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原位肝移植术后胆道吻合口狭窄的综合微创治疗效果:单中心60例分析

田文杰, 董鼎辉, 郝杰, 等. 原位肝移植术后胆道吻合口狭窄的综合微创治疗效果:单中心60例分析[J]. 器官移植, 2022, 13(5): 597-604. doi: 10.3969/j.issn.1674-7445.2022.05.008
引用本文: 田文杰, 董鼎辉, 郝杰, 等. 原位肝移植术后胆道吻合口狭窄的综合微创治疗效果:单中心60例分析[J]. 器官移植, 2022, 13(5): 597-604. doi: 10.3969/j.issn.1674-7445.2022.05.008
Tian Wenjie, Dong Dinghui, Hao Jie, et al. Comprehensive minimally invasive treatment for biliary anastomotic stenosis after orthotopic liver transplantation: a single center analysis of 60 cases[J]. ORGAN TRANSPLANTATION, 2022, 13(5): 597-604. doi: 10.3969/j.issn.1674-7445.2022.05.008
Citation: Tian Wenjie, Dong Dinghui, Hao Jie, et al. Comprehensive minimally invasive treatment for biliary anastomotic stenosis after orthotopic liver transplantation: a single center analysis of 60 cases[J]. ORGAN TRANSPLANTATION, 2022, 13(5): 597-604. doi: 10.3969/j.issn.1674-7445.2022.05.008

原位肝移植术后胆道吻合口狭窄的综合微创治疗效果:单中心60例分析

doi: 10.3969/j.issn.1674-7445.2022.05.008
基金项目: 

陕西省自然科学基础研究计划 2022JM-564

西安市科技计划项目 21YXYJ0109

详细信息
    通讯作者:

    李宇,博士,副主任医师,研究方向为肝移植及肝胆胰肿瘤微创治疗,Email: liyu-820219@163.com

  • 中图分类号: R617,R657.4+6

Comprehensive minimally invasive treatment for biliary anastomotic stenosis after orthotopic liver transplantation: a single center analysis of 60 cases

More Information
  • 摘要:   目的  探讨以内镜逆行胆胰管造影术(ERCP)为主的综合微创方案治疗肝移植术后胆道吻合口狭窄(BAS)的临床效果。  方法  回顾性分析60例肝移植术后BAS受者的资料,其中男54例,女6例,年龄(48±10)岁。首先采用ERCP治疗,成功后放置胆道塑料或金属支架,失败者选择经皮经肝胆道引流术(PTCD)会师法或经口单人操作胆道镜(SpyGlass)通过狭窄,以上均失败者则进行磁吻合再通法或其他特殊方法。总结肝移植术后BAS的发生及治疗情况,分析治疗结果、脱支架情况及复发情况。  结果  肝移植术后发生BAS的中位时间为8(4,13)个月,术后1年内、1~2年及2年以上诊断BAS的受者分别为39例、16例及5例。60例肝移植术后BAS受者均得到成功救治,其中56例首先进行ERCP,41例完成BAS治疗,成功率为73%,导丝不能通过是ERCP失败的主要原因;PTCD、SpyGlass及磁吻合再通法的成功率分别为5/9、5/7及7/8;2例通过经皮胆道镜导丝钝头突破技术和胆道十二指肠内瘘口放置支架治疗成功。38例经过3(3,4)次ERCP、13(8,18)个月支架留置后达到脱支架标准,其中塑料支架25例,金属支架13例,塑料支架留置时间较金属支架长(P < 0.05)。6例在脱支架后12(8,33)个月狭窄复发,复发率为16%。复发者再次ERCP治疗,5例成功脱支架无复发。多因素分析结果提示狭窄诊断时间迟、脱支架前ERCP治疗次数多是BAS复发的独立危险因素(均为P < 0.05)。  结论  以ERCP为主的综合微创方案可提高肝移植术后BAS治疗成功率,远期效果满意,BAS诊断时间迟、脱支架所需ERCP次数多是BAS复发的独立危险因素。

     

  • 图  1  肝移植术后BAS的治疗方法

    注:A图为ERCP+多支塑料支架;B图为ERCP+胆道全覆膜金属支架;C图为PTCD会师技术;D图为SpyGlass辅助导丝超选重度狭窄(箭头示中心性针尖样狭窄);E图为磁吻合再通(箭头示子母磁体);F图为经皮经肝胆道镜引导导丝钝头突破技术(箭头示导丝钝头)。

    Figure  1.  Treatment of BAS after liver transplantation

    图  2  本组肝移植术后BAS受者治疗流程

    Figure  2.  Treatment process of BAS recipients after liver transplantation in this group

    表  1  脱支架后BAS复发危险因素的单因素分析

    Table  1.   Univariate analysis of risk factors for recurrence of BAS after stent removal

    临床因素 例数 复发例数 Wald值 比值比 95%可信区间 P
    性别 6.382 0.238 0.078~0.725 0.012
      男 34 5
      女 4 1
    年龄 - - 1.542 0.971 0.926~1.017 0.214
    支架类型 3.112 2.258 0.913~5.582 0.078
      塑料支架 25 3
      金属支架 13 3
    磁吻合 0.394 1.483 0.433~5.081 0.530
      是 6 1
      否 32 5
    T管引流 0.774 1.569 0.575~4.276 0.379
      是 8 1
      否 30 5
    胆瘘 1.240 1.777 0.646~4.888 0.265
      是 7 1
      否 31 5
    ERCP治疗次数 - - 21.061 2.752 1.786~4.241 < 0.001
    支架留置时间 - - 0.149 1.017 0.934~1.108 0.700
    狭窄诊断时间 - - 4.588 1.028 1.002~1.054 0.032
    注:①为连续变量。
    下载: 导出CSV

    表  2  脱支架后BAS复发危险因素的多因素分析

    Table  2.   Multivariate analysis of risk factors for recurrence of BAS after stent removal

    临床因素 B值 标准误 Wald值 比值比 95%可信区间 P
    狭窄诊断时间 0.044 0.017 6.823 1.045 1.011~1.080 0.009
    ERCP治疗次数 1.250 0.258 23.389 3.490 2.103~5.792 < 0.001
    常量 -7.080 1.201 34.756 0.001 - < 0.001
    注:①-为无数据。
    下载: 导出CSV
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  • 收稿日期:  2022-04-11
  • 网络出版日期:  2022-09-14
  • 刊出日期:  2022-09-15

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