原位肝移植后胆管损伤的病理学改变(英文)

Pathological changes of bile duct injury after orthotopic liver transplantation

背景:肝移植术后胆道损伤引起的并发症是临床上诊治的难点,是抑制肝移植发展的瓶颈。目的:在成功应用胆道内镜治疗肝移植术后胆道并发症的同时,对胆管的损伤进行观察记录并取活检病理,分析不同胆管损伤、组织病理学类型与肝移植术后胆管并发症的关系。设计、时间及地点:病例分析,于2001-07/2005-10在大连市肝胆外科研究所,友谊医院肝胆外科完成。对象:将19例肝移植术后患者根据胆管并发症发生情况分为3组:正常组4例,胆管损伤组12例,肝动脉损伤组3例。方法:利用内镜技术,分别对3组患者进行胆管观察、记录,内镜下取活检进行病理分析。对于无T管者,应用子母胆道镜观察、取活检。主要观察指标:应用胆道内镜观察T管造影、肝内外胆管黏膜外观及病理学检查结果、供-受体胆管吻合口的愈合情况。胆管损伤组经内镜取石、狭窄扩张治疗后行上述指标的复查。结果:①正常组患者肝内外胆管解剖正常,无狭窄、瘢痕,胆管黏膜颜色正常,供-受体胆管吻合口愈合佳。病理学检查均可见修复性的黏膜组织,被覆上皮完整。②胆管损伤组患者胆管内有各种类型的单发、多发及铸型结石,胆管均有不同程度损伤,经内镜取净结石、解除梗阻后,胆管黏膜均有不同程度的修复,造影检查胆树恢复正常。③肝动脉损伤组患者胆管壁缺血坏死,丧失胆管的组织结构,明显充血,胆泥和结石完全灌满供体胆树,Ⅲ级胆管间断具有胆管的组织结构;病理学检查发现胆管壁弥漫坏死,结构不清,大量胆汁渗入,可见增生的肉芽组织和化脓灶。结论:在原位肝移植中胆管均有不同程度的损伤,冷保存/再灌注损伤是导致胆管树损害最重要的始动因素,胆管周围血管丛的损伤和微循环障碍可能是胆管损伤的途径之一。

BACKGROUND： Complications, caused by bile duct injury after liver transplantation, are difficult for diagnosis and treatment and the bottlenecks for the development of liver transplantation. OBJECTIVE： To observe and record bile duct injury and do biopsy in parallel with treating biliary complications following liver transplantation successfully with choledochoscope, and to analyze the relationships between various bile duct injuries, histopathological types and biliary complications following liver transplantation. DESIGN, TIME AND SETTING： Case analysis was carried out at Dalian Institute of Hepatobiliary Surgery, Department of Hepatobiliary Surgery, Dalian Friendship Hospital between July 2001 and October 2005. PARTICIPANTS： Nineteen patients after liver transplantation were divided into three groups according to the occurrence of biliary complications： four cases for normal group, twelve cases for bile duct injury group, three cases for hepatic artery injury group. METHODS： They were observed, diagnosed and recorded respectively and take biopsy for pathological analysis through the choledochoscope. With regard to the cases without T-tube, choledochoscope combined duodenoscope were used to take biopsies. MAIN OUTCOME MEASURES： Choledochoscope was used to observe T-tube cholangiography, the appearances and pathological changes of internal and external bile duct mucous membrane, healing of the donor-receptor bile duct stoma. Patients in the bile duct injury group were done examinations described above after endoscopic stone extraction and stenosis expansion. RESULTS： The internal and external bile duct anatomy of the patients in the normal group were normal, without bile duct stenosis and scar, their bile duct mucous membrane looked good, and the anastomosis of the donor-receptor bile duct healed well. Restored mucous tissue coating with intact epithelium was found by pathological examination. Various kinds of bile duct stones, simple, multiple and casting mould stones, were found in patients of the bile duct injury group. Bile duct mucous membranes were injured at different degrees and repaired after removing stones and relieving obstruction by endoscope. Contrast examination demonstrated that bile duct tree regained normal. In hepatic artery injury group, patients had bile duct wall ischemic necrosis and lost bile duct normal structure, congestion was obvious, biliary sludge and stones completely filled in the bile duct tree. Interrupted bile duct structure were found in III grade bile ducts. Pathological examination revealed extensive bile duct wall necrosis, indistinct structure, more bile infiltration, proliferative granulation tissue and suppuration focus. CONCLUSION： Bile ducts are injured at different degrees in orthotopic liver transplantation; cold preservation/reperfusion injury is the most important initiating agent leading to bile duct tree injuries; the vessel plexus damage and microcirculatory disturbance surrounding the bile ducts maybe one of the mechanisms of the bile duct injury.