肝移植术后早期黄疸的原因分析及处理体会

目的 分析肝移植术后早期黄疸的原因，总结诊断和处理体会。方法 17例患者肝移植术后早期出现黄疸20次，其中3例行背驮式肝移植，14例行经典式肝移植，术后应用他克莫司（FK506）、霉酚酸酯及泼尼松预防排斥反应。术后早期每日复查血液生化，当血清胆红素水平超过正常值时，立即行多普勒超声、血管造影等辅助检查，明确产生黄疸的原因，并进行针对性处理。结果 导致黄疸的原因，5例次为免疫抑制剂中毒，其中2例次停用FK5063～5d，1例次将FK506更换为西罗莫司，2例次减少FK506的用量，黄疸消退；5例次为急性排斥反应，经激素冲击治疗，2～4周黄疸消退；6例次为胆道狭窄、梗阻，其中1例次未进行处理，3d后黄疸逐渐消退，另5例次中，4例次采用内镜下逆行胰胆管造影置管术（ERCP）及内镜下鼻胆管引流，次日血清胆红素下降，另1例次ERCP效果不佳，2个月后行胆肠吻合术；1例次为肝动脉栓塞，立即手术取栓；1例次为肝右静脉栓塞，用尿激酶溶栓；1例次为静脉营养所致黄疸，肝功能恶化；1例次因供肝有轻微肝硬化，药物中毒后，黄疸逐渐加重，停用免疫抑制剂，行血浆吸附治疗，效果不佳。结论 肝移植术后早期黄疸常见，原因多为免疫抑制剂中毒、急性排斥反应、胆道狭窄及阻塞、肝动脉栓塞等；产生黄疸的原因需根据生化指标、多普勒超声、放射学检查以及肝穿刺活检判断；针对黄疸的产生原因进行针对性治疗。

Treatment of perioperative jaundice in liver transplantation

Objective To explore the etiologies,diagnosis and treatment principles of perioperative jaundice in liver transplantation.Methods Seventeen cases of liver transplant patients who experienced perioperative jaundice in the year 2004 were reviewed.Results Five out of 17 patients developed(immuno)-suppressant intoxication,5 acute rejection,6 biliary stricture,one hepatic artery thrombosis,one hepatic vein thrfombosis,one parenteral nutrition and one marginal donor organ and so on.The(patients) with acute(rejection) was treated with methylprednisolone salvage regimen and they were all(reversible),but jaundice(decreased) slowly and in the end was normal within 2 to 4 weeks.Immuno(suppressant) intoxication was(treated) through reduction,change and withdrawal of(immunosuppre-)(ssants,and jaundice) gradually became normal in a few days.Biliary stricture was treated first through(endoscopic) retrograde cholangio-pancreatography((ERCP)) and endoscopic nasobiliary drainage((ENBD)),one case was later treated with Roux-en-Y choledochojejunostomy,one case was treated through(ERCP) and ENBD three times,and the results were all satisfactory.Hepatic arterial(throm-)(bosis was immediately) treated via operational removal of intravascular thrombosis,and the patient recovered soon.Hepatic vein thrombosis,which blocked incompletely and was treated by thrombolysis,was not changeable,but liver function became normal.Because of parenteral nutrition and marginal donor(organ),jaundice of 2 cases was treated through serum exchange/absorbent,due to shortage of money and donor organ,jaundice continued to increase,so the relatives gave up the further treatment.(Conclusions) Jaundice is commonly seen perioperatively in liver transplantation.The etiologies include drug-(related) intoxication,acute rejection,biliary stricture,hepatic vascular thrombosis and so on.Consecutive biochemistry monitoring and Doppler ultrasonography,sometimes selectively in com-(bination with radiology,) may confirm the diagnosis of jaundice.According to the etiologies,some()measurements of treatment show good results.The conservative treatment is first advocated,and the operation(including) retransplantation is selectively performed.