胆道内镜对肝移植术后胆管损伤变化的观察

Diagnosis and treatment of biliary injury after orthotopic liver transplantation with choledochofibroscope

目的对原位肝移植术后胆道并发症进行内镜观察和治疗，为肝移植胆管损伤机制的研究提供参考和帮助。方法利用胆道内镜技术，对肝移植术后正常组、胆管损伤组、肝动脉损伤组的病例进行观察，内镜下取活检进行病理分析。对于无T管者，应用子母胆道镜进行。结果正常的9例肝内外胆管解剖正常，无狭窄、瘢痕，胆管黏膜颜色正常，供一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，上皮下纤维组织和小血管增生，散在浆细胞、淋巴细胞浸润。胆管损伤组的12例中，胆管内有各种类型的单发、多发及铸型结石，胆管均有不同程度的损伤，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。肝动脉损伤组3例：胆管壁缺血坏死，丧失胆管的组织结构，仅见纤维样组织构成的管道，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：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。结论原位肝移植并胆管损伤、缺血的病例术后胆管均有不同程度的损伤，胆道内镜是诊治肝移植术后胆道并发症的首选方法。

Objective To provide information and assistance for research of bile duct injury in OLT through endoscopic observation and treatment of biliary complications after liver transplantation. Methods After OLT, all the cases in normal group, bile duct injury group and hepatic artery injury group were observed, diagnosed and recorded respectively. Meanwhile, the biopsy was performed through the endoscopy for pathological examination. For those cases without T tube, the biopsy was conducted by eholedochoscopy in combination with duodenoscopy. Results The exterior and interior bile duct anatomy of the 9 cases in the normal group was normal. They had no 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. Fibrous tissue and small vascular proliferation happened under epithelium scattered with plasmocyte and lymphocyte. Various kinds of bile duct stones-simple, multiple and casting mould type, were found in 12 cases with bile duct injury. Bile duct mucous membrane injured in different degrees was re paired after stone removed and obstruction relieved by endoscope. Bile duct tree becoming normal was seen by pacification examination. Three cases in the hepatic injury group had bile duct ischemic necrosis, losing of normal structure without bile duct wall and mucous membrane. Conclusion Bile ducts are injured in different degrees in OLT. The choledochofibroscopy is of the first choice for diagnosis and treatment of complications after OLT.