胆道镜在肝移植术后早期胆道内胆栓治疗中的应用

Application of chulcdochoscope in the treatment of early biliary casts after orthotopic liver transplantation

目的探讨胆道镜在肝移植术后早期胆道内胆栓治疗中的应用价值。方法31例原位肝移植，胆道重建采取胆总管端端吻合，并行T管引流，术后6～20周经T管造影提示胆道内结石形成，均伴有不同程度的肝功能异常。在进行胆道镜治疗前，采用16F外引流管经T管途径扩张及支撑窦道，1周后经窦道放入胆道镜达肝总管，用活检钳及取石网篮取出结石，逐级探查肝内胆道，必要时取活检组织，同时观察胆道吻合口、受者的胆道及Oddi括约肌情况。术后置入外引流管。结果除1例在扩张窦道过程中撕裂窦道外，其余病例均操作顺利，可完整取出胆树状铸型胆栓。31例中，22例（70．97％）治疗有效，术后肝功能基本恢复正常，拔除引流管后病情稳定；8例（25．81％）病情得到控制，术后肝功能基本恢复正常，拔除引流管后病情反复，需再次置入外引流管支撑；1例（3．22％）治疗后未见明显好转，病情进行性加重，接受再次肝移植。结论胆道镜下可直观了解胆道情况，解除胆道梗阻，可作为治疗肝移植术后早期胆道内胆栓的一种手段。

Objective To discuss the value of choledochoscope in the treatment of early biliary casts after orthotopic liver transplantation （OLT）. Methods In 31 cases of OLT, the bile duct was rebuilt by end-to-end cholangiocholangiostomy and T-tube drainage done. After 6-20 weeks, all cases were found having biliary casts by cholangiography, associated with abnormal liver function. All cases were subjected to fistula dilatation and 16Fr biliary drainage done before choledochoscopic treatment. After one week, choledochoscopy were performed through fistula tract and casts extracted by biopsy forceps or basket. Intrahepatic bile duct, stoma, recipient common bile duct and Oddi＇s sphincter were observed. Biliary drainage was done after treatment. Results All the cases were operated on successfully and integrative dendritic biliary casts were extracted except one case of fistula tract destruction during dilation. In 22 cases （70. 97%）, the treatment was effective and postoperative liver functions restored. In 8 cases, the disease conditions were controlled and postoperative liver functions restored, but the illness was worsen after extraction of drainage tube, and drainage tube replaced. In 1 case （3. 22 %）, no obvious improvement was obtained after treatment and disease conditions were aggravated progressively, so liver re-transplantation was performed. Conclusion Choledochoscopy can-examine bile tract visibalely and relieve bile duct obstruction, which can be used as a therapy for early biliary casts after OLT.