肝移植术后胆道并发症的处理:附258例报告

Diagnosis and treatment of biliary complications after liver transplantation:analysis of 258 cases

目的：探讨原位肝移植术后胆道并发症的诊断、治疗及预防方法。方法回顾分析2004年8月~2011年12月施行的258例成人尸体原位肝移植（DDLT）的临床资料，对56例胆道并发症的诊断及治疗经验进行总结分析。结果258例原位肝移植，发生胆道并发症56例，发生率为22.13%，其中胆道狭窄32例（57.14%%），胆漏24例（42.86%）；其中36例（64.29%）为单纯类型，20例（35.71%）为复合类型，包括胆漏或胆道梗阻合并胆道结石、胆道感染、胆泥形成及胆道出血等。56例行ERCP、PTC等内镜、介入处理31例（55.36%），治愈及好转23例次（74.19%），3例经上述方法处理后效果不佳，后均死于MODS。结论手术方式的掌握、胆管吻合方式的掌握和成熟可明显降低胆道并发症发生率；胆道并发症首选非手术治疗（包括ERCP），其次为手术胆道探查，而再次肝移植对肝移植物无功能患者则成为最有效的救命手段；肝移植术后胆道并发症诊治关键在于预防。

Objective To investigate the approaches to diagnosis, treatment and prevention of the biliary complications after orthotopic liver transplantation （OLT）. Methods The clinical data were collected from 258 adult patients receiving orthotopic liver transplantation between August, 2004 and December, 2011, among whom 56 patients with biliary complications were identified to analyze the diagnosis and treatment of the complications. Results The incidence of biliary complication was 22.13%in the 258 recipients of secondary liver transplantation. Of the 56 patients with biliary complication, 32 （57.14%） had biliary stricture and 24 （42.86%） had bile leakage;36 （64.29%） patients presented a simple type of biliary complication and 20 （35.71%） had a composite type, including bile leakage, biliary obstruction, biliary calculi, biliary tract infections, biliary sludge formation, and biliary tract bleeding. Thirty-one patients （55.36%） underwent routine endoscopic retrograde cholangiopancreato-graphy （ERCP）, percutaneous transhepatic cholangiography （PTC） and other endoscopic or interventional treatments, and 23 （74.19%） were cured or showed improvement, while 3 died due to multiple organ dysfunction syndrome （MODS）. Conclusion Appropriate surgical approaches and skills in bile duct anastomosis are crucial to reduce the incidence of biliary complications following liver transplantation. Non-surgical treatment （including ERCP） is the primary option, followed by surgical bile duct exploration, for the management of biliary complications; liver retransplantation is the most effective life-saving means for patients with liver graft non-function. But still, prevention of biliary complications is of pivotal importance to improve the outcome of liver transplantation.