劈离式肝移植术后胆管并发症

Biliary complication following split liver transplantation

目的探讨体外劈离式肝移植术后胆管并发症的危险因素及其防治措施。方法2006年6月至2010年9月，我院共施行劈离式肝移植术33例，其中1例于术后10d死亡，予以排除。其余32例患者中男性18例，女性14例，平均年龄33．4岁（6个月～65岁）。胆管重建方式胆管端端吻合20例，胆肠吻合12例。胆管并发症的诊断依靠T管造影、经皮经肝胆管造影（PTC）、经内镜逆行胆胰管造影、磁共振胰胆管造影（MRCP）等方法。胆管并发症定义为存在需要外科、介入、内镜等方法治疗的胆漏或胆管狭窄。结果受者中位随访时间13．5个月（3-54个月）。32例患者中11例患者发生12次胆管并发症（37．5％），其中肝断面胆漏3例（9．3％），胆管吻合口漏4例（12．5％），左肝管残端漏1例（3．1％），胆管吻合口狭窄1例（3．1％），缺血性胆管狭窄3例（9．3％）。8例发生胆漏的受者中6例经手术或穿刺放置引流后痊愈，2例因腹腔内感染死亡。单因素分析表明，移植物类型、胆管重建方式等均不是肝断面胆漏的危险因素。结论与全肝移植和活体肝移植相比，劈离式肝移植术后胆管并发症尤其是胆漏更为常见。进一步防治胆管并发症是改善劈离式肝移植预后的重要因素。

Objective To determine the incidence, risk factors and measures to prevent biliary complications after ex vivo split liver transplantation （SLT）. Method 33 ex vivo SLT were performed between June 2006 and September 2010. One patient was excluded from this analysis because of early postoperative death. There were 18 males and 14 females, with a mean age of 33.4 yr （range, 6 mo to 65 yr）. Biliary reconstruction was carried out by duct-to-duct anastomosis in 20 and Roux-en-Y hepaticojejunostomy in 12 patients. Biliary complication was defined as either bile leak or bile duct stricture which required surgery, interventional radiology or endoscopic treatment. These biliary complications were confirmed by percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, or T-tube cholangiography. Result The median follow-up was 13.5 months （3 to 54 mo）. Twelve （37.5%） biliary complications occurred in 11 patients： hepatic parenchymal leak from the transected liver surface in 9.3% （3/32）, anastomotic leaks in 12.5% （4/32）, anastomotic strictures in 3.1% （1/32）, stump leaks from the left bile duct in 3.1% （1/32）, and ischemic biliary strictures in 9.3% （3/32）. Two patients died of abdominal sepsis in the 8 patients who had biliary leaks. Univariate analysis showed that graft type and biliary reconstruction were not significant risk factors for biliary leaks. Conclusion Compared with whole liver transplantation and living donor liver transplantation, biliary complications of SLT are more common. Prevention and treatment of biliary complications are important factors to improve the result of SLT.