经皮介入治疗在肝移植术后胆道并发症中的应用探讨

Investigation of percutaneous interventional treatments for biliary complications after liver transplantation

目的 探讨经皮介入治疗在肝移植术后胆道并发症中应用的方法、疗效及安全性.方法 回顾性分析2006年1月至2015年12月在中山大学附属第三医院接受经皮介入治疗的127例肝移植后胆道并发症患者的影像资料及临床资料,其中胆道并发症包括胆漏11例,胆管吻合口狭窄28例,肝门区胆管狭窄30例,肝内多发性胆管狭窄51例,胆脂瘤7例.治疗方式包括单纯经皮经肝胆管引流术（PTBD）、PTBD配合球囊扩张、PTBD配合球囊扩张及胆道内支架术.引流方式包括胆道外引流及胆道内外引流.术后定期随访并观察疗效及手术相关并发症.结果 127例患者首次PTBD成功率为97.6％ （124/127）.介入治疗的总体治愈率、好转率及无效率分别为37.8％ （48/127）、44.9％（57/127）和17.3％（22/127）.其中,胆漏组11例全部治愈,治愈率为100％;胆管吻合口狭窄组治愈18例（64.3％）,好转10例（35.7％）,治疗有效28例（100％）;肝门区胆管狭窄组治愈12例（40.0％）,好转16例（53.3％）,无效2例（6.7％）,治疗有效28例（93.3％）;肝内多发性胆管狭窄组治愈7例（13.7％）,好转28例（54.9％）,无效16例（31.4％）,治疗有效35例（68.6％）;胆汁瘤组好转3例（3/7）,无效4例（4/7）.胆漏组疗效最佳,胆汁瘤组疗效最差（P＜0.001）.引流管期间主要并发症为胆道感染,其中外引流及内外引流胆道感染发生率分别为32.4％ （34/105）及81.8％ （18/22）（P＜0.001）.结论 PTBD是治疗肝移植术后胆道并发症的安全、有效手段,结合球囊扩张及内支架.置入可有效改善患者症状,提高生存质量.肝移植术后合并胆脂瘤的患者介入疗效有限,建议尽早行再次肝移植术术.胆道外引流方式可显著降低胆道感染发生率.

Objective To investigate the technique,efficacy,and safety of percutaneous interventional treatments for biliary complications （BC） after liver transplantation （LT）.Methods The clinical and imaging data of 127 patients with BC after LT,who received percutaneous interventional treatments in the Third Affiliated Hospital of Sun Yat-sen University from January 2006 to December 2015,were analyzed retrospectively.On the basis of the cholangiographic appearance,patients were classified into 5 groups：biliary leakage group （n =11）,anastomotic biliary strictures group （n=28）,hilar biliary strictures group （n =30）,multifocal biliary strictures group （n =51）,and bilomas group （n =7）.The modality of interventional treatments was percutanous transhepatic biliary drainage （PTBD）,PTBD combined with balloon dilation,PTBD combined with balloon dilation and stent implantation.The methods of biliary drainage included external drainage and external-internal drainage.All the patients were followed up after treatment.The curative effect and operation-correlated complications were observed.Results The first successful rate of PTBD was 97.6% （124/ 127）.The total curative rate,improvement rate and inefficacy rate of interventional treatments were 37.8% （48/127）,44.9% （57/127） and 17.3% （22/127） respectively.In biliary leakage group,all the patients were cured by percutaneous interventional treatments with the curative rate being 100%.In anastomotic biliary strictures group,the cure and improvement rates were 64.3% （18/28） and 35.7% （10/28） respectively.The efficacy rate was 100% （28/28）.In hilar biliary strictures group,the cure,improvement and inefficacy rates were 40% （12/30）,53.3% （16/30） and 6.7% （2/30） respectively.The efficacy rate was 93.3% （28/30）.In multifocal biliary strictures group,the cure,improvement and inefficacy rates were 13.7% （7/51）,54.9% （28/51） and 31.4% （16/51） respectively.The efficacy rate was 68.6% （35/51）.In bilomas group,3 cases （3/7） obtained improvement and treatment of 4 cases was inefficative.The efficacy was the best for the patients with bilary leakage,and it was the worst for the patient with bilomas （P〈0.001）.The main operation-correlated complication was bile tract infection during drainage.The rates of bile tract infection were 32.4% （34/105） and 81.8% （18/22） in patients with external drainage and external-internal drainage,respectively.There was statistically significant difference between these two items （P〈 0.001）.Conclusion PTBD combined with balloon dilation and biliary stent implantation is a safe and effective therapeutic modality for BC after LT,which can improve patients＇ clinical symptoms,improve patients＇ quality of life.The patients with bilomas should be treated by retransplantation as soon as possible.The biliary external drainage can decrease the rate of biliary tract infection significantly.