儿童劈离式肝移植的胆管分型与重建

韦金铭; 冯啸; 曾凯宁; 杨卿; 姚嘉; 傅斌生; 张彤; 黄心如; 刘博颖; 陈规划; 杨扬; 易述红

doi:10.3969/j.issn.1674-7445.2022.06.015

儿童劈离式肝移植的胆管分型与重建

doi: 10.3969/j.issn.1674-7445.2022.06.015

510630 广州，中山大学附属第三医院肝移植中心

基金项目:

广东省自然科学基金 2020A1515010574

详细信息

作者简介:

通讯作者:
易述红，博士，主任医师，研究方向为肝移植及其相关基础研究，Email：yishuhong@163.com

中图分类号: R617, R575
计量
- 文章访问数: 231
- HTML全文浏览量: 107
- PDF下载量: 72
- 被引次数: 0
出版历程
- 收稿日期: 2022-07-20
- 网络出版日期: 2022-11-14
- 刊出日期: 2022-11-15

Classification and reconstruction of bile duct in pediatric split liver transplantation

Department of Liver Transplantation, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China

More Information

Corresponding author: Yi Shuhong, Email: yishuhong@163.com

摘要

摘要: 目的探讨儿童劈离式肝移植左肝内胆管（LHD）的解剖分型、胆道重建方式及其与术后胆道并发症的关系。方法回顾性分析75例儿童劈离式肝移植受者的临床资料。供肝劈离前采用碘普罗胺注射液经胆总管逆行造影，根据二、三、四段肝内胆管走向确定供肝LHD的解剖分型，总结不同LHD分型的胆道重建方案，分析儿童劈离式肝移植术后胆道并发症的发生及治疗情况。结果 75个供肝中，LHD解剖分型为Ⅰ型57例（76%）、Ⅱ型9例（12%）、Ⅲ型4例（5%）、Ⅳ型5例（7%）。75例儿童受者的胆道重建方案包括左肝管-空肠Roux-en-Y吻合69例（Ⅰ型53例、Ⅱ型8例、Ⅲ型4例、Ⅳ型4例），胆总管-空肠Roux-en-Y吻合1例（Ⅳ型），左肝管-胆总管端端吻合5例（Ⅰ型4例、Ⅱ型1例）。术后6例发生胆道并发症，发生率为8%，其中胆道吻合口狭窄3例，胆道吻合口胆漏2例，肝断面胆漏1例。发生在Ⅰ型4例，发生在Ⅲ型2例，LHD经典型与解剖变异型的胆道并发症发生率差异无统计学意义（均为P > 0.05）。3例胆道吻合口狭窄受者中，2例行经皮经肝胆道引流术（PTCD），1例行再次胆肠吻合术；2例胆道吻合口胆漏受者均行PTCD；1例断面胆漏受者予局部引流。6例患儿治疗后均存活。结论供肝中24%存在LHD的解剖变异，其中Ⅱ型最多，为12%。供肝劈离前常规胆道造影和精细的胆道吻合技术可以有效降低胆道并发症的发生率。术后胆道并发症的发生与LHD解剖分型无明显相关性。
- 劈离式肝移植 /
- 儿童 /
- 左肝内胆管 /
- 解剖分型 /
- 胆道造影 /
- 胆道重建 /
- 胆道吻合口狭窄 /
- 胆漏
Abstract: Objective To investigate the anatomical classification of left intrahepatic bile duct (LHD) and the pattern of bile duct reconstruction during pediatric split liver transplantation and their relationship with postoperative biliary complications. Methods Clinical data of 75 pediatric recipients undergoing split liver transplantation were analyzed retrospectively. Before splitting the donor liver, iopromide injection was used for retrograde cholangiography through the common bile duct. According to the patterns of intrahepatic bile ducts in the second, third and fourth segments, the anatomical classification of LHD of the donor liver was determined. The biliary reconstruction regimens for different classification types of LHD were summarized. The incidence and treatment of biliary complications after pediatric split liver transplantation were analyzed. Results Among 75 donor livers, the anatomical classification of LHD included 57 cases (76%) of type Ⅰ, 9 cases (12%) of type Ⅱ, 4 cases (5%) of type Ⅲ and 5 cases (7%) of type Ⅳ LHD, respectively. Among 75 pediatric recipients, 69 cases (53 cases of type Ⅰ, 8 type Ⅱ, 4 type Ⅲ and 4 type Ⅳ) underwent the left hepatic duct-jejunum Roux-en-Y anastomosis, 1 case received common bile duct-jejunum Roux-en-Y anastomosis (type Ⅳ), and 5 cases underwent the left hepatic duct-common bile duct end-to-end anastomosis (4 cases of type Ⅰ and 1 type Ⅱ). Postoperative biliary complications occurred in 6 cases (8%), including 3 cases of biliary anastomotic stenosis, 2 cases of biliary anastomotic leakage and 1 case of bile leakage on the hepatic resection surface. Among 6 recipients, 4 cases were classified as type Ⅰ and 2 cases of type Ⅲ LHD. No significant difference was observed in the incidence of biliary complications between typical type and anatomical variant type of LHD (all P > 0.05). Among 3 recipients with biliary anastomotic stenosis, 2 cases underwent percutaneous transhepatic cholangial and drainage (PTCD) and 1 case repeatedly received biliary-intestinal anastomosis. Two cases of biliary anastomotic leakage underwent PTCD and 1 case of bile leakage on the hepatic resection surface received local drainage. All 6 children survived after treatment. Conclusions Anatomical variation of LHD can be observed in 24% of donor livers, and type Ⅱ accounts for the highest proportion of 12%. Prior to donor liver splitting, routine cholangiography and fine biliary anastomosis may effectively lower the incidence of biliary complications. The incidence of postoperative biliary complications is not significantly associated with the anatomical classification of LHD.
- Split liver transplantation /
- Children /
- Left intrahepatic bile duct /
- Anatomical classification /
- Cholangiography /
- Biliary reconstruction /
- Biliary anastomotic stricture /
- Bile leakage

HTML全文

下载: 全尺寸图片幻灯片

图 1 供肝LHD解剖分型

注：A图示Ⅰ型；B图示Ⅱ型；C图示Ⅲ型；D图示Ⅳ型。红色数字2、3、4分别代表肝内二、三、四段胆管。

Figure 1. Anatomical classification of LHD of donor liver

下载: 全尺寸图片幻灯片

参考文献(36)

[1]	PERITO ER, ROBERTS JP. Editorial: optimizing outcomes for children requires ensuring access to living: donor and split liver transplants[J]. Transplantation, 2022, 106(9): 1736-1737. DOI: 10.1097/TP.0000000000004174.
[2]	SMITH JM, WEAVER T, SKEANS MA, et al. OPTN/SRTR 2017 annual data report: intestine[J]. Am J Transplant, 2019, 19(Suppl 2): 284-322. DOI: 10.1111/ajt.15277.
[3]	NAMGUNG JM, HWANG S, AHN CS, et al. Korea-nationwide incidence of pediatric deceased donors and single-institutional status of liver transplantation using pediatric donor liver grafts[J]. Korean J Transplant, 2020, 34(3): 178-184. DOI: 10.4285/kjt.2020.34.3.178.
[4]	MOGUL DB, LUO X, BOWRING MG, et al. Fifteen-year trends in pediatric liver transplants: split, whole deceased, and living donor grafts[J]. J Pediatr, 2018, 196: 148-153. DOI: 10.1016/j.jpeds.2017.11.015.
[5]	D'ALESSANDRO AM, KNECHTLE SJ, CHIN LT, et al. Liver transplantation in pediatric patients: twenty years of experience at the University of Wisconsin[J]. Pediatr Transplant, 2007, 11(6): 661-670. DOI: 10.1111/j.1399-3046.2007.00737.x.
[6]	YOON KC, SONG S, LEE S, et al. Outcomes of split liver transplantation vs living donor liver transplantation in pediatric patients: a 5-year follow-up study in Korea[J]. Ann Transplant, 2022, 27: e935682. DOI: 10.12659/AOT.935682.
[7]	NAKAMURA T, TANAKA K, KIUCHI T, et al. Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases[J]. Transplantation, 2002, 73(12): 1896-1903. DOI: 10.1097/00007890-200206270-00008.
[8]	SHARMA V, SARASWAT VA, BAIJAL SS, et al. Anatomic variations in intrahepatic bile ducts in a north Indian population[J]. J Gastroenterol Hepatol, 2008, 23(7 Pt 2): e58-e62. DOI: 10.1111/j.1440-1746.2008.05418.x.
[9]	SWAIN B, SAHOO RK, SEN KK, et al. Evaluation of intrahepatic and extrahepatic biliary tree anatomy and its variation by magnetic resonance cholangiopancreatography in Odisha population: a retrospective study[J]. Anat Cell Biol, 2020, 53(1): 8-14. DOI: 10.5115/acb.19.177.
[10]	CHO A, OKAZUMI S, YOSHINAGA Y, et al. Relationship between left biliary duct system and left portal vein: evaluation with three-dimensional portocholangiography[J]. Radiology, 2003, 228(1): 246-250. DOI: 10.1148/radiol.2281020740.
[11]	UYSAL F, OBUZ F, UÇAR A, et al. Anatomic variations of the intrahepatic bile ducts: analysis of magnetic resonance cholangiopancreatography in 1011 consecutive patients[J]. Digestion, 2014, 89(3): 194-200. DOI: 10.1159/000358558.
[12]	SONG GW, LEE SG, HWANG S, et al. Preoperative evaluation of biliary anatomy of donor in living donor liver transplantation by conventional nonenhanced magnetic resonance cholangiography[J]. Transpl Int, 2007, 20(2): 167-173. DOI: 10.1111/j.1432-2277.2006.00419.x.
[13]	CAROLLO V, DI FRANCESCO F, RICOTTA C, et al. Bile duct anatomical variations: relevance for liver division and preparing left split liver grafts for pediatric transplantation: cohort study[J]. Int J Surg, 2021, 90: 105979. DOI: 10.1016/j.ijsu.2021.105979.
[14]	YAGI S, SINGHAL A, JUNG DH, et al. Living-donor liver transplantation: right versus left[J]. Int J Surg, 2020, 82S: 128-133. DOI: 10.1016/j.ijsu.2020.06.022.
[15]	崔子林, 朱志军, 张雅敏, 等. 应用MRCP术前评估活体肝移植供者胆管系统[J]. 中华肝胆外科杂志, 2010, 16(6): 418-421. DOI: 10.3760/cma.j.issn.1007-8118.2010.06.008. CUI ZL, ZHU ZJ, ZHANG YM, et al. Preoperative evaluation of donor biliary system with MRCP in living donor liver transplantation[J]. Chin J Hepatobiliary Surg, 2010, 16(6): 418-421. DOI: 10.3760/cma.j.issn.1007-8118.2010.06.008.
[16]	WELLE CL, MILLER FH, YEH BM. Advances in MR imaging of the biliary tract[J]. Magn Reson Imaging Clin N Am, 2020, 28(3): 341-352. DOI: 10.1016/j.mric.2020.03.002.
[17]	AYUSO JR, AYUSO C, BOMBUY E, et al. Preoperative evaluation of biliary anatomy in adult live liver donors with volumetric mangafodipir trisodium enhanced magnetic resonance cholangiography[J]. Liver Transpl, 2004, 10(11): 1391-1397. DOI: 10.1002/lt.20281.
[18]	LIM CJ, HONG K, LEE JM, et al. Clinical usefulness of T1-weighted MR cholangiography with Gd-EOB-DTPA for the evaluation of biliary complication after liver transplantation[J]. Ann Hepatobiliary Pancreat Surg, 2021, 25(1): 39-45. DOI: 10.14701/ahbps.2021.25.1.39.
[19]	BATTULA NR, ANBARASAN R, THUMMA V, et al. Utility of a routine bench cholangiogram for ex situ split liver procedure[J]. Clin Transplant, 2019, 33(7): e13614. DOI: 10.1111/ctr.13614.
[20]	LAU NS, JACQUES A, MCCAUGHAN G, et al. Addressing the challenges of split liver transplantation through technical advances. a systematic review[J]. Transplant Rev (Orlando), 2021, 35(3): 100627. DOI: 10.1016/j.trre.2021.100627.
[21]	WEI L, ZHANG ZT, ZHU ZJ, et al. A new approach to accomplish intraoperative cholangiography in left lateral segmentectomy of living liver donation[J]. Ann Transplant, 2019, 24: 155-161. DOI: 10.12659/AOT.915400.
[22]	SAKAMOTO K, OGAWA K, TAMURA K, et al. Usefulness of a balloon catheter for intraoperative cholangiography during living donor hepatectomy: a product investigation[J]. Ann Transplant, 2020, 25: e929062. DOI: 10.12659/AOT.929062.
[23]	YILMAZ C, KARACA CA, FERECOV R, et al. Duct-to-duct biliary reconstruction in pediatric split-liver transplantation[J]. Liver Transpl, 2018, 24(3): 432-435. DOI: 10.1002/lt.24970.
[24]	KITAMI M, TAKASE K, MURAKAMI G, et al. Types and frequencies of biliary tract variations associated with a major portal venous anomaly: analysis with multi-detector row CT cholangiography[J]. Radiology, 2006, 238(1): 156-166. DOI: 10.1148/radiol.2381041783.
[25]	XIAO F, SUN LY, WEI L, et al. Cholangiojejunostomy for multiple biliary ducts in living donor liver transplantation: a case report[J]. World J Clin Cases, 2021, 9(11): 2649-2654. DOI: 10.12998/wjcc.v9.i11.2649.
[26]	KOLLMANN D, GOLDARACENA N, SAPISOCHIN G, et al. Living donor liver transplantation using selected grafts with 2 bile ducts compared with 1 bile duct does not impact patient outcome[J]. Liver Transpl, 2018, 24(11): 1512-1522. DOI: 10.1002/lt.25197.
[27]	KISS M, DESHPANDE RR, NEMESKÉRI Á, et al. Optimal line of hepatotomy for left lateral living donor liver transplantation according to the anatomical variations of left hepatic duct system[J]. Pediatr Transplant, 2015, 19(5): 510-516. DOI: 10.1111/petr.12468.
[28]	JUNG DH, IKEGAMI T, BALCI D, et al. Biliary reconstruction and complications in living donor liver transplantation[J]. Int J Surg, 2020, 82S: 138-144. DOI: 10.1016/j.ijsu.2020.04.069.
[29]	杨梅雨, 张新萍, 尹强, 等. 儿童肝移植20例围手术期并发症临床分析[J]. 中国小儿急救医学, 2020, 27(5): 385-387. DOI: 10.3760/cma.j.issn.1673-4912.2020.05.016. YANG MY, ZHANG XP, YIN Q, et al. Clinical analysis of perioperative complications of liver transplantation in 20 children[J]. Chin Pediatr Emerg Med, 2020, 27(5): 385-387. DOI: 10.3760/cma.j.issn.1673-4912.2020.05.016.
[30]	YAN KL, GOMES AS, MONTELEONE PA, et al. Management of biliary stricture in pediatric liver transplantation patients: long-term outcomes[J]. Liver Transpl, 2021, 27(12): 1788-1798. DOI: 10.1002/lt.26095.
[31]	LEE AY, LEHRMAN ED, PERITO ER, et al. Non-operative management of biliary complications after liver transplantation in pediatric patients: a 30-year experience[J]. Pediatr Transplant, 2021, 25(6): e14028. DOI: 10.1111/petr.14028.
[32]	DULCETTA L, MARRA P, CARBONE FS, et al. Biliary complications in pediatric liver transplantation: findings of percutaneous transhepatic cholangiography in a large single-center cohort[J]. Pediatr Radiol, 2022, 52(6): 1061-1074. DOI: 10.1007/s00247-021-05278-3.
[33]	VALENTINO PL, WANG T, SHABANOVA V, et al. North American biliary stricture management strategies in children after liver transplantation: a multicenter analysis from the Society of Pediatric Liver Transplantation (SPLIT) Registry[J]. Liver Transpl, 2022, 28(5): 819-833. DOI: 10.1002/lt.26379.
[34]	KARAKAS HM, CELIK T, ALICIOGLU B. Bile duct anatomy of the Anatolian Caucasian population: Huang classification revisited[J]. Surg Radiol Anat, 2008, 30(7): 539-545. DOI: 10.1007/s00276-008-0365-y.
[35]	FARMER DG, VENICK RS, MCDIARMID SV, et al. Predictors of outcomes after pediatric liver transplantation: an analysis of more than 800 cases performed at a single institution[J]. J Am Coll Surg, 2007, 204(5): 904-916. DOI: 10.1016/j.jamcollsurg.2007.01.061.
[36]	CAROLLO V, CANNELLA R, SPARACIA G, et al. Optimizing liver division technique for procuring left lateral segment grafts: new anatomical insights[J]. Liver Transpl, 2021, 27(2): 281-285. DOI: 10.1002/lt.25895.