肝臟移植術(shù)后膽道并發(fā)癥的防治

1、肝臟移植術(shù)后膽道并發(fā)癥的防治               作者：史憲杰 周寧新 紀(jì)文斌 陳永亮 段偉東 楊滔 董家鴻 黃志強【摘要】  目的 探討原位肝移植術(shù)后膽道并發(fā)癥的防治方法。方法 回顧性分析我院2002年6月至2006年9月完成的160例肝移植資料，其中行膽管空腸RouxenY吻合術(shù)10例、膽管膽管端端吻合術(shù)150例。術(shù)后超聲、CT、MRI、膽道造影和血清學(xué)檢查了解移植肝形態(tài)、血流動力學(xué)及肝功能。98例隨訪248個月。結(jié)果 發(fā)生膽道并發(fā)癥

2、24例(18%)，其中因肝動脈狹窄或栓塞引起的膽漏、膽道狹窄和肝內(nèi)局限性壞死7例(5例經(jīng)溶栓及內(nèi)支架介入治療后恢復(fù)、2例因肝功能衰竭并感染死亡)；膽道狹窄8例(6例經(jīng)再次手術(shù)和ERCP及PTCD膽道內(nèi)、外支撐等介入治療恢復(fù)、2例膽管消融并發(fā)膽管炎死亡)；膽漏7例(6例經(jīng)再次手術(shù)或超聲引導(dǎo)下穿刺置管引流治愈、1例保守治愈)；膽道鑄型2例(均經(jīng)再次手術(shù)治愈)。結(jié)論 供肝的質(zhì)量和完整的動脈采集及膽道黏膜的保護，精細(xì)的動脈和膽管吻合是預(yù)防肝移植術(shù)后膽道并發(fā)癥的關(guān)鍵。肝動脈溶栓、ERCP及PTCD膽道內(nèi)支撐等是治療膽道并發(fā)癥的有效手段。 【關(guān)鍵詞】  肝臟移植； 膽道并發(fā)癥 

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    肝臟移植目前已成為治療終末期肝膽疾病的有效手段。但肝移植術(shù)后膽道并發(fā)癥是導(dǎo)致肝移植失敗的主要原因之一，其發(fā)生率高達15%34%1。因此，預(yù)防和治療膽道并發(fā)癥對提高肝移植療效和改善患者生活質(zhì)量有重要的臨床意義。本文結(jié)合我院2002年6月至2006年9月160例肝移植患者臨床資料，探討肝移植術(shù)后膽道并發(fā)癥的防治方法。    1  資料和方法    1.1  一般資料 

10、0;  本組160例，男142例，女18例；其中成人159例，兒童1例；年齡870歲，中位年齡46.5歲。成人均為尸體供肝移植，熱缺血時間412 min，冷缺血時間416 h。兒童為親體肝移植，供肝為受者母親的左半肝，供肝熱缺血時間為0，冷缺血時間為140 min。供受者間ABO血型相符160例。供肝冷灌注和保存用4 腎保存液3000 ml、UW液2000 ml?；颊咴l(fā)?。郝砸倚椭匕Y肝炎29例，終末期肝硬化27例，肝硬化合并肝癌81例, 暴發(fā)性肝功能衰竭11例，遺傳代謝性疾病3例，酒精性肝硬化4例，不能手術(shù)切除的巨大肝腫瘤5例。    1.2

11、0; 手術(shù)方式    經(jīng)典原位肝移植4例，背馱式肝移植156例，所有病例均未作體外靜脈轉(zhuǎn)流。修整供肝時繼續(xù)以4 UW液和生理鹽水行肝動脈、門靜脈和膽道的灌洗，供肝動脈如有變異，均以80 Prolene線進行整形至理想吻合口徑(圖1)。病肝切除后，供肝植入重建順序：肝臟流出道、門靜脈、肝動脈和膽道。肝靜脈流出道采用腔靜脈以40 Prolene線側(cè)側(cè)吻合；門靜脈以50 Prolene線端端吻合；肝動脈以70、80 Prolene線端端連續(xù)吻合；膽道重建方式：供肝膽管盡量剪至肝門血運豐富處，以40整形線或50/60 PDS線連續(xù)縫合。全組行膽管空腸RouxenY吻合術(shù)1

12、0例；膽管膽管端端吻合150例，其中放置膽道內(nèi)支撐管引流28例。     1.3  術(shù)后處理    應(yīng)用FK506或環(huán)孢素A、驍悉和強的松三聯(lián)或二聯(lián)抗排斥治療。圍手術(shù)期常規(guī)抗感染、抗病毒、適當(dāng)抗凝，同時加強利膽和保肝對癥治療。乙肝病毒陽性患者術(shù)后服用拉米夫定100 mg/d加小劑量人乙型肝炎免疫球蛋白。術(shù)后超聲、CT、MRI、膽道造影和血清學(xué)等檢查了解移植肝臟形態(tài)、血流動力學(xué)及肝臟功能情況。    2  結(jié)果    全組發(fā)生膽道并發(fā)癥24例(18%)，其中因肝動脈狹窄或栓塞引起的膽漏、膽道狹窄和肝內(nèi)局限性壞死7例；膽道狹窄8例(單純吻合口狹窄3例、肝內(nèi)膽管彌漫性狹窄3例、吻合口狹窄伴肝內(nèi)膽