肝移植术后胆道并发症的内镜诊断和治疗(附250例次临床资料分析)

Endoscopic diagnosis and treatment of biliary complications after liver transplantation: Clinical analysis of 250 times of procedures

目的总结经内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)诊断和内镜治疗肝移植术后胆道并发症的经验。方法回顾性分析139例原位肝移植术后合并胆道并发症行ERCP资料,通过ERCP发现10种胆道并发症,发生部位包括移植肝、吻合口和受体胆管、十二指肠乳头等,其中常见的并发症为胆管、吻合口狭窄(102/139,73.4%),胆管炎(94/139,67.6%),胆总管和肝内胆管胆泥、胆结石形成(75/139,54.0%),十二指肠乳头功能紊乱(20/139,14.4%),胆漏(17/139,12.2%),T管相关的并发症(4/139,2.9%)等。少见的有十二指肠乳头狭窄(1/139,0.7%),介入治疗相关的并发症(2/139,1.4%),胆道出血(3/139,2.2%),胆管过长、扭曲(4/139,2.9%)等。治疗方法:EST(112/139,80.6%),扩张管和气囊扩张器扩张(157/250,62.8%),塑料内支架(139/250,55.6%),鼻胆管引流、冲洗(87/250,34.8%),取石(27/250,10.8%)等。结果本组139例共行250次ERCP,插管成功率达99.2%(248/250),总治愈率达70.5%(98/139),好转率为18.7%(26/139),总有效率为89.2%(124/139),中转手术9例(9/139,6.5%),无效4例(4/139,2.9%),放弃或失访2例。术后并发症主要包括:胆道感染37例,ENBD管滑脱26例,胆泥、胆结石形成18例。结论内镜是诊断和治疗肝移植术后胆道并发症的主要方法。

Objective To evaluate the clinical value of endoscopic retrograde cholangiopancreatography （ERCP） in the diagnosis and treatment of biliary complications after orthotroptic liver transplangtation. Methods We retrospectively reviewed the clinical data of 139 patients with biliary complications after orthotropic liver transplangtation, and summarized 10 categories of biliary complications. The location of biliary complications included donor liver, anastomotic stoma, receptor biliary duct, duodenal papilla, and so on. Common complications were biliary duct or anastomotic strictures （ 102/139, 73.4% ） , cholangitis （94/139, 67.6% ） , common bile duct or intrahepatic cholelithiasis （75/139, 54.0% ） , dysfunction of the duodenal papilla （20/139, 14.4% ） , bile leakage （17/139, 12. 2% ）, and complications related to T-tube （4/139, 2. 9% ）. Infrequent complications involved duodenal papillary stenosis （1/139, 0.7% ） , complications related to PTC （2/139, 1.4% ） , biliary bleeding （3/139, 2.2% ） , and too long and twisted bile duct （4/139, 2. 9% ）. The treatment methods included EST （112/139, 80. 6% ）, dilatable bougie or balloon dilatation （157/250, 62.8% ） , plastic stent placement （139/250, 55.6% ） , ENBD and irrigation （87/250, 34.8% ） , and gallstone removal （27/250, 10.8% ）. Results A total of 250 times of ERCP was performed in the 139 patients, the success rate of intubation being 99.2% （24-8/250）. The total cure rate reached 70.5% （98/139） and the improvement rate was 18.7% （26/139） , with a total effective rate of 89.2% （124/139）. There were 9 patients with conversions to open surgery （9/139, 6.5% ） , 4 patients with no improvement （4/139, 2.9% ）, and 2 patients with spontaneous quitting treatment or loss of follow-up, The postoperative complications included cholangitis in 37 patients, the dislodgement of ENBD tube in 26 patients, and biliary sludge or stone in 18 patients. Conclusions ERCP is an effective way to diagnose and treat the biliary complications after orthotroptic liver transplantation.