Organ transplantation center, Peking University, Li GuangmingIn recent years, with the rapid development of China's liver transplantation, t
Organ transplantation center, Peking University, Li Guangming
In recent years, with the rapid development of China's liver transplantation, transplantation complication rate decreased year by year, biliary complications to 3%~20% after operation. The mortality rate dropped to 1~10%, but after liver transplantation biliary complications is still a major cause of graft dysfunction.
There are many types of biliary complications, and associated with postoperative vascular complications, infection and immune rejection. There were two kinds of complications: the early biliary complications occurred within the first 30 days after liver transplantation, and the incidence of late biliary complications occurred more than 30 or 30 days after liver transplantation. Most of the literatures were classified into two categories according to their pathological findings: bile leakage and bile duct obstruction.
Bile leakage including anastomotic leakage, bile leakage and bile leakage of T tube. With the improvement of liver transplantation technology and the application of microsurgical technique in the bile duct anastomosis, the bile leakage complications related to the operation of liver transplantation have been reduced to a very low level.
Bile duct obstruction is still the main complication of liver transplantation. The causes of bile duct obstruction after liver transplantation are very complex, and there are many related factors. At the same time, there are different clinical types of bile duct complications, such as stenosis of bile duct, stenosis of bile duct, stenosis of bile duct, biliary cast syndrome, bile cyst (Biloma).
The main causes of anastomotic stricture of the bile duct are anastomotic technique and local blood supply. Anastomosis stenosis there are four main methods: 1 drug treatment: suitable for narrow light, very light in patients with impaired liver function, using drugs can reach the cholagogic effect. 2, interventional therapy: the majority of patients with anastomotic stenosis and this method can be used to achieve accurate results. Through T tube sinus, PTC or ERCP balloon dilatation and stent. 3, surgical treatment: for the interventional treatment of patients with common bile duct end to end anastomosis, can change the way of anastomosis, the establishment of bile duct jejunum anastomosis and correct anastomotic stenosis. Anastomotic anastomotic stenosis due to poor local blood supply caused by the main preventive measures is to shorten the poor blood supply of hepatic bile duct, bile duct receptor to maximize the retention of good blood supply, and reduce the tension of anastomosis, without anastomotic bile duct was too long. At present, the use of microsurgical techniques for bile duct anastomosis.
Biliary anastomotic stenosis complicated reasons: in the first time of donor liver cold ischemia is a timely and effective intrahepatic bile duct flush, two warm ischemia time, hepatic artery thrombosis, hepatic resection, accessory hepatic artery loss, ischemia time, donor recipient ABO blood group incompatibility, cytomegalovirus infection, chronic rejection and recurrence of primary disease (such as the primary disease of sclerosing cholangitis). There are three main methods for treatment of non anastomotic stricture of bile duct: 1. Ursodeoxycholic acid and other drugs to promote bile excretion, effective for patients with mild symptoms, mild stenosis. For patients with multiple stenosis, the symptoms are obvious, waiting for a liver transplant. 2, balloon dilation, stent support. Short term results are good, but the good long-term effect depends on repeated ERCP intervention, multiple balloon dilatation and replacement of the support tube. The treatment of multiple stenosis caused by arterial embolization is more effective. 3, liver transplantation. Accompanied by hepatic artery embolization, recurrent cholangitis and even liver abscess and multiple intrahepatic stricture endoscopic therapy, re transplantation is the only effective way. Because of many causes of intrahepatic bile duct stenosis, so the prevention of bile duct stricture should be from various aspects. The most important thing is to reduce the time of cooling blood supply to the liver, the first time when the donor liver is cut, the intrahepatic bile duct flushing, the blood supply of the donor bile duct and the prevention of hepatic artery thrombosis.
Biliary cast syndrome (Biliary Cast, Syndrome, BCS) is refers after liver transplantation in hepatic bile duct necrosis material filling the mold forming the biliary tree like, known as the "biliary cast" (Biliary Cast BC), which caused a series of clinical manifestations, and may be associated with one or more non anastomotic stenosis or necrosis of bile duct epithelium. The causes of BCS were as follows: 1. The disturbance of blood supply to the bile duct and the damage to the blood supply of the bile duct during the operation. 2, physical and chemical factors: bile salt in the bile duct under the condition of ischemia has a heavy toxic effect on the biliary epithelium, and the mixture of low temperature and UW can aggravate the toxic effect. 3, for liver quality: warm ischemia time (warm ischemic time, WIT), cold preservation time (cold preservation time, CPT) the shorter, the lower the incidence of BCS. 4. The warm ischemia time of bile duct: cause the bile duct epithelium to be in the two warm ischemia, after the hepatic artery opens, appear more serious reperfusion injury. Therefore, the shorter the time of biliary warm ischemia, the more effective to prevent BCS. 5. Ischemia reperfusion injury: ischemia reperfusion injury is an important cause of acute biliary tract injury. 6, surgical skills: with the skill of surgery and improve the awareness of the disease, showed a gradual downward trend. 7, high concentration contrast agent stimulation. 8, local stimulation. 9, the new liver bile secretion disorders: a new liver after recovery of blood flow, the components of bile (bile salt phosphatidylcholine) secretion, bile salt / phospholipid ratio is high, the more serious injury of bile duct endothelial, this process is mainly composed of high concentration of bile salt mediated toxicity of biliary epithelial guide. For BCS, prevention and reduction of cold and warm ischemia time of donor liver, timely and effective bile duct irrigation after donor hepatectomy and recovery of blood.
Bile cyst (Biloma): also known as biloma, because early diagnosis and timely treatment of bile leakage, extrahepatic bile accumulation is quite rare, however in the intrahepatic segmental obstruction area or serious biliary tree ischemic damage area, intrahepatic cysts can occur. Secondary infection is caused by sepsis and further aggravate biliary damage.
Surgical drainage is often the most effective method.
Papillary dysfunction: papillary dysfunction of liver transplantation in patients with bile duct anastomosis in the slow development, gradually evolved into a full dilatation of bile duct (including bile duct, donor and acceptor) and the occurrence of mild to moderate bilirubin and liver enzymes are elevated, bile duct anastomosis, the most common complication, and supply nipple blood vessels and nerves were cut off, the incidence rate of about 5%. Because of the clinical symptoms are hidden, no change at the beginning, often misdiagnosed as rejection and treatment. Endoscopic Odis sphincterotomy is satisfactory, and some patients can relieve symptoms by relieving sphincter spasm.
Splenic artery steal syndrome: a cause of multiple intrahepatic bile duct stricture after liver transplantation and the cause of bile duct cast formation. Thickening of the splenic artery shunting most of the celiac trunk artery blood, resulting in subacute ischemia of the biliary epithelium. If the diameter of the splenic artery was obviously larger than that of the common hepatic artery, the splenic artery should be properly treated in the operation.
About T type tube is placed in the problem, at present we have consensus, is to minimize the T tube placement. But for the following cases, we suggest that the location is good: for the liver cold and warm ischemia time is too long, the donor liver fat becomes obvious, for the recipient blood group incompatibility and the difference between the caliber of the donor bile duct too far.
Biliary complications are important factors affecting the prognosis of orthotopic liver transplantation. Because of its complex etiology, it will be a difficult process to significantly reduce its incidence. First, we should pay attention to prevention, and then try to achieve early diagnosis as soon as possible, and can take effective measures. Due to the application of MRCP technology to provide help for the early diagnosis of biliary tract complications, interventional therapy and ERCP and assisted by PTC has been taken seriously, although some of the biliary complications such as diffuse effect of bile duct stenosis were still not satisfied, but with improved method of accumulation and practice, inevitably as an effective treatment method. This makes many patients avoid surgical reconstruction of bile duct and liver transplantation. However, liver transplantation is still the final choice for severe biliary complications.