内镜逆行胆胰管造影术处理心脏死亡器官捐献供体肝移植受体术后胆道狭窄临床分析

doi:10.3877/cma.j.issn.1674-0793.2015.02.010

目的

探讨内镜逆行胆胰管造影技术(ERCP)在心脏死亡器官捐献供体(DCD)肝移植术后胆道狭窄治疗中的临床应用价值。

方法

回顾性分析2011 年9 月至2014 年6 月接受DCD 肝移植手术治疗的34 例肝移植受体的临床资料。

结果

磁共振胰胆管造影(MRCP)作为诊断肝移植术后胆道狭窄的标准方法,34 例DCD 肝移植术后发生胆道狭窄8 例,发生率为23.53%,其中2 例为吻合口狭窄,胆道狭窄组的肝移植等待时间明显长于非胆道狭窄组[(72.5 ± 86.0) d vs(14.4 ± 30.1) d,U=40.0,P=0.01]。 1 例自行再通,7 例接受ERCP 胆道内支架置入均获成功,ERCP术后并发胰腺炎4 例(57.14%),胆管炎1 例(14.29%)和胆管炎合并肝脓肿1 例(14.3%)。

结论

胆道狭窄是DCD 肝移植术后常见并发症,MRCP 是诊断肝移植术后胆道狭窄的重要非有创性检查手段,ERCP 胆道内支架置入是处理肝移植术后胆道狭窄的有效治疗方式,仍需进一步观察ERCP的疗效。

关键词: 内镜逆行胰胆管造影, 心脏死亡器官捐献供体, 肝脏移植, 胆道狭窄, 治疗

Objective

To explore the role of endoscopic retrograde cholangiopancreatography(ERCP)in the treatment of biliary strictures after liver transplantation with donation after cardiac death (DCD).

Methods

The clinical data of thirty-four patients undergoing liver transplantation between September 2011 and June 2014 in our hospital was retrospectively analyzed.

Results

Magnetic resonance cholangiopancreatography(MRCP) was the standard method for the diagnosis of biliary stricture after liver transplantation. The biliary stricture incidence rate after liver transplantation with DCD was 23.53% (8/34), including two cases of anastomotic stricture, and 6 cases of non-anastomotic stricture. The waiting time for liver transplantation in the biliary stricture group was longer compared with that in the non biliary stricture group[(72.5±86.0) d vs (14.4±30.1) d, U=40.0, P=0.01]. One biliary stricture case recovered to normal without any intervention. Seven liver transplant recipients with biliary stricture were cured successfully by placing biliary tract stent through ERCP. The complications after ERCP was acute pancreatitis in 4 cases(4/7, 57.14%), 1 case with cholangitis (1/7, 14.29%) and 1 case with combined cholangitis and hepatic abscess (1/7, 14.29%).

Conclusions

Biliary stricture is the common complication after liver transplantation with DCD, while MRCP is an importantly noninvasive detective method for the diagnosis of biliary stricture after liver transplantation. Placing biliary tract stent through ERCP is the effective treatment for the biliary stricture after liver transplantation. Its curative effect for the biliary stricture needs further investigation.

Key words: Endoscopic retrograde cholangiopancreatography, Donation after cardiac death, Liver transplantation, Biliary stricture, Treatment

表1 34 例DCD 肝移植受体术后发生胆道狭窄情况比较

项目	胆道狭窄组	非胆道狭窄组	统计值	P值
例数	8	26
男∶女	8∶0	24∶2	1.1^a	1.00
年龄(岁, $\bar{x}$ ±s)	48.6±8.4	48.9±7.9	103.5	1.00
原发病[例(%)]			11.7^a	0.04
乙肝相关	6(75.0)	23(88.5)
原发性肝癌	1(12.5)	10(38.5)
酒精性肝硬化	1(12.5)	0(0)
乙肝并丙肝肝硬化	1(12.5)	0(0)
急性肝衰竭	0(0)	7(26.9)
慢加急性肝衰竭	2(25.0)	3(11.5)
ALT(U/L, $\bar{x}$ ±s)	48.6±20.2	65.9±70.7	101.0	0.92
ALB(g/L, $\bar{x}$ ±s)	33.6±8.0	34.2±7.5	100.0	0.89
TBIL(μmol/L, $\bar{x}$ ±s)	114.7±170.8	169.9±223.2	86.5	0.49
MELD评分( $\bar{x}$ ±s)	18.3±10.6	19.3±10.0	95.0	0.73
等待时间(d, $\bar{x}$ ±s)	72.5±86.0	14.4±30.1	40.0	0.01
中位随访时间(月)	5.3(1.5~32)	17.3(3~26)	57.5	0.06

表1 34 例DCD 肝移植受体术后发生胆道狭窄情况比较

项目	胆道狭窄组	非胆道狭窄组	统计值	P值
例数	8	26
男∶女	8∶0	24∶2	1.1^a	1.00
年龄(岁, $\bar{x}$ ±s)	48.6±8.4	48.9±7.9	103.5	1.00
原发病[例(%)]			11.7^a	0.04
乙肝相关	6(75.0)	23(88.5)
原发性肝癌	1(12.5)	10(38.5)
酒精性肝硬化	1(12.5)	0(0)
乙肝并丙肝肝硬化	1(12.5)	0(0)
急性肝衰竭	0(0)	7(26.9)
慢加急性肝衰竭	2(25.0)	3(11.5)
ALT(U/L, $\bar{x}$ ±s)	48.6±20.2	65.9±70.7	101.0	0.92
ALB(g/L, $\bar{x}$ ±s)	33.6±8.0	34.2±7.5	100.0	0.89
TBIL(μmol/L, $\bar{x}$ ±s)	114.7±170.8	169.9±223.2	86.5	0.49
MELD评分( $\bar{x}$ ±s)	18.3±10.6	19.3±10.0	95.0	0.73
等待时间(d, $\bar{x}$ ±s)	72.5±86.0	14.4±30.1	40.0	0.01
中位随访时间(月)	5.3(1.5~32)	17.3(3~26)	57.5	0.06

表2 两组器官捐献供体临床特点

项目	胆道狭窄组	非胆道狭窄组	统计值	P值
例数	8	26
供体类型			4.9^a	0.09
C-Ⅰ	4	8
C-Ⅱ	1	0
C-Ⅲ	3	18
年龄(岁, $\bar{x}$ ±s)	35.6±15.5	35.4±11.5	101.5	0.94
原发病[例(%)]			3.7^a	0.29
脑外伤	5(62.5)	16(61.5)
脑血管意外	2(25.0)	9(34.6)
脑肿瘤	0(0)	1(3.8)
其他	1(12.5)	0(0)
BMI(kg/m², $\bar{x}$ ±s)	21.3±1.7	22.5±1.6	62.5	0.10
ALT(U/L, $\bar{x}$ ±s)	143.1±152.6	249.7±471.2	103.0	0.98
TBIL(μmol/L, $\bar{x}$ ±s)	25.9±22.8	18.1±11.7	90.5	0.60
ALP(U/L, $\bar{x}$ ±s)	138.3±144.2	162.8±148.9	75.0	0.25
热缺血时间(min, $\bar{x}$ ±s)	5.1±7.2	6.2±5.8	88.0	0.52
冷缺血时间(h, $\bar{x}$ ±s)	5.0±1.2	5.4±2.1	98.0	0.82

表2 两组器官捐献供体临床特点

项目	胆道狭窄组	非胆道狭窄组	统计值	P值
例数	8	26
供体类型			4.9^a	0.09
C-Ⅰ	4	8
C-Ⅱ	1	0
C-Ⅲ	3	18
年龄(岁, $\bar{x}$ ±s)	35.6±15.5	35.4±11.5	101.5	0.94
原发病[例(%)]			3.7^a	0.29
脑外伤	5(62.5)	16(61.5)
脑血管意外	2(25.0)	9(34.6)
脑肿瘤	0(0)	1(3.8)
其他	1(12.5)	0(0)
BMI(kg/m², $\bar{x}$ ±s)	21.3±1.7	22.5±1.6	62.5	0.10
ALT(U/L, $\bar{x}$ ±s)	143.1±152.6	249.7±471.2	103.0	0.98
TBIL(μmol/L, $\bar{x}$ ±s)	25.9±22.8	18.1±11.7	90.5	0.60
ALP(U/L, $\bar{x}$ ±s)	138.3±144.2	162.8±148.9	75.0	0.25
热缺血时间(min, $\bar{x}$ ±s)	5.1±7.2	6.2±5.8	88.0	0.52
冷缺血时间(h, $\bar{x}$ ±s)	5.0±1.2	5.4±2.1	98.0	0.82

表3 34 例肝移植受体术中及术后情况(Mann-Whitney U 检验,)

项目	胆道狭窄组	非胆道狭窄组	U值	P值
例数	8	26
术中出血量(ml)	7 888±3 619	6 100±5 097	65.0	0.12
术中输血量(RBC,U)	17.6±10.3	18.0±12.0	98.5	0.84
无肝期(min)	76.5±16.4	69.6±20.2	79.0	0.32
手术时间(min)	513.1±109.9	480.8±96.5	92.0	0.64
术后峰值
ALT(U/L)	629.3±693.6	739.6±885.1	83.0	0.41
AST(U/L)	1 771±1 514	1 621±1 702	99.0	0.86
TBIL(μmol/L)	230.0±113.6	123.8±87.2	39.0	0.01
ICU住院时间(d)	4.6±5.0	4.0±2.4	89.5	0.57
术后住院时间(d)	30.8±15.8	23.6±10.5	63.0	0.10

表3 34 例肝移植受体术中及术后情况(Mann-Whitney U 检验,)

项目	胆道狭窄组	非胆道狭窄组	U值	P值
例数	8	26
术中出血量(ml)	7 888±3 619	6 100±5 097	65.0	0.12
术中输血量(RBC,U)	17.6±10.3	18.0±12.0	98.5	0.84
无肝期(min)	76.5±16.4	69.6±20.2	79.0	0.32
手术时间(min)	513.1±109.9	480.8±96.5	92.0	0.64
术后峰值
ALT(U/L)	629.3±693.6	739.6±885.1	83.0	0.41
AST(U/L)	1 771±1 514	1 621±1 702	99.0	0.86
TBIL(μmol/L)	230.0±113.6	123.8±87.2	39.0	0.01
ICU住院时间(d)	4.6±5.0	4.0±2.4	89.5	0.57
术后住院时间(d)	30.8±15.8	23.6±10.5	63.0	0.10

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Endoscopic retrograde cholangiopancreatography in the treatment of biliary strictures after liver transplantation with donation after cardiac death

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Endoscopic retrograde cholangiopancreatography in the treatment of biliary strictures after liver transplantation with donation after cardiac death