肝移植术后胆道并发症内镜分型及治疗预后评估

Endoscopic classification and prognosis of bile duct complications followed by liver transplantation

目的近十年来肝移植术后胆道并发症的种类发生了很大变化,需要采用新的分型方法,以利于内镜下进行系统的诊断治疗。方法将肝移植术后胆道并发症患者按 ERCP 影像分型,吻合口(G)分为正常(Ⅰ)、狭窄(Ⅱ)、胆漏(Ⅲ)、游离(Ⅳ),供肝肝内外胆管(B)分为正常(Ⅰ)、局限性狭窄(Ⅱ)、广泛性狭窄(Ⅲ)、液化(Ⅳ),Ⅱ、Ⅲ中又分为无胆栓(a)、有胆栓(b)。自2004年1月至2006年12月间,248例肝移植术后胆道并发症患者进行了此种分型,对吻合口及肝内外胆管狭窄者分别行扩张及单或多支架支撑治疗,有胆栓者行清除胆栓术。对内镜治疗预后进行评估。结果 248例中,吻合口并发症 GⅠ 43例(17.3%),GⅡ193例(77.8%),GⅢ12例(4.8%),GⅣ 0例;供肝肝内外胆管并发症 BⅠ 89例(35.9%),BⅡ9例(3.6%),BⅢ143例(57.7%),BⅣ7例(2.8%);吻合口狭窄合并供肝肝内外胆管并发症有193例,其中 GⅡBⅠ 79例(40.9%),GⅡBⅡ5例(2.6%),GⅡBⅢ102例(52.8%),GⅡBⅣ7例(3.6%);BⅡ9例中,BⅡa 5例,BⅡb 4例;BⅢ143例中,BⅢa 66例,BⅢb 77例。对吻合口狭窄术后6个月内行单支架引流,6个月以后行扩张术并多支架引流;对胆漏操作中避免胆管离断,不建议扩张,多行鼻胆管引流,胆漏明确治愈后多支架支撑;肝内胆管局限性狭窄者行局部扩张,多支架支撑;有胆栓者时机成熟行取栓术;肝内胆管广泛狭窄无胆栓者预后好于有胆栓者,影响引流效果的因素是感染和清除胆栓,支架留置尽量超过1年。肝内胆管结构消失者常伴有吻合口狭窄,多支架引流效果差。结论肝移植术后胆道并发症主要为 GⅡBⅠ和 GⅡBⅢ型。单纯吻合口狭窄者经内镜多支架支撑治疗后预后佳;吻合口狭窄合并供肝肝内外胆管局限性狭窄经内镜治疗,不论有无胆栓,预后均较好;供肝肝内外胆管广泛狭窄合并或不合并吻合口狭窄者经内镜治疗预后欠佳,合并有胆栓者预后差;供肝肝内外胆管结构消失或液化者经内镜治疗常无效;单纯吻合口胆漏者内镜治疗效果好。

Objective The sort of biliary complications has changed over the past decade. Modalities of treatment have also changed towards a primarily nonoperative, endoscopy-based strategy. For systemically diagnosis and treatment, a new classification system is needed. We utilized ERCP methodology to classify and evaluate prognosis of bile duct complications after liver transplantation. Methods 248 patients with biliary complications after liver transplantation were evaluated and treated from January 2004 to December 2006. For the patients with anastomotic stricture, extrahepatic obstruction, and intrahepatic stricture, we conducted dilation, single or multiple stenting, and removed biliary casts if necessary. Results In 248 patients, 43 （17.3%） patients who had anastomostic complication were GⅠ, 193 （77.8%） patients who had anastomostic complication were GⅡ, 12 （4.8%） were GⅢ, and 0 （0%） was GⅣ, respectively. 89 （ 35.9% ） patients who had donor extra-/intra-hepatic bile duct complication were BⅠ, 9 （3.6%） were BⅡ, 143 （57. 7% ） were BⅢ, and 7 （2. 8% ） were BⅣ, respectively. 193 patients had both anastomostic and donor extra-intra-hepatic bile duct complications. Of which, 79 （40.9%） were GⅡBⅠ, 5 （2.6%） were GⅡBⅡ, 102 （52. 8% ） were GⅡBⅢ, and 7 （3.6%） were GⅡBⅣ, respectively. In the 9 patients with BⅡ complications, 5 （55.6%） had bile casts, 4 （44.4%） had nothing. In the 143 patients with Bill complications, 77 （53. 8% ） had bile casts, 66 （46. 1% ） had not anything. Based on our findings, we proposed following as standard-of-care treatment. For anastomostic complications, single stenting was used within 6 months for anastomostic stricture, followed by dilation and multiple stenting 6 months later. For leakage, nasobiliray drainage is recommended, long time drainage is fine. Dilation is not recommended in order to avoid bile duet disconnection. After treatment of leakage, multiple stenting is recommended to prevent stricture. For local intra-hepatic stricture, localized dilation and multiple stenting showed effective results. If possible, cast removal procedure should be conducted at least one year stenting. Prognosis of BⅢa patients was better than that of BⅢb. Success rate for multiple stenting was 83.9% （112/143） and effective rate was 85.5% （112/131 ）. Risk factors include infection and cast removal. Stents were recommended to be kept more than one year. Those patients whose intra-hepatic bile duet structure was abnormal often co-existed with anastomostic stricture. Although multiple stenting and close monitoring were highly recommended, the results were not promising. Conclusion According to our classification, most eases of biliary complications after liver transplantation are GⅡBⅠ and GⅡBⅢ. Patients who had good prognosis include： anastomostic leak, anastomostic stricture after multiple stenting and anastomostic stricture with limited donor extra-/intra-hepatic stricture patients no matter what there were bile casts. Patients who had bad prognosis include： expanded donor extra-/intra-hepatic stricture patients with or without anastomostic stricture, and patients with bile casts. Endoscopy - based treatment usually can not deliver effective therapeutic effects for patients with disappearing or liquidizing structure. Second transplantation is recommended. Further study is needed to validate this classification and prognostic methodology.