胆道支架管在肝移植复杂胆道重建中的应用

肝移植术后并发症的原因及防治20 世纪八十年代中期以来，原位肝移植（ OLT ）已成为终末期肝病的金标准治疗。

虽然OLT的手术成功率已达90 % ~10 0% , 5年、1 0年生存率分别已达 70%~80%、 60%~70 %，但仍有不少问题尚未解决或不可避免，移植后并发症发生率高达 14%~55 %左右，直接影响了移植后的近远期生存率。

下面就 OLT 术后并发症的原因及防治作一简述。

一、肝移植术后外科并发症1．术后出血：（1）腹腔内出血：较常见，发生率 10%~20%，是术中和术后早期的主要死因。

原因有肝硬化致凝血功能差；后腹膜等侧枝循环创面渗血；移植肝小血管分支未被结扎出血；血管吻合口漏血；膈肌血管出血；供肝功能不良致凝血因子缺乏；外源性凝血因子补充不足；转流术中肝素的作用，转流停止后未作充分的中和；引流管出口处腹壁出血等。

常见出血部位为① 门脉高压后腹膜侧枝循环创面（如腔静脉后），②膈肌血管，⑧新肝韧带创面，④新肝活检处。

⑤ 腹腔引流管洞口等。

腹腔内出血一般多指发生在术后1~3d，除表现为持续性的引流管血性液体外，最常见的为高度的腹胀及进行性血压下降，部分病人因血块堵塞可致引流管无排。

若诊断为活动性出血，应果断进行剖腹止血。

我院25例OLT发生术后腹腔内大出血 1 例。

（2）消化道出血：多为胃十二指肠粘膜糜烂或应激性溃疡所致，曲张静脉破裂出血不多见。

供肝功能正常时，出血量一般不大，给予 H2 受体拮抗剂或泵抑制剂后均可停止。

2．血管并发症：肝动脉、门静脉及肝上、肝下下腔静脉四个吻合口均可出现相关的血管并发症，早期血管并发症的出现往往导致供肝的丢失，多与手术技术不当有关。

（1）肝动脉血栓形成：肝动脉管腔最小，吻合技术要求更高，最容易出现并发症，尤其是小儿。

原因常为吻合技术不当，肝流出道不畅，排斥反应，供肝血管较小和肝动脉变异，活体或劈离式肝移植等引起。

肝动脉栓塞后会出现以下结果：移植早期发生的主干栓塞往往导致移植肝无功能（PNF ）;分支血管的缺血引起胆管缺血坏死，出现胆瘘或胆道狭窄；肝局灶性坏死感染。

肝移植术后胆管吻合口狭窄经内镜胆道支架治疗的预后评价1. 引言1.1 胆管吻合口狭窄的相关介绍胆管吻合口狭窄是肝移植术后常见的并发症之一，其发生率约为10%左右。

胆管吻合口狭窄指的是在肝移植术后，术后胆管与肠道连接的部位出现狭窄，导致胆汁排泄受阻，引起胆汁淤积和胆汁性肝炎等并发症。

病因主要包括手术操作不当、术后感染、血管缺血、移植胆管缺血、异体抗原反应等因素。

胆管吻合口狭窄的临床表现主要包括黄疸、腹痛、发热、恶心呕吐等症状，严重时可导致胆汁性肝硬化和再次移植的需要。

对于肝移植术后胆管吻合口狭窄的治疗显得尤为重要。

1.2 内镜胆道支架治疗的应用背景内镜胆道支架治疗是一种广泛应用于胆道疾病领域的介入治疗手段，其应用背景主要是解决胆道狭窄或梗阻引起的病症。

内镜胆道支架通过支撑胆道壁，扩张狭窄的胆管，保持通畅的胆道，达到缓解症状、促进胆汁排泄的治疗效果。

与传统的外科手术相比，内镜胆道支架治疗具有创伤小、恢复快、并发症少等优点，成为一种安全有效的治疗方法。

在肝移植术后胆管吻合口狭窄的治疗中，内镜胆道支架的应用越来越受到重视。

由于肝移植术后胆管吻合口狭窄可能导致胆汁潴留、黄疸等严重并发症，而内镜胆道支架可以快速、准确地解决这一问题，提高患者的生活质量和存活率。

内镜胆道支架治疗在肝移植术后胆管吻合口狭窄中具有重要意义，为患者提供了一种有效的治疗选择。

2. 正文2.1 肝移植术后胆管吻合口狭窄的发生原因肝移植术后胆管吻合口狭窄的发生原因是多种因素综合作用的结果。

手术操作不当是导致胆管吻合口狭窄的主要原因之一。

手术操作不慎导致胆管周围组织炎症反应加剧，进而导致瘢痕组织形成，使得胆管口狭窄。

术后感染也是胆管吻合口狭窄的常见原因之一。

感染导致胆管周围组织炎症反应，增加了组织瘢痕形成的可能性，从而导致胆管口狭窄。

术后胆管损伤、胆汁淤积、缺血再灌注损伤等因素也可能促进胆管吻合口狭窄的发生。

在肝移植术后的临床实践中，需要密切关注手术操作及术后管理，在避免并发症的有效预防和治疗胆管吻合口狭窄的发生，以提高患者的治疗效果和生存率。

原位肝移植后胆管狭窄与胆道内镜下球囊扩张及支撑管治疗杨玉龙;陈海龙;谭文翔;冯众一;王晓光;席力罡;郭宏伟;毛卫;吕文才【期刊名称】《中国组织工程研究》【年(卷),期】2008(012)031【摘要】背景:肝移植术后胆管狭窄主要是胆管吻合口的狭窄,介入球囊扩张只能暂时通畅胆道,没有根本解决问题.目的:观察应用胆道内镜技术诊断和治疗原位肝移植后胆管狭窄的效果.设计、时间及地点:病例分析,于2001-07/2005-10在大连市肝胆外科研究所,大连市友谊医院肝胆外科住院患者10例,天津第一中心医院器官移植科伟院患者4例均在行原位肝移植术后发生胆管狭窄.对象:纳入14例中男10例,女4例,平均年龄46岁,肝移植术均采用供、受者胆管端-端吻合.方法:对14例原位肝移植术后发生胆管狭窄的病例进行胆道内镜的诊断和分析,同时采用胆道镜下球囊扩张后支撑管方法治疗肝移植后胆道狭窄.主要观察指标:T管造影、内镜下肝内外胆管黏膜直观:结石的分布、吻合口胆管黏膜的;供-受体胆管吻合口的愈合情况:炎症水肿的情况、狭窄;经内镜取石、狭窄扩张治疗后上述指标的复查.结果:①胆管狭窄的诊断:经胆道造影和内镜诊断胆管吻合口狭窄13例,其中1例是结石导致的狭窄假象:非吻合口狭窄1例.②胆管狭窄的治疗:通过胆道造影明确的吻合口狭窄中,1例采取球囊扩张1次治愈,2例行经内镜十二指肠乳头括约肌切开术+网篮取石+鼻胆引流术后仍然发生胆系感染和黄疸而行手术以及纤维胆道镜治疗.通过T型管造影,1例发现条状负影,无狭窄,纤维胆道镜观察胆管吻合口愈合佳,黏膜移行良好;2例肚内显影差或不显影而呈胆管消失改变,纤维胆道镜取净结石后,扩张吻合口的狭窄后支撑三四个月后狭窄消失,黏膜移行良好.8例肝内外胆管显影模糊,肝外和肝内Ⅰ、Ⅱ级胆管有条索状、柱状、树枝状负影和非吻合性狭窄征象,纤维胆道镜观察取净结石后观察吻合口处均有不同程度的狭窄、充血水肿,扩张支撑平均2.5个月后,狭窄消失,黏膜移行佳.1例造影提示吻合口狭窄,狭窄扩张后,内镜观察未发现结石,支撑2个月后拔管治愈.结论:胆道内镜可直观原位肝移植术后胆管狭窄的情况,进行可靠的诊断,并有效完成支撑管扩张治疗胆管狭窄.%BACKGROUND:Biliary stricture following liver transplantation is mainly focus on biliary stoma stricture; while, balloon dilatation temporarily keeps biliary tract open but not works out a solution at all.OBJECTIVE: To discuss the diagnosis and treatment of postoperative biliary stricture after orthotopie liver transplantation by the endoscope technique.DESIGN, TIME AND SETTING: A case analysis, which was performed at Dalian Liver and Gall Surgical Institute. Ten patients hospitalized from the Department of Liver and Gall Surgery of Dalian Friendship Hospital and four patients hospitalized from the Department of Organ Transplantation of Tianjin First Central Hospital were diagnosed as biliary stricture after orthotopic liver transplantation.PARTICIPANTS: Among 14 patients, 10 males and 4 females with mean age of 46 years provided end-to-end biliary anastomose.METHODS: Fourteen cases of postoperative biliary stricture after orthotopic liver transplantation were analyzed and diagnosed by endoscope technique. And by endoscope technique, the stricture was supported with tube after balloon dilatation.MAIN OUTCOME MEASURES: Bile duct mucous membrane under T-tube radiography and endoscope; calculary distribution and bile duct mucous membrane at stoma; healing of biliary stoma of donors and recipients; inflammatory edema and stricture; recheck of above-mentioned parameters after stricture expansion byendoscopic stone extraction technique.RESULTS: Thirteen cases of postoperative biliary stricture after orthotopic liver transplantation were analyzed and diagnosed by endoscope technique, including one was induced by calculus, and one non-stoma stricture. One case was treated with balloon dilation; biliary infection and jaundice occurred in 2 cases after endoscopic sphincterotomy (EST) + basket lithotripsy + endoscopic nasobiliary drainage (ENBD), so operations or fibrocholedochoscope treatments had to be carried out. By T tube radiography, in 1 case there was strip-like negative simulacrum or no stricture, well-healed anastomosis and good mucous membranel transition; poor or no intrahepatic visualization were found in 2 cases, so anastomosis dilation was processed after the calculi removal by fibrocholedochoscope, stricture disappeared in 3 or 4 months; in 8 cases there were blur extrahepatic or intrahepatic biliary visualization, cord-like, column or branch-like negative simulacrum in biliary ducts and sign of non-anastomosis stricture, after removal of calculi, anastomosis stricture and congestion, edema were found, all these disappeared after average 2.5 months of dilation; the other 1 case was found stricture by T the radiography, but no calculi was found with fibrocholedochoscope, finally the Ttube was removed after 2 months of stricture dilation.CONCLUSION: Endoscopy is significant to directly reflect and reliably diagnose postoperative biliary stricture and effectively treat biliary stricture by anastomosis dilation.【总页数】6页(P6181-6186)【作者】杨玉龙;陈海龙;谭文翔;冯众一;王晓光;席力罡;郭宏伟;毛卫;吕文才【作者单位】大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连医科大学附属第一医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001;大连市肝胆外科研究所,友谊医院肝胆外科,辽宁省大连市,116001【正文语种】中文【中图分类】R617【相关文献】1.一例重度胆管狭窄患者行胆道镜及经T管窦道球囊扩张治疗的护理 [J], 王咏梅;王景梅;刘颖琪2.内镜下乳头小切开后球囊扩张配合中药治疗老年人胆总管结石治疗体会 [J], 周立芳;张重阳;张许霞;肖彬;李晓华;邢志勇3.球囊扩张式冠脉支架治疗原位肝移植后肝动脉狭窄 [J], 黄强;戴定可;翟仁友;钱晓军;王剑锋;李建军4.原位肝移植后经皮胆道内治疗胆管狭窄 [J], 黄强;戴定可;于平;钱晓军;翟仁友5.镍钛形状记忆合金胆道内支撑管治疗胆管狭窄(附6例报告) [J], 赵广臣;肖振山;张铁鑫因版权原因，仅展示原文概要，查看原文内容请购买。

肝移植术后胆管吻合口狭窄经内镜胆道支架治疗的预后评价[Abstract] Objective To analyze the clinical effect and prognosis of endoscopic biliary stent in the treatment of bile duct anastomotic stenosis after liver transplantation. Methods Convenient select from September 2015 to January 2017，36 patients with bile duct anastomotic stenosis after liver transplantation were enrolled in our hospital. All patients underwent endoscopic biliary stenting to analyze the clinical remission rate and treatment success rate and complications. Results A total of 160 endoscopic retrograde cholangiopancreatography were performed in 36 patients. The success rate was 152，and the technical success rate was 95% （152/160）. In the early stage of operation，there were 12 complications. There were 10 occurrences after the small stent placement operation，and 2 occurrences after the four stents were placed. Conclusion Endoscopic biliary stent for the treatment of bile duct anastomotic stenosis after liver transplantation can provide greater support for biliary tract，especially in the treatment of refractory stenosis with less stent treatment，and will not have postoperative complications. The incidence is reduced and it is extremely safe.[Key words] Endoscopic biliary stent; Liver transplantation; Bile duct anastomotic stenosis; Clinical effect; Prognosis肝移植术后一种常见的并发症为胆道狭窄，其发生率在40%左右，其中胆道吻合口狭窄为主要的狭窄类型[1-2]。