入治疗探讨

目的  探讨肝移植术后缺血性胆道病变(ITBL)患者接受介入治疗的安全性及疗效。方法  回顾性分析2006年1月至2014年2月在中山大学附属第三医院介入血管科接受介入治疗的76例肝移植术后ITBL患者的影像及临床资料。按胆道造影表现分为3组:肝门区狭窄组(28例), 肝内多发狭窄组(42例), 胆汁瘤组(6例)。治疗方式包括单纯经皮经肝胆管引流术(PTBD)、PTBD配合球囊扩张、PTBD配合球囊扩张及胆道内支架术。引流方式包括胆道外引流及胆道内外引流。术后随访并观察疗效及胆道并发症。结果  76例患者的PTBD首次成功率为97%(74/76)。介入治疗的总体治愈率、好转率及无效率分别为21%(16/76)、51%(39/76)、28% (21/76)。其中, 肝门区狭窄组治愈10例(36%), 好转16例(57%), 无效2例(7%), 治疗有效22例(93%); 多发性狭窄组治愈6例(14%), 好转21例(50%), 无效15例(36%), 治疗有效27例(64%); 胆汁瘤组好转2例(2/6), 无效4例(4/6)。肝门区狭窄患者的疗效优于多发性狭窄患者(P < 0.05), 多发性狭窄患者的疗效优于胆汁瘤患者(P < 0.001)。引流管期间主要并发症为胆道感染, 其中外引流及内外引流胆道感染发生率分别为20%(13/64)及67%(8/12), 比较差异有统计学意义(P < 0.001)。结论  PTBD是治疗肝移植术后ITBL的安全、有效手段之一。结合球囊扩张及内支架置入可有效改善患者症状, 提高生存质量。采用胆道外引流可显著降低胆道感染发生率。

Interventional treatment for ischemic-type biliary lesion after liver transplantation

Objective To investigate the safety and efficacy of interventional treatment for ischemic-type biliary lesion(ITBL) after liver transplantation(LT). Methods The clinical and imaging data of 76 patients with ITBL after LT, who received interventional treatment in the Department of Interventional Vascular Radiology of the Third Affiliated Hospital of Sun Yat-sen University from January 2006 to February 2014, were retrospectively analyzed. On the basis of the cholangiographic appearance, patients were classified into 3 groups:hilar biliary stricture group(n=28), multifocal biliary stricture group(n=42), and biloma group (n=6). The modalities of interventional treatment were percutanous transhepatic biliary drainage(PTBD), PTBD combined with balloon dilation, PTBD combined with balloon dilation and plastic stent implantation. The methods of biliary drainage included external drainage and external-internal drainage. All the patients were followed up after treatment. The curative effect and biliary complication was observed. Results The first successful rate of PTBD was 97%(74/76). The total curative rate, improvement rate and ineffective rate of interventional treatment were 21%(16/76), 51%(39/76) and 28%(21/76). In hilar biliary stricture group, the cure, improvement and inefficacy rates were 36%(10/28), 57%(16/28)and 7%(2/28). The efficacy rate was 93%(22/28). In multifocal biliary stricture group, the cure, improvement and inefficacy rates were 14%(6/42), 50%(21/42)and 36%(15/42). The efficacy rate was 64%(27/42). In biloma group, 2 cases(2/6) were cured and treatment of 4 cases was ineffective. The efficacy of hilar biliary stricture group was better than that of multifocal biliary stricture group(P < 0.05). The efficacy of multifocal biliary stricture group was better than that of biloma group(P < 0.001). The main biliary complication was biliary tract infection during drainage. The rates of bile tract infections were 20%(13/64)and 67%(8/12) in patients with external drainage and external-internal drainage, respectively. There was significant difference between these two items (P < 0.001). Conclusions PTBD is a safe and effective therapeutic modality for ITBL after LT, which combined with balloon dilation and biliary stent implantation can improve patients' clinical symptoms, elevate patients' quality of life. The biliary external drainage can decrease the rate of biliary tract infection significantly.