45例肝移植术后胆管狭窄的治疗体会

Treatment of biliary stricture after orthotopic liver transplantation

目的探讨肝移植术后胆管狭窄的治疗方法及其效果。方法回顾性分析45例肝移植术后胆管狭窄患者的临床资料。45例患者胆管狭窄的发生部位为吻合口狭窄8例、肝总管狭窄4例、肝门部狭窄12例、肝内胆管弥漫性狭窄16例及肝内、外胆管多发性狭窄5例。45例患者采用的治疗方法主要为：经十二指肠镜逆行胆管造影介入治疗；经皮肝穿刺胆管造影介入治疗；胆肠吻合术及再次肝移植术。结果45例患者的总治愈率为64．4％（29／45），好转率为20．0％（9／45）。介入治疗的治愈率为24．4%（11／45），好转率为20．0％（9／45），无效率为55．6%（25／45）；与胆管狭窄相关的死亡率为15．6％（7／45）。25例经介入治疗无效的患者中，有4例接受了胆肠吻合术，2例治愈，2例好转；其余21例（肝内胆管弥漫性狭窄16例，肝内、外胆管多发性狭窄5例）发生了移植肝功能丧失，其中5例因肝功能衰竭死亡，16例接受了再次肝移植术，术后有2例死于围手术期真菌感染。随访期间，有2例患者因肝癌复发而死亡，其余36例存活良好。结论对于肝移植术后胆管吻合口狭窄和肝外及肝门部胆管狭窄，介入治疗效果较好。肝内胆管弥漫性狭窄和肝内、外多发性胆管狭窄经介入治疗无效时应尽早行再次肝移植术。

Objective To investigate therapies and efficacy for biliary stricture after orthotopic liver transplantation （OLT）. Methods The clinical data of 45 patients with biliary stricture after OLT were retrospectively analyzed. Among 45 patients, there were 8 cases of anastomotic biliary strictures, 4 cases of common hepatic duct strictures, 12 cases of hepatic hilum biliary strictures, 16 cases of intrahepatic diffuse biliary strictures, and 5 cases of mixed biliary strictures. The patients received therapies including endoscopic retrograde cholangiography （ ERCP ）, percutaneous transhepatic eholangiography （PTC）, choledochojejunostomy, and liver retransplantation. Results The total curative rate of 45 patients with biliary stricture was 64. 4%, the improvement rate was 20. 0 %, and the total effective rate was 84. 4 %. The curative rate of interventional therapy in this study was 24. 4 %, the improvement rate was 20. 0 %, and the total effective rate of interventional therapy was 44. 4 %. The mortality rate associated with biliary stricture was 15.6 %. Sixteen of 21 with intrahepatic diffuse and mixed biliary strictures underwent liver re-transplantation, and the remaining 5 patients died due to liver function failure while still on the waiting list. Among these 16 patients receiving liver re-transplantation, 2 died of perioperative fungal infection. Conclusions Interventional therapy is effective to anastomotic and extrahepatic as well as hepatic hilum biliary strictures following OLT. Liver re-transplantation should he carried out as early as possible in intrahepatic diffuse and mixed biliary stricture patients if interventional therapy was inefficient.