肝移植术后胆管吻合口狭窄与胆管损伤的内镜观察及治疗

Endoscopic Observation and Treatment of Bile Duct Anastomotic Stricture and Biliary Injury Following Liver Transplantation

目的 探讨肝移植术后吻合口狭窄与胆管损伤的关系及内镜治疗效果。方法 回顾性分析2001年7月至2014年10月期间我院24例肝移植术后胆管造影诊断为吻合口狭窄患者的临床资料。结果 1 24例肝移植术后吻合口狭窄包括：Ⅰa型3例,Ⅰb型2例,Ⅱ型4例,Ⅲa型1例,Ⅲb型5例,Ⅲc型9例。2胆道镜及胆道子母镜观察见Ⅰa、Ⅲa型肝内胆管黏膜发红,吻合口处黏膜条状糜烂、溃疡并有融合;Ⅱ型肝内及吻合口处黏膜发红,无糜烂及溃疡;Ⅲb型肝内胆管黏膜广泛糜烂、溃疡,吻合口黏膜发红;Ⅰb、Ⅲc型肝内胆管及吻合口处黏膜广泛糜烂、溃疡,部分胆管黏膜呈片状、局灶性或全层坏死。3有17例吻合口狭窄经T管瘘道胆道镜治疗,取出铸型、狭窄处球囊扩张及塑料支架支撑2~6个月后狭窄解除、无复发。有1例Ⅰb型采用经皮肝穿刺胆管引流＋经皮经肝胆道镜治疗,狭窄球囊扩张及塑料支架支撑,术后19个月进展为Ⅱ型狭窄;2例Ⅰa型经ERCP取出铸型,其中1例于术后5个月进展为Ⅱ型狭窄;2例Ⅱ型经ERCP球囊扩张及多枚塑料支架支撑3个月,其中1例于狭窄解除后1个月复发。该3例进展或复发患者再次经ERCP球囊扩张＋多枚塑料支架支撑4--6个月,取出支架后2--5个月狭窄再次复发,经ERCP置入覆膜可回收金属支架支撑4~7个月后狭窄解除。有1例Ⅲb型及1例Ⅲc型经ERCP球囊扩张及多枚塑料支架支撑,术后并发胆系感染及黄疸,再次开腹胆道镜取出铸型,然后置入塑料支架支撑而治愈。结论 肝移植术后胆管狭窄均伴有不同程度的胆管损伤,其中Ⅱ型最轻,Ⅰa、Ⅲa型次之,Ⅲb型较重,Ⅰb、Ⅲc型最重。胆道镜治疗肝移植术后吻合口狭窄疗效确切,ERCP不适用于Ⅰb、Ⅲb及Ⅲc型吻合口狭窄。

Objective To discuss the relation between bile duct anastomotic stricture and bile duct injury by endo- scopic observation following liver transplantation and it＇s efficacy of endoscopic treatment. Method The clinical data of 24 cases of bile duct anastomotic stricture following liver transplantation diagnosed by cholangiography were analyzed retro- spectively. Results （1） Twenty-four cases of bile duct anastomotic strictures were included in 3 cases of type Ⅰa, 2 cases of type Ⅰb, 4 cases of type Ⅱ, 1 case of type ilia, 5 cases of type Ⅲb, and 9 cases of type Ⅲc. （1） The redness ofintrahepatic bile duct mucosa, banding erosion, ulcer and fusion of anastomotic stricture mucosa could be seen in type Ia and Ⅲa. The redness ofintrahepatic bile duct and anastomotic stricture mucosa could be seen in type Ⅱ without ulcer and fusion. The extensive erosion and ulcer ofintrahepatic be duct and redness ofanastomotic stricture mucosa could be seen in type Ⅲb. The extensive erosion, ulcer and partial necrosis of intrahepatic bile duct and anastomotic stricture mucosa could be seen in type Ib and Ⅲc. 2 Seventeen cases were cured by choledochoscopy through T tube, the biliary casts were moved out and the anastomotic strictures were relieved by balloon dilatation and placement of plastic stenting for 2 to 6 months, no recurrence happened. One case of type Ib treated by percutaneous transhepatic cholangial drainage （PTCD） and percutaneous transhepatic cholangioscopy （PTCS） was developed into the stricture of type Ⅱ during following-up for 19 months. Two cases of type Ia were treated by ERCP, the biliar casts were moved, one of which was cured, another 1 case was developed into the stricture of type 1] during following-up for 5 months. Two cases of type II were treated by ERCP, the biliary casts were moved, balloon dilatation and placement of plastic stent were performed, one of which was cured, another 1 case was recurrent during following-up for 1 months. The strictures were not relieved by multiple plastic stents for 4 to 6 months in 3 patients with recurrence and progress, but which was relieved by full-covered self-expanding removable metal stents for 4 to 7 months, there was no recurrence during following-up. One case of type Ⅲb and one case of type Ⅲc received the secondary open operation or choledochoscopy and placement of plastic stent for biliary infection and jaundice after the treatment of ERCP were cured. Conclusions Biliary stricture following liver transplantation accompanies different degree biliary injury. The slightest is type Ⅱ and type Ⅰ a, type Ⅲa is the second, type Ⅲb is more serious, and type Ⅰ b and type Ⅲc are the worst. Choledochoscopy is a better choose for anastomotic strictures. ERCP is not a better choose for anastomotic strictures of type Ⅰb, Ⅲb, and Ⅲc.