肝移植胆系并发症的防治

目的 探讨原位肝移植胆系并发症的预防及治疗。方法 回顾性分析1999年2月至2002年12月完成的95例次原位肝移植。门静脉、下腔静脉转流下原位肝移植12例,背驮式肝移植78例,活体部分肝移植5例。胆道重建：胆管对端吻合91例,放置胆道外引流55例,36例未放置胆道引流。胆管空肠Roux-en-Y吻合4例。胆管吻合及胆肠吻合应用5旬或6-0 Vicryl缝线或PDS缝线间断或连续缝合。术后以血清学检查、超声、胆道造影等手段随访。结果 共发生胆系并发症7例,发生率7．3％。2例术后7、10d吻合口胆漏,致胆汁性腹膜炎,再次手术引流。1例术后1个月胆管吻合口狭窄,内窥镜下支架内支撑治愈。2例拔除T管时胆漏,1例保守治愈,1例腹腔镜下缝合窦道、腹腔引流治愈。1例术后5个月因胆管消融、胆管炎死亡。1例术后10d因肝动脉血栓形成继发胆管坏死后死亡。74例随访1-42个月(平均11．4个月),胆道造影及(或)超声检查未见肝内外胆管狭窄,无胆泥、胆石形成,血清学检查提示肝功能状态良好。结论供肝切取时保护胆管黏膜及肝外胆管动脉供给,实现精细胆管黏膜对黏膜无张力对端吻合是预防胆系并发症的关键。内窥镜下狭窄段胆管扩张、内支撑是治疗肝移植肝外胆管狭窄的有效手段。

Prevention and management of biliary complications following orthotopic liver transplantation

Objective To prevent and manage biliary complications after orthotopic liver transplantation(OLT). Methods Ninety-five patients of OLT performed at our institute from February, 1999 to December 2002 were retrospectively analysed. Recipient operation was performed using standard method combined with veno-venous bypass in 12 patients and piggyback method in 78 patients and living-related liver transplantation in 5 patients. Biliary reconstruction was performed by end-to-end choledochocholedochostomy(C-C)over a T-tube in 55 patiens and without a T-tube in 36 patients while the remaining 4 patients underwent Roux-en-Y choledochojejunostomy(CRY). C-C and CRY were performed by the interrupted or contiuous suture with 5-0 or 6-0 Vicryl or PDS. Routine examination of liver function, Doppler ultrasonography and cholangiography were performed during the follow-up period. Results Biliary complications occurred in 7 patients (7.3%). Two patients with bile leakage at the anastomotic site developed biliary peritonitis on the seventh and tenth postoperative day and needed reoperation. One patient developed anastomotic biliary stricture one month after the operation and was cured by endoscopic stenting . Two patients developed bile leakage after T-tube removal. One of the two patients was treated conservatively and the other underwent a exploratory laparotomy to ligate the T-tube tract and drain the peritoneal cavity. One patient died of biliary vast syndrome five months after OLT and one patient died of biliary tract necrosis secondary to hepatic artery thrombosis on the tenth postoperative day. One - 42-month (mean 11.4 months) follow-up revealed no biliary stricture in 74 patients. No biliary stone and biliary sludge were detected by Doppler ultrasound and/or cholangiography. Serological examinations proved that liver grafts functioned well in these patients. Cfonclusions To prevent biliary complications, it is crucial to protect biliary mucosa and arterial blood supply of the common bile duct while harvesting the graft and to obtain perfect mucosa-to-mucosa apposition of no-tension end-to-end anastomosis of the bile duct. Endoscopic dilation and stent ing are effective for post-OLT extrahepatic biliary stricture.