肝移植术后乳糜性腹水的诊治经验

Diagnosis and treatment experience of chylous ascites after liver transplantation

目的探讨肝移植术后乳糜性腹水的发生率及诊治经验。方法回顾性分析2012年6月至2015年4月在中山大学附属第三医院行同种异体原位肝移植术的241例患者中，术后发生乳糜性腹水的18例患者临床资料。所有患者均签署知情同意书，符合医学伦理学规定。其中男15例，女3例；年龄26～63岁，中位年龄44岁。患者均接受尸体全肝移植，且为首次肝移植，手术方式为改良背驮式肝移植。观察患者的临床表现、腹腔引流量及引流时间、治疗手段及临床转归。结果本组患者肝移植术后乳糜性腹水的发生率为7．5％（18／241），典型表现为术后1周开始进食后出现大量乳糜色浑浊腹水，乳糜试验阳性。术后诊断时间的中位数为11（7～27）d。所有患者均给予禁食或少量低脂流质饮食、肠外营养联合生长抑素等保守治疗。患者拔除腹腔引流管时间为21（11～42）d，术后住院时间为41（22～59）d。其中17例痊愈出院，1例因多重耐药鲍曼不动杆菌肺炎死亡。结论肝移植术后发生乳糜性腹水不利于患者术后康复，大量乳糜色腹水、乳糜试验阳性可明确诊断，应首选生长抑素联合肠外营养等保守治疗。

Objective To investigate the incidence, diagnosis and treatment experience of chylous ascites after liver transplantation （LT）. Methods Clinical data of 18 patients developing chylous ascites out of 241 patients undergoing allogeneic orthotopic LT in the Third Affiliated Hospital of Sun Yat-sen University between June 2012 and April 2015 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among the patients, 15 were males and 3 were females with the age ranging from 26 to 63 years old and the median age of 44 years old. All patients underwent complete cadaveric LT for the first time and the procedure was modified piggyback LT. The clinical manifestations, the volume and time of peritoneal fluid drainage, treatments and clinical outcome of the patients were observed. Results The incidence of chylous ascites after LT was 7.5%（18/241）, and the typical manifestations were large quantity of turbid ascites with chyle color observed when the patients began to take food 1 week after surgery, and the chylous test was positive. The median of postoperative diagnosis time was 11（7-27） d. All patients received the conservative treatments, including fasting or a small mount of low-fat liquid diet, parenteral nutrition in combination of somatostatin. The time of removing peritoneal drainage tube was 21（11-42） d, and the postoperative length of hospital stay was 41（22-59） d. Seventeen patients healed and discharged while 1 patient died due to multidrug-resistant Aeinetobacter baumannii pneumonia. Conclusions Chylous ascites after LT is bad for the postoperative rehabilitation, and it can be confirmed by large quantity of chylous ascites and positive chylous test. Conservative treatments like somatostatin in combination with parenteral nutrition should be the first choice.