肝移植术后早期肝动脉缺血与胆道并发症及肝动脉介入治疗的价值

The role of early hepatic artery ischemia on bfliary complications after liver transplantation and hepatic arterial interventional therapy

目的探讨肝移植术后早期肝动脉缺血对胆道并发症发生和预后的影响，以及早期肝动脉介入治疗的价值。方法自2003年10月至2007年6月，在中山大学附属第三医院收治720例原位肝移植（OLT）患者中，共有32例在移植术后4～65（25±15）d彩超发现肝动脉缺血并经肝动脉造影（DSA）和（或）CT肝动脉成像证实，其中肝动脉狭窄（HAS）30例，肝动脉血栓（HAT）2例。32例中，20例接受了肝动脉介入治疗。以再次肝移植及患者死亡为观察终点，随访32例患者的临床转归。结果20例（62．5％）发生胆道并发症，包括单纯胆总管狭窄2例，肝内外胆管狭窄13例，肝内胆管狭窄5例，同时合并胆漏2例、胆汁瘤4例、胆源性肝脓肿3例。20例中，8例为HAS接受了成功的肝动脉介入治疗者，但治疗时间均在发现HAS2周后；10例为HAS未接受肝动脉介入治疗者；1例为HAT溶栓开通者；1例为HAS支架治疗失败者。20例患者中位随访时间262d（22～517d），死亡10例，再次肝移植6例，健在4例；6、12、24个月移植肝累积存活率分别为60．O％、34．9％和0。12例未发生胆道并发症，其中9例为HAS接受了成功的肝动脉介入治疗者，其治疗时间均在发现HAS2周内；2例为HAS病检提示急性排斥反应者，均及时应用抗排斥药物冲击治疗；1例为HAT溶栓失败接受再次肝移植者。该12例中位随访时间952d（14～1398d），死亡3例，再次肝移植1例，健在8例；6、12、24个月移植肝累积存活率分别为75．0％、66．7％和66．7％。结论肝移植术后早期肝动脉缺血是引起胆道并发症的重要原因，早期成功的肝动脉介入治疗有助于减少胆道并发症、提高患者的预后。

Objective To explore the influence of early hepatic artery ischemia on the occurrence and prognosis of biliary complications after orthotopic liver transplantation （ OLT）, and the value of early hepatic arterial interventional therapy. Methods In the 720 recipients who received OLT in our hospital from October 2003 to June 2007, 32 cases were detected hepatic artery stenosis （ HAS, 30 cases） or hepatic artery thrombosis （ HAT, 2 cases） by color Doppler Ultrasound from 4 to 65 days （ mean, 25 ± 15 ） after OLT. All of them were confirmed by DSA and/or CT angiography. Of the 32 patients, 20 were treated by hepatic arterial interventional therapy. The end-point of follow-up was the time of patient＇s death and retransplantation. Results In this study, 20 cases developed biliary complications, including the common bile duct stenosis in 2 cases, intra- and extra hepatic bile duct stenosis in 13 cases and multiple intrahepatic bile duct stenosis in 5 cases. Among them, 2 patients complicated with bile leakage, 4 with biloma and 3 with liver abscess. Of the 20 patients, 8 with HAS received successful hepatic arterial interventional therapy which was performed two weeks after HAS detected; 10 with HAS didn＇t receive hepatic arterial interventional therapy; 1 with HAT received successful thrombolysis; 1 with HAS received failed hepatic artery stent implantation. During a median follow-up of 262 days （range, 22 -517 days）, 10 patients died, 6 underwent retransplantation, and the other 4 survived; cumulated survival rates at 6, 12 and 24 months were 60. 0% , 34. 9% and 0, respectively. 12 cases didn＇t develop biliary complications. Nine of them received successful hepatic arterial interventionat therapy within 2 weeks HAS detected, 2 with acute rejection received flushing anti-rejection therapy, 1 with HAT received retransplantation because of unsuccessful thrombolysis. During a median follow-up of 952 days （range, 14 -1398 days）, 3 patients died, 1 underwent retransplantation, and the other 8 survived; cumulated survival rates at 6, 12 and 24 months were 75%, 66. 7% and 66. 7%, respectively. Condusion Early hepatic artery ischemia after OLT is an important agent for biliary complications. Early and successful hepatic arterial interventional therapy helped to reduce the incidence of biliary complications and improve the patients＇ prognosis.