肝移植手术相关并发症的防治

Prophylaxis and treatment of operation-correlated complications in orthotopic liver transplantation

目的总结和探讨原位肝移植手术相关并发症发生的原因、预防及治疗。方法对1993年4月至2004年12月所实行的647例次原位肝移植患者的临床资料进行回顾性分析。结果肝移植手术后共发生并发症73例,发生率11.3%(73/647),包括血管并发症39例(6.0%,39/647),其中肝动脉23例(3.6%),门静脉6例(0.9%),腔静脉10例(1.5%),其中腔静脉并发症均发生在非腔静脉整形患者;放置内支架治疗肝动脉狭窄2例,均成功;肝动脉血栓形成者行再次移植治疗,成功率为4/6,再血管化和气囊扩张成功率分别为3/7和2/7;放置内支架治疗门静脉吻合口狭窄和腔静脉狭窄的成功率为3/3和10/10。发生胆道并发症34例(5.3%),其中放置T管患者发生胆道并发症27例,未放置T管患者7例,两组吻合口胆漏、胆道狭窄和感染的发生率比较,差异有统计学意义(P<0.01)。结论传统背驮式肝移植术能有效预防腔静脉并发症的发生;放置内支架技术治疗血管狭窄性病变效果好;早期肝动脉血栓形成应采取再次肝移植;确保供肝胆道系统的血供是减少胆道并发症的关键;不放置T管的胆管端端吻合术,是胆道重建的首选术式。

Objective To investigate the commom reasons, prophylaxis and treatment of operation correlated complications in orthotopic liver transplantation （OLT）. Methods Six hundred and forty-seven patients who underwent OLT from Apt 1993 to Dec 2004 were enrolled and analyzed retrospectively. Results There were totally 39 cases （ 6. 0%, 39/647 ） of vascular complications including 23 cases （ 3.6% ） of hepatic artery complications, 6 cases （0. 9% ） of portal vein complications and 10 cases （ 1.5% ） of vena cava complications. All vena cava complications were occurred in the patients of non-cavaplasty. The success rate of stent placement in treatment of hepatic artery stenosis was 2/2 ; for patients with hepatic artery thrombosis, the success rate of retransplantation was 4/6, that of revasculation and balloon dilation were 3/7 and 2/7 respectively. Stent placement can treat both anastomotic strictures and vena cava stricture with the cure rate of 3/3 and 10/10 respectively. There were 34 cases of biliary complications, in which 27 cases were in patients with T tube, and 7 cases in without T tube. The incidence of biliary leak and biliary infection was significantly different between these two groups. Conclusions The modified piggyback （cavaplasty） technique could prevent the incidence of vana cava complications effectively. Stent placement is an effective way to treat vascular stenosis. And retransplantation should be performed in early hepatic artery thrombosis. It is important to protect the blood supply of biliary system, and choledochostomy without T tube is the first choice for biliary reconstruction.