肝移植术后非肝动脉性缺血性胆管损伤的早期胆管造影诊断

Ischemic-type biliary lesions without hepatic artery occlusion after liver transplantation： early diagnosis of cholangiography

目的分析和研究肝移植术后非肝动脉性缺血性胆管损伤的危险因素和早期胆管造影的诊断价值。方法对253例行原位肝移植患者的早期胆管造影表现和晚期胆管造影表现进行对照研究，以评价早期胆管造影对于缺血性胆管损伤的诊断价值；同时对所有患者的相关临床因素进行统计学分析，以确定与缺血性胆管损伤发生的相关危险因素。获得的数据采用t检验、X^2检验、秩和检验进行统计学分析。结果早期胆管造影诊断表现正常者189例，表现异常者64例，其中33例表现为肝内胆管充盈不良，31例表现为胆管不规则。晚期胆管造影诊断为正常者199例，诊断为缺血性胆管损伤54例。64例早期胆管造影表现异常的患者中39例被晚期胆管造影证实发生了缺血性胆管损伤，其中33例早期胆管造影表现为肝内胆管充盈不良的患者中10例发生了缺血性胆管损伤，31例早期胆管造影表现为胆管不规则的患者中29例发生了缺血性胆管损伤。而早期胆管造影表现正常的189例患者中仅15例发生了缺血性胆管损伤。早期胆管造影正常与否与晚期是否发生缺血性胆管损伤之间具有明显的相关性（X^2=79．999，P=0．000，r=0．490），根据肝移植术后早期胆管造影表现诊断是否发生缺血性胆管损伤具有较高的敏感度（72．22％）、特异度（87．44％）、阳性预测值（60．94％）和阴性预测值（92．06％）。Logistic回归分析显示，早期胆管造影表现异常是发生缺血性胆管损伤的危险因素（OR=15．193，P=0．000）。结论肝移植术后早期胆管造影异常表现与晚期发生缺血性胆管损伤具有一致性，依靠其诊断缺血性胆管损伤具有较好的敏感度、特异度和预测值，特别是早期出现胆管不规则表现的诊断价值更高。

Objective To evaluate the value of cholangiography for early diagnosis of ischemic-type biliary lesions（ITBL） after liver transplantation. Methods Two hundred and fifty-three patients with liver transplantaion between Jan 2004 and Oct 2006 were recruited. Initial cholangiography was compared with terminal cholangiography to evaluate the value of initial cholangiography of ITBL. The t test, Chi-square test, sum rank test were used for statistics. Results Based on initial cholangiography, 189 patients were diagnosed with normal appearance, while 64 patients were diagnosed with abnormal appearance. The abnormal initial cholangiography appearances included poor filling in 33 patients and irregularity in 31 patients. Based on terminal cholangiography, 199 patients were diagnosed with normal appearance and 54 patients with ITBL In patients with abnormal initial cholangiography, ITBL was occurred in 39 of 64 patients including 10 of 33 poor filling patients and 29 of 31 irregularity patients. In patients with normal initial appearance, ITBL was only occurred in 15 of 189 patients. The abnormal initial cholangiography was associated with ITBL significantly （ X^2 = 79. 999, P = 0. 000, r = 0. 490 ）. Initial cholangiography had an overall sensitivity of 72. 22%, and specificity of 87.44%, with positive and negative predictive values of 60.94% and 92. 06%, respectively. The abnormal initial cholangiography was a risk factor of ITBL by logistic regression analyses（OR = 15. 193 ,P = 0. 000）. Conclusion The abnormal initial cholangiography is associated with ITBL. Initial cholangiography, especially minimal irregular of intrabepatic biliary tract, is a sensitive and specific method for the detection of ITBL after liver transplantation.