原位肝脏移植术后胆瘘的类型与治疗

Type and management of biliary fistula after orthotopic liver transplantation

目的探讨原位肝脏移植术后胆瘘的类型、方法选择及不同方式的治疗结果。方法回顾性分析2000年1月-2019年3月于西安交通大学第一附属医院住院治疗的24例肝移植术后胆瘘患者资料。根据是否合并狭窄将胆瘘分为4型。患者均接受内镜或介入治疗,包括经内镜鼻胆管引流术(endoscopic nasobiliary drainage,ENBD)、经内镜胆道内支架放置术(endoscopic retrograde biliary drainage,ERBD)或经皮经肝胆道引流术(percuteneous transhepatic cholangial drainage,PTCD)。观察指标为胆瘘发现时间、胆瘘位置、经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)及PTCD并发症、腹腔或胆道引流管拔出时间、新发胆道狭窄等。结果 24例胆瘘于肝移植术后(46.5±36.6) d(6~122 d)发现。Ⅰ~Ⅳ型胆瘘分别有6例、14例、2例和2例。22例胆瘘治愈,总体治愈率91.7%。24例均首先接受ERCP,技术成功率及治愈率分别为87.5%(21/24)和85.7%(18/21)。Ⅰ~Ⅳ型胆瘘ERCP的治愈率分别为6/6、84.6%(11/13)、1/2和0,ENBD与ERBD的胆瘘治愈比列分别为8/10和6/8。5例ERCP未成功者接受PTCD治疗,成功及临床治愈比例分别为4/5和3/4。术后胆道感染发生率为33.3%(8/24),Ⅱ型胆瘘胆管炎发生率高于Ⅰ型[35.7%(5/14)比16.7%(1/6)],合并非吻合口狭窄者比合并吻合口狭窄者更易发生胆管炎[83.3%(5/6)比16.7%(3/18)]。结论原位肝移植术后胆瘘首选ERCP,次选PTCD。Ⅰ~Ⅳ型胆瘘分别优选ENBD、ENBD联合ERBD、ENBD及PTCD治疗。

Objective To discuss the type,treatment and results of different therapies of biliary fistula after orthotopic liver tansplantation(OLT).Methods Data of 24 patients who developed biliary fistula after OLT in the First Affiliated Hospital of Xi’an Jiaotong University from January 2000 to March 2019 were retrospectively analyzed.Patients with biliary fistula were classified into 4 types according to presence or absence of stricture.All patients were treated by endoscopic retrograde cholangiopancreatography(ERCP)or interventional therapy,including endoscopic nasobiliary drainage(ENBD),endoscopic retrograde biliary drainage(ERBD)or percuteneous transhepatic cholangial drainage(PTCD).Main outcome measurements were the onset time of biliary fistula,the site of biliary fistula,the complications of ERCP or PTCD,the time of removing abdominal or biliary drainage tube,and the onset of new biliary stricture.Results Biliary fistula was found in(46.5±36.6)days(6-122 days)after OLT.The numbers of patients in four types of biliary fistula were 6,14,2 and 2,respectively.Biliary fistula was cured in 22 patients,wilh clinical cure rate of 91.7%.All patients underwent ERCP first,and the technical success rate and clinical cure rate were 87.5%(21/24)and 85.1%(18/21),respectively.The clinical cure rates of ERCP for Ⅰ〜Ⅳ biliary fistula were 6/6,84.6%(11/13),1/2,and 0,respectively.The clinical cure rates of ENBD and ERBD were 8/10 and 6/8,respectively.Five cases in whom ERCP failed,underwent PTCD,with technical success and clinical cure rates of 4/5 and 3/4 respectively.Eight patients(33.3%)developed cholangitis after treatment,and the incidence rate seemed higher in type Ⅱ biliary fistula than that in type Ⅰ[35.7%(5/14)VS 16.7%(1/6)].Incidence of cholangitis was higher in patients with nonanastomotic stricture than those with anastomotic stricture[83.3%(5/6)VS 16.1%(3/18)].Conclusion The first line treatment for biliary fistula after OLT is ERCP,followed by PTCD.The best procedures of biliary fistula type Ⅰ〜Ⅳ were ENBD,ENBD combined with ERBD,ENBD and PTCD,respectively.