活体肝移植术后胆管并发症的处理与预防

Treatment and prevention of biliary complications after living donor liver transplantation

目的探讨活体肝移植术后胆管并发症的防治。方法84例活体肝移植，成人56例，小儿28例；良性终末期肝病66例，肝细胞肝癌18例。供受体胆管端端吻合重建50例，供体肝管与受体肝管端端和胆总管端侧吻合重建1例，供体肝管与受体肝管和胆囊管吻合1例，供体胆管与受体卒肠Roux—en-Y吻合重建32例，所有胆管重建后均置入4Fr或6Fr内支架管从受体胆总管前壁或空肠袢盲端侧肠壁引出体外。结果术后发生胆管并发症24例，发生率为28．5％，胆管胆管吻合与肝管宅肠Roux—en-Y吻合胆漏发生率差异显著（8．3％vs16．7％，P〈0．05）。胆管胆管吻合与肝管空肠Roux-en—Y吻合胆管狭窄发生率差异显著（50％vs16．7％，P〈0．05）。单支胆管与多支胆管发生胆管并发症差异娃著（20．8％vs79．2％，P〈0．05）。胆漏者保守治疗治愈4例，再次手术治疗治愈4例；胆管狭窄内镜下球囊扩张和鼻胆管引流治疗治愈4例，好转2例，再次手术胆管空肠Roux-en—Y吻合治疗治愈6例，经皮肝脏穿刺胆管狭窄球囊扩张治疗支架管引流治疗好转4例。该组资料无因胆管并发症死亡病例。结论良好的胆管血供和吻合技术，选择恰当的胆管重建方式，足降低活体肝移植术后胆管并发症的重要措施。

Objective To discuss the treatment and prevention of bile duct complications after living donor liver transplantation. Methods The clinical data of 84 cases of living donor liver transplantation including 56 adult recipients and 28 pediatric recipients were analyzed. Amongst the 84 patients, 66 had benign end-stage liver diseases and 18 hepatocellular carcinoma. Duct-to duct biliary reconstruction was performed in 50 cases. One recipient received an end to-end and end to-side anastomosis of hepatic duct of donor and hepatic duct and common bile duct of recipient and another underwent end-to end anastomosis of hepatic duct of donor and hepatic duct and cystic duct of recipient while the other 32 cases hepaticojejunostomy. 4Fr or 6Fr stent was routinely inserted into bile duct after biliary reconstruction and elicited from the anterior wall of common bile duct or lateral wall of jejunal caecum of recipient in all the 84 cases. Results Twenty-four cases had biliary complications and the incidence was 28.5 %. The incidence of biliary leakage was significantly different between duct toduct reconstruction and hepaticojejunostomy （8.3% vs 16.7%, P〈0.05）. The incidence of biliary stricture was markedly different between duct to-duct reconstruction and hepaticojejunostomy （50% vs 16.7%, P〈0.05）. The biliary complication was remarkably different between single hepatic duct and multiple hepatic duct （20.8% vs 79.2, P〈0.05）. Four eases of biliary leakage were cured with conservative treatment and the other 4 need reoperation. Four cases of biliary stricture were cured by way of endoscopic dilation and nose-biliary drainage, 2 cases turned to be better. Six cases were cured by conversion of hepaticojejunostomy and 4 turned to be better by way of percutaneous transhepatic biliary dilation and drainage. The recipients didn＇t die of biliary complications. Conelusion It is necessary to decrease the hiliary complications after living donor liver transplantation, to be satisfactory blood supply and anastomotic teehnigue and select appropriato biliary reconstruction.