Mahajani R V, Cotler S J, Uzer M F
Division of Digestive Diseases, Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois 60612-3824, USA.
Endoscopy. 2000 Dec;32(12):943-9. doi: 10.1055/s-2000-9619.
Anastomotic biliary strictures are the most common cause of biliary obstruction following liver transplantation. We studied the efficacy and safety of endoscopic management of anastomotic strictures retrospectively.
A stricture at choledocho-choledochal anastomosis was identified in 30 of 354 sequential adult liver-transplant recipients at our institution. Balloon dilation was performed in 29 patients and a stent was inserted across the anastomotic stricture in one patient at initial endoscopy. A total of nine patients did not require further treatment; ten had repeated dilation (median 2). A stent was placed for persistent anastomotic stricture in six patients and for other indications in four patients. Outcomes studied were improvement in cholestasis, stricture diameter, and need for surgical treatment. Safety of therapy was assessed with nature and number of procedural complications.
The median serum bilirubin level decreased from 3.25 mg/dl to 1.1 mg/dl (P < 0.001) and median alkaline phosphatase decreased from 451.5 IU/l to 125 IU/l (P = 0.001) following endoscopic therapy. Cholestasis improved in 26 of 30 patients with therapy. Of the remainder, three of three patients with concurrent nonanastomotic strictures and one patient with anastomotic stricture and histologic evidence of rejection showed worsening cholestasis at follow-up. Stricture diameter improved from a median of 2.5 mm to 7 mm (P < 0.001). Median follow-up was 17.9 months from the last therapeutic endoscopy. Five treatable, nonlethal complications occurred after 77 procedures. None of the patients required surgery for anastomotic stricture during a follow-up period up to 58 months.
Endoscopic management offers effective and safe treatment for posttransplantation anastomotic biliary strictures and avoids the need for surgical intervention.
吻合口胆管狭窄是肝移植术后胆道梗阻最常见的原因。我们回顾性研究了内镜治疗吻合口狭窄的有效性和安全性。
在我们机构连续的354例成年肝移植受者中，有30例在胆总管 - 胆总管吻合口处发现狭窄。29例患者接受了球囊扩张，1例患者在初次内镜检查时在吻合口狭窄处置入了支架。共有9例患者无需进一步治疗；10例患者接受了重复扩张（中位数为2次）。6例患者因持续性吻合口狭窄置入了支架，4例患者因其他指征置入了支架。研究的结局指标包括胆汁淤积的改善情况、狭窄直径以及手术治疗需求。通过操作并发症的性质和数量评估治疗的安全性。
内镜治疗后，血清胆红素中位数水平从3.25mg/dl降至1.1mg/dl（P<0.001），碱性磷酸酶中位数从451.5IU/l降至125IU/l（P = 0.001）。30例接受治疗的患者中有26例胆汁淤积得到改善。其余患者中，3例合并非吻合口狭窄的患者和1例有吻合口狭窄且有排斥组织学证据的患者在随访时胆汁淤积加重。狭窄直径从中位数2.5mm改善至7mm（P<0.001）。自最后一次治疗性内镜检查起，中位随访时间为17.9个月。77次操作后发生了5例可治疗的非致命并发症。在长达58个月的随访期内，没有患者因吻合口狭窄需要手术治疗。
内镜治疗为移植后吻合口胆管狭窄提供了有效且安全的治疗方法，避免了手术干预的需要。
