肝移植术后肝内弥漫性胆管狭窄的再次肝移植治疗

Experiences of liver retransplantation for postoperative diffuse biliary strictures

目的探讨肝移植术后肝内弥漫性胆管狭窄行再次肝移植治疗的临床经验。方法回顾性分析中山大学附属第一医院2001年1月至2009年12月施行的53例再次肝移植患者的临床资料，其中因首次肝移植术后肝内胆管弥漫性狭窄行再次肝移植手术患者20例（20／53）。分析其预后及影响因素。结果20例术后肝内胆管弥漫性狭窄的发生时间为首次肝移植术后3—16个月，平均6．3个月。胆道狭窄的类型包括肝内弥漫性胆管狭窄16例，肝内外胆管多发性狭窄者4例；20例患者术前均经介入及其他综合治疗无效，行再次肝脏移植。行再次肝移植20例患者中，14例获治愈。6例死于围手术期合并症，其中严重腹腔感染和多脏器衰竭3例，胆瘘2例，血管合并症（肝动脉栓塞）1例。术后随访1～5年，平均1．8年；术后1、6个月和1年的累计生存率分别为80．0％、75．0％和70．O％。结论再次肝移植是挽救肝内弥漫性胆管狭窄无法介入治疗或介入治疗失败的最终治疗手段；把握最佳手术时机和提高手术技巧，以及有效防治围手术期感染是提高该类患者生存率的关键。

Objective To investigate the feasibility and management of retransplantation for diffuse biliary strictures occurring after initial liver transplantation. Methods The clinical data of 53 consecutive liver retransplantation patients at our hospital from January 2001 to December 2009 were collected and analyzed retrospectively. Among them, 20 （37.7%） were due to diffuse biliary strictures. Results Diffuse biliary strictures appeared at 3 - 16 months after initial transplantation. The mean time was 6. 3 months. The specific types included intra-hepatic diffuse biliary strictures （n = 16 ） and multi-strictures involving both intra- ＆ extra-hepatic biliary ducts （n = 4 ）. Retransplantation was performed after a failure of intervention or/and other comprehensive treatments. Among them, 14 were cured and 6 died from peri-operative complications including serious abdominal infection ＆ MODS （multiple organ dysfunction syndrome） （n = 3, 50% ）, biliary fistula （n =2, 33.3% ） and hepatic artery embolism （n = 1, 16. 7% ）. These patients were followed up for a mean time of 1.8 years （range：l -5 years）. The accumulative survival rates at 1, 3 and 6 months were 80. 0%, 75.0% and 70.0% respectively. Conclusions Liver retransplantation is the ultimate treatment for diffuse biliary strictures after liver transplantation. The survival rate is associated with operative timing, surgical techniques and peri-operative management.