肝移植术后胆管吻合口狭窄内镜胆道支架治疗

摘要

Objective To evaluate the therapeutic effect of endoscopic management of plastic stents of post-liver transplantation anastomotic biliary stricture. Methods From January 2010 to October 2015, clinical data of patients with post-liver transplantation anastomotic biliary stricture and received endoscopic retrograde cholangiopancreatog﹣raphy and plastic stents management was collected. The technical success rate, ERCP-related complications, clinical remission rate and long-term complications were main outcome measurements to compare the efficacy and safety of different number of stents in managing post-liver transplantation anastomotic biliary stricture. Results Among the 18 patients (0.5 ~ 60.0 months) with post-liver transplantation ABSs, seven patients received less plastic stents treat﹣ment (< 3 stents), nine patients with persistent anastomotic or recurrent stricture received multiple plastic stents treatment (≥ 3 stents), two patients received multiple plastic stents treatment once suffered with post-liver trans﹣plantation ABSs. The endoscopic technical success rate was seventy-six over eighty (95.0 %). Among the seven pa﹣tients received less plastic stents treatment, one loss to follow-up, two were still under treatment, one died of acute hepatic failure, one died of septic stock, one combined with biliary fistula resulted in treatment failure, one achieved clinical remission, the clinical remission rate was one third (33.3 %). Among the eleven patients received multiple plastic stents treatment, two loss to follow-up, one was still under treatment, two received surgery because of failed treatment, six achieved clinical remission, the clinical remission rate was 75.0 % (6/8). The average diameters and stent durations of management of 1 stent, 2 stents, 3 stents, 4 stents, 5 stents, 7 stents were 8.5 F, 17.0 F, 24.0 F, 28.0 F, 36.0 F, 50.0 F. Among the six early postoperative complications, five cases occurred in less stent manage﹣ment and one occurred in MPSs management, the early postoperative complication rate was 7.5 %(6/80). No severe ERCP-related complications and procedure-related deaths. Conclusions Endoscopic management of plastic stents is safe and effective for post-liver transplantation ABSs. Providing larger biliary support, the multiple plastic stents treatment was superior to less plastic stents treatment in view of clinical remission rate, especially for refractory one. Multiple plastic stents did not increase the incidence of complications, it could be used as the first-line treatment of post-liver transplantation duct-to-duct biliary anastomosis for its safety and effectivity.%目的：评价肝移植术后胆管吻合口狭窄（ABSs）经内镜逆行胰胆管造影（ERCP）下胆道塑料支架治疗的效果。方法收集2010年1月-2015年10月肝移植术后出现ABSs并在广西医科大学第一附属医院内镜中心进行内镜下胆道塑料支架置入治疗的病例资料。记录内镜治疗操作及术后并发症发生情况，统计技术成功率、临床缓解率和并发症发生率等，总结及评价不同数目胆道支架治疗肝移植术后ABSs的安全性及有效性。结果18例肝移植术后（0.5～60.0个月）患者，7例始终接受少支架治疗（<3支），11例接受了多胆道塑料支架（MPSs）治疗（≥3支）。所有80次ERCP操作共76次获得成功，技术成功率为95.0%。7例中，1例失访，2例仍在治疗中，1例因急性排斥反应致肝功能衰竭死亡，1例因感染性休克死亡，1例合并胆瘘的患者治疗失败，1例获得临床缓解，缓解率为33.3%（1/3）。11例中，2例失访，1例仍在治疗，2例因内镜治疗失败转外科治疗，余6例获得临床缓解，缓解率为75.0%（6/8）。置入1、2、3、4、5和7支架的平均支架总口径分别为8.5、17.0、24.0、28.0、36.0和50.0 F。术后早期并发症共6例次，发生率为7.5%（6/80），其中5例次发生在少支架置入操作后，1例次发生在4支支架操作之后。所有患者ERCP术后无严重的手术相关并发症及死亡发生。结论肝移植术后ABSs采用MPSs治疗，甚至最大化支架治疗的方法，能提供更大的胆道支撑力，临床缓解率更高，尤其对于少支架治疗存在困难的顽固型狭窄具有较大优势，同时不增加术后并发症发生率，安全性及有效性均较高，可作为目前肝移植胆管端端吻合术后ABSs的一线治疗方法。