微创治疗胆道非吻合口狭窄的价值

Minimally invasive managements for non-anastomotic biliary stricture after orthotopic liver trans- plantation

目的评估微创方法治疗肝移植术后胆道非吻合口狭窄（NABS）的价值。方法回顾性分析13例肝移植术后NABS患者的临床资料，比较不同类型NABS患者经内镜下逆行胰胆管途径（ERCP途径）及经皮肝穿刺胆管途径（PTCD途径）的微创治疗效果，并总结NABS患者再次肝移植的手术指征。结果4例行PTCD途径治疗，效果不佳，后期3例改ERCP途径治疗。8例微创治疗后有效，有效率8／13；余5例改手术治疗，其中再次肝移植4例、胆肠吻合1例。Ⅰ型（围肝门部狭窄）、Ⅱ型（肝门部＋肝内胆管狭窄）、Ⅲ型（肝内胆管多发狭窄）NABS患者微创治疗有效率分别为3／4、4／7、1／2。II型及Ⅲ型患者近一半（4／9）需再次肝移植，合并肝动脉狭窄的NABS患者再次肝移植率高达2／3。结论微创方法是治疗NABS的首选方案，主要依靠ERCP实施，PTCD疗效欠佳。根据胆管造影显现的狭窄类型，Ⅰ型患者微创治疗效果最佳。微创治疗无效的Ⅱ型及Ⅲ型患者，尤其是合并肝动脉狭窄者，应及时转手术治疗，以免错失手术机会。

Objective To evaluate the clinical value of minimally invasive methods for non-anasto- motic biliary stricture （NABS） after orthotopic liver transplantation. Methods The clinical data of 403 pa- tients who underwent liver transplantation during recent 10 years in Liver Transplantation Center at General Hospital of Guangzhou Military Commanmol were analyzed retrospectively, and 13 patients with NABS were selected. The outcomes of 3 types of NABS patients treated by endoscopic retrograde cholangiopancreatogra- phy（ERCP） or percutaneous transhepatic cholangial drainage（PTCD） were compared and the indication for re-transplantation was identified. Results PTCD treatments of 4 patients were proved ineffective. The short- term curative rate of minimally invasive treatments was 8/13. Five patients eventually required surgical treat- ments （re-transplantation in 4, Roux-en-Y anastomosis in 1 ）. According to cholangiography results, NABS were divided into 3 types, namely hepatic bile duct strictures （n = 4, type Ⅰ ）, multiple extra-hepatic and intrahepatic biliary strictures （ n = 7, type Ⅱ ）, intrahepatic biliary strictures （ n = 2, type Ⅲ ）. The success rates of minimally invasive treatment in 3 types of NABS were 3/4, 4/7 and 1/2, respectively. Nearly half of type 11 and type m patients needed re-transplantation,which was more likely for those patients with hepatic artery stenosis （2/3）. Conclusion NABS treated with minimally invasive methods are preferred. Based on the appearance of biliary stricture, type Ⅰ patients had the best prognosis. For those type Ⅱ and type Ill patients who failed minimally invasive treatment, especially combined with hepatic arterial stenosis, surgical treatment should be timely, so as not to lose a chance for re-transplantation.