初步探讨肝内胆管结石行肝移植术的适应证

Preliminary Experience with Indications for Liver Transplantation for Hepatolithiasis

目的探讨肝内胆管结石患者行肝移植的适应证。方法回顾性分析我院2000年1月至2006年12月期间先后接受外科治疗的肝内胆管结石患者1 431例的临床资料,手术包括T管插入联合术中胆道纤维内镜肝内取石术、肝切除术、胆总管空肠吻合术及肝移植术。结果961例患有左或右肝内胆管结石者接受了肝切除术或T管插入联合术中胆道纤维内镜肝内取石术,结石残余率为7.5%(72/961);470例患有双侧肝内胆管结石者接受了除肝移植术外的上述其他手术治疗,结石残余率为21.7%(102/470)。残余结石患者中仅15例肝内胆管结石患者接受了肝移植术,术后患者全部存活。根据胆汁性肝硬变的程度,受者分为胆汁性失代偿性肝硬变(n=7)和胆汁性代偿性肝硬变或无肝硬变(n=8)2组。2组在手术时间、液体灌注量及失血量方面差异有统计学意义(P<0.05)。胆汁性失代偿性肝硬变组7例患者中有6例出现了手术并发症,而胆汁性代偿性肝硬变或无肝硬变组受者恢复平稳,未出现并发症。所有受者术后1年的健康状况和心理健康满意度较移植术前有明显改善(P<0.05)。结论对于肝硬变明确者、继发性胆汁性失代偿性肝硬变者、或肝内胆管结石弥漫性分布难以取出且无法行肝切除、胆总管空肠吻合和胆道镜手术者,可选择肝移植术治疗。

Objective To explore the indications for liver transplantation among patients with hepatolithiasis.Methods Data from 1 431 consecutive patients with hepatolithiasis who underwent surgical treatment from January 2000 to December 2006 were retrospectively collected for analysis.Surgical procedures included T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones,hepatectomy,cholangiojejunostomy,and liver transplantation.Results Nine hundred and sixty-one patients who had a stone located in the left or right intrahepatic duct underwent hepatectomy or T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones.The rate of residual stones was 7.5%（72/961）.Four hundred and seventy patients who had a stone located in the bilateral intrahepatic ducts underwent surgical procedures other than liver transplantation;the rate of residual stones was 21.7%（102/470）.Only 15 patients with hepatolithiasis underwent liver transplantation;they all survived.According to the degree of biliary cirrhosis,recipients were divided into 2 groups： a group with biliary decompensated cirrhosis（n=7）,or group with biliary compensated cirrhosis or noncirrhosis group（n=8）.There were significant differences in operative times,transfusion volumes and blood losses between 2 groups（P0.05）.In the first group,6 of 7 patients experienced surgical complications,and in the second,8 recipients recovered smoothly with no complications.Health status,disability and psychological wellness of all recipients（n=15） were significantly improved in 1 year after transplantation as compared with pretransplantation（P0.05）.Conclusion Liver transplantation is a possible method to address hepatolithiasis and secondary decompensated biliary cirrhosis or difficult to remove,diffusely distributed intrahepatic duct stones unavailable by hepatectomy,cholangiojejunostomy,and choledochoscopy.