肝移植围胆道重建的手术技巧和细节处理

Surgical technique and key points for reconstructing the biliary tract in orthotopic liver transplantation

目的探讨原位肝移植术中围胆道重建的手术技巧和细节对胆道并发症发生率的影响。方法将广州军区总医院2003年8月至2006年12月和2007年1月至2009年7月两个时间段共167例肝移植病例分成A组(74例)和B组(93例),收集两组患者的临床资料,对供肝的获取,受体的胆道重建方式、手术技巧与细节、术后胆道并发症发生情况及预后进行总结与分析。结果 B组的温缺血时间明显短于A组。两组胆管重建方式比较差异无统计学意义(P>0.05)。B组进行以下常规操作:除了对供肝胆囊进行灌洗外,均常规经胆总管插管对肝内胆管进行充分灌洗;修整供肝时,经供肝动脉灌注肝素-利多卡因-生理盐水;胆道重建前,先用导尿管冲洗胆管下段,然后用纤维胆道镜进行胆道探查并疏通胆道;修剪供体胆管时注意保护胆管血供;供受体胆管长度的确定强调遵循两个原则,一是供体胆管尽可能短,二是吻合时保持微张力。A组则未强调上述常规操作。A组、B组围手术期死亡率相近,分别为5%和6%;胆道并发症发生率分别为11%和6%(P<0.05)。结论在围胆道重建过程中充分灌洗供肝胆道、保证供受体胆道血供、缩短温缺血时间、疏通胆管下段以及微张力吻合胆管,可显著降低胆道并发症发生率。

Objective To study the effect of the surgical techniques and key points for reconstructing the biliary tract on incidence rate of biliary complication in orthotopic liver transplantation. Methods One hundred and sixty-seven cases of liver transplantation during two phases from August 2003 to December 2006 and January 2007 to July 2009 in General Hospital of Guangzhou Military Command of PLA were classified into group A （74 cases） and group B （93 cases） respectively. The clinical data of the two groups were collected and compared, including the procurement of the liver graft, the operation technique and procedures of reconstructing the biliary duct, the complications of the biliary duct after operation and the prognosis of patients. Resuits The warm ischemia time of group B was shorter than that of group A. There was no significant difference in the reconstruction way of the biliary duct between the two groups （ P 〉 0. 05 ）, The routine procedures were performed in group B as following： except for the irrigation of the gallbladder with cold physiologic saline, the bile common duct was also intubated to sufficiently irrigate the intra-hepatic bile duct. The hepatic artery was infused with physiological saline solution with heparin and lidocaine during liver graft trimming. Before reconstruction of the biliary duct, the inferior segment of the bile common duct was irrigated with saline using urethral catheter, then explored and dredged with the fiber choledochoscope. The blood supply of the bile duct of the graft should be protected during procurement. Two key points should be kept in mind to determine the length of the recipient and the donor bile duct. First, the donor bile duct should be short as far as possible. Second, the anastomosis should have micro-tension. The mortality in group A and group B were 5% and 6% , and the morbility of biliary complications were 11% and 6% （ P 〈 0. 05 ）. Conclusion Sufficient perfusion of donor bill ary duct, adequate blood supply of both donor and recipient biliary duct, shortening warm ischemia time, care- ful exploration of recipient bile duct and maintaining micro-tension of bile-duct anastomosis are key points to reduce the incidence of biliary complications.