肝脏移植术后胆道并发症的防治

1、肝脏移植术后胆道并发症的防治               作者：史宪杰 周宁新 纪文斌 陈永亮 段伟东 杨滔 董家鸿 黄志强【摘要】  目的 探讨原位肝移植术后胆道并发症的防治方法。方法 回顾性分析我院2002年6月至2006年9月完成的160例肝移植资料，其中行胆管空肠RouxenY吻合术10例、胆管胆管端端吻合术150例。术后超声、CT、MRI、胆道造影和血清学检查了解移植肝形态、血流动力学及肝功能。98例随访248个月。结果 发生胆道并发症

2、24例(18%)，其中因肝动脉狭窄或栓塞引起的胆漏、胆道狭窄和肝内局限性坏死7例(5例经溶栓及内支架介入治疗后恢复、2例因肝功能衰竭并感染死亡)；胆道狭窄8例(6例经再次手术和ERCP及PTCD胆道内、外支撑等介入治疗恢复、2例胆管消融并发胆管炎死亡)；胆漏7例(6例经再次手术或超声引导下穿刺置管引流治愈、1例保守治愈)；胆道铸型2例(均经再次手术治愈)。结论 供肝的质量和完整的动脉采集及胆道黏膜的保护，精细的动脉和胆管吻合是预防肝移植术后胆道并发症的关键。肝动脉溶栓、ERCP及PTCD胆道内支撑等是治疗胆道并发症的有效手段。 【关键词】  肝脏移植； 胆道并发症 

3、0;  【Abstract】  Objective  To investigate the prevention and management methods of biliary complications after orthotopic liver transplantation (OLT). Methods  A retrospective analysis was done on 160 patients treated with OLT from June 2002 to September 2006 in our department. B

4、iliary reconstruction was performed by Rouxeny choledochojejunostomy in 10 patients and endtoend anastomosis of bile duct in 150. Doppler ultrasonography, CT, MRI, cholangiography and serologic examination were performed to understand morphous, hemodynamics and function of the transplanted liver aft

5、er operation. All patients were followed up for 248 months. Results  Biliary complications occurred in 24 patients (18%) including 7 with biliary fistula, biliary stricture and hepatic local necrosis due to the hepatic artery stricture or thrombosis, of whom 5 recovered after thrombolysis and e

6、ndoprosthesis such as hepatic artery antithrombosis or placement of intravascular stent but 2 died of hepatic failure complicated by infection. Biliary stricture occurred in 8 patients, of whom 6 recovered after reoperation and interventional therapy with ERCP and PTCD but 2 died of complicated chol

7、angitis. Biliary fistula occurred in 7 patients, of whom 6 were cured by reoperation and biliary drainage via B mode ultrasonography and 1 recovered with conservative therapy. Intrabiliary moldings occurred in 2 patients who were cured by reoperation. Conclusions  The donors quality, intact art

8、ery, protection of biliary mucosa and fine anastomose of artery and bile duct are key to preventing biliary complications following OLT. Intervention techniques such as hepatic artery antithrombosis, ERCP and PTCD are effective for treating biliary complications.    【Key words】 

9、Liver transplantation;  Biliary complication    肝脏移植目前已成为治疗终末期肝胆疾病的有效手段。但肝移植术后胆道并发症是导致肝移植失败的主要原因之一，其发生率高达15%34%1。因此，预防和治疗胆道并发症对提高肝移植疗效和改善患者生活质量有重要的临床意义。本文结合我院2002年6月至2006年9月160例肝移植患者临床资料，探讨肝移植术后胆道并发症的防治方法。    1  资料和方法    1.1  一般资料 

10、0;  本组160例，男142例，女18例；其中成人159例，儿童1例；年龄870岁，中位年龄46.5岁。成人均为尸体供肝移植，热缺血时间412 min，冷缺血时间416 h。儿童为亲体肝移植，供肝为受者母亲的左半肝，供肝热缺血时间为0，冷缺血时间为140 min。供受者间ABO血型相符160例。供肝冷灌注和保存用4 肾保存液3000 ml、UW液2000 ml。患者原发病：慢性乙型重症肝炎29例，终末期肝硬化27例，肝硬化合并肝癌81例, 暴发性肝功能衰竭11例，遗传代谢性疾病3例，酒精性肝硬化4例，不能手术切除的巨大肝肿瘤5例。    1.2

11、0; 手术方式    经典原位肝移植4例，背驮式肝移植156例，所有病例均未作体外静脉转流。修整供肝时继续以4 UW液和生理盐水行肝动脉、门静脉和胆道的灌洗，供肝动脉如有变异，均以80 Prolene线进行整形至理想吻合口径(图1)。病肝切除后，供肝植入重建顺序：肝脏流出道、门静脉、肝动脉和胆道。肝静脉流出道采用腔静脉以40 Prolene线侧侧吻合；门静脉以50 Prolene线端端吻合；肝动脉以70、80 Prolene线端端连续吻合；胆道重建方式：供肝胆管尽量剪至肝门血运丰富处，以40整形线或50/60 PDS线连续缝合。全组行胆管空肠RouxenY吻合术1

12、0例；胆管胆管端端吻合150例，其中放置胆道内支撑管引流28例。     1.3  术后处理    应用FK506或环孢素A、骁悉和强的松三联或二联抗排斥治疗。围手术期常规抗感染、抗病毒、适当抗凝，同时加强利胆和保肝对症治疗。乙肝病毒阳性患者术后服用拉米夫定100 mg/d加小剂量人乙型肝炎免疫球蛋白。术后超声、CT、MRI、胆道造影和血清学等检查了解移植肝脏形态、血流动力学及肝脏功能情况。    2  结果    全组发生胆道并发症24例(18%)，其中因肝动脉狭窄或栓塞引起的胆漏、胆道狭窄和肝内局限性坏死7例；胆道狭窄8例(单纯吻合口狭窄3例、肝内胆管弥漫性狭窄3例、吻合口狭窄伴肝内胆