肝移植术后胆管吻合口狭窄的内镜处理

Endoscopic management of biliary anastomotic stricture after orthotopic liver transplantation

目的探讨内镜下处理原位肝移植术（OLT）后胆管吻合口狭窄（AS）的有效方案，并对影响疗效的因素进行分析。方法65例OLT后超过3个月的患者接受ERCP诊疗，在行狭窄段充分扩张后，置入尽可能多的塑料支架，维持支架支撑6个月以上，随访观察AS改善情况。结果该组患者共接受90次治疗，分别采用不扩张、探条扩张和6～10mm气囊扩张进行狭窄段扩张；置入2～6根塑料支架，平均置入3根，总口径达14—42F，平均达22．8F，支架支撑0．2～37．8个月，平均8．0个月。迄今共有54例次接受支架拔除及胆管再造影评估，其中26例次显示AS基本消除，采用气囊扩张加2根以上支架（总口径〉21F）支撑满3个月及以上者AS消除率达81．0％（17／21）。有3例患者在拔管后狭窄复发，均为支撑不足6个月者。结论根据OLT患者的病情，采用分期循序的内镜处理原则是行之有效的，内镜下采用扩张加多支架支撑，有望基本消除AS，为取得满意的疗效，应尽可能采用气囊扩张并同时置入2根以上（至少21F）支架，支撑时间不宜少于6个月。

Objective To investigate an effective endoscopic management of biliary anastomotic strictures （AS） following orthotopic liver transplantation （OLT） and to evaluate the factors which may affect the outcome. Methods Sixty-five patients, who were diagnosed as AS 3 months after OLT, underwent ERCP. After adequate dilation of the narrowing bile ducts, plastic stents, as many as possible, were inserted across the strictures and kept in place for at least six months. Results A total of 90 consecutive endoscopic procedures were performed in 65 patients. Before stents placement, the strictures were dilated by catheter or balloon （diameter range： 6 -10 mm）, or not dilated, according to the status of the bile ducts. An average of 3 （ranging from 2 to 6） plastic stentts were placed with mean total size of 22. 8 F （range 14 -42 F）, and the stents were kept for 8.0 months on average （ range 0. 2 - 37. 8 months）. Of 90 procedures of stents placement, 54 （60%） were followed by stents removal and cholangiography, which confirmed stricture resolution in 26 （48. 1% ）. The stricture resolution rate was 81.0% （ 17/21 ） in patients who underwent balloon dilation followed by more than 3 stents （ 〉21 F） for at least 3 months. Stricture re-occurred in 3 patients after stents removal, in whom stents were kept less than six months. Conclusion Endoscopic sequential intervention is effective for post-OLT biliary strictures according to the stage and grade. Radical dilation with maximal stenting can lead to complete resolution of AS. To achieve better result, if possible, balloon dilatation followed by three or more endoprotheses （of at least 21 F） sustaining for more than 6 months is necessary.