Fan Sheung-Tat, Lo Chung-Mau, Liu Chi-Leung, Tso Wai-Kuen, Wong John
Centre for the Study of Liver Disease, Department of Surgery and Diagnostic Radiology, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
Ann Surg. 2002 Nov;236(5):676-83. doi: 10.1097/00000658-200211000-00019.
To identify the possible reasons of failure of biliary reconstruction in right lobe live donor liver transplantation (LDLT) and to devise the best method of reconstruction and treatment strategy for the complications.
Right lobe LDLT was associated with a high biliary complication rate (15-64%) in the reported series. The causes of failure were not completely understood and the best treatment strategy has not been defined.
From 1996 to 2001, 74 patients received right lobe LDLT. The operative procedures of the first 37 patients were critically reviewed to identify the possible reasons of leakage or stenosis from the anastomosis. The causes included right hepatic duct ischemia, double or triple hepaticojejunostomies, unrecognized branch of right hepatic duct, jejunal opening smaller than the size of right hepatic duct, and ductal plasty without division of newly created septum. The second 37 patients had biliary reconstruction by a modified technique that preserved blood supply to the right hepatic duct and aimed at avoidance of risk factors.
The overall complication rate decreased from 43% in the first 37 patients to 8% in the second 37 patients. There was no leakage from the anastomosis in the second group of patients. Percutaneous transhepatic biliary drainage (PTBD) for the biliary complications resulted in right portal vein and hepatic artery injury in four patients and accounted for mortality in three of them. To avoid complications from PTBD, three patients in the second group developing stenosis of hepaticojejunostomy had repeated hepaticojejunostomy without preoperative PTBD and recovered.
With identification of risk factors and modification of the surgical technique, the complication rate of biliary reconstruction of right lobe LDLT could be reduced. Repeated hepaticojejunostomy without preoperative PTBD is the preferred approach once a complication develops.
确定右半肝活体肝移植（LDLT）中胆管重建失败的可能原因，并设计最佳的重建方法及并发症的治疗策略。
在已报道的系列研究中，右半肝LDLT的胆管并发症发生率较高（15% - 64%）。失败原因尚未完全明确，最佳治疗策略也未确定。
1996年至2001年，74例患者接受了右半肝LDLT。对前37例患者的手术过程进行严格回顾，以确定吻合口漏或狭窄的可能原因。原因包括右肝管缺血、双或三联肝空肠吻合术、未识别的右肝管分支、空肠开口小于右肝管管径、胆管成形术时未分开新形成的隔膜。后37例患者采用改良技术进行胆管重建，该技术保留右肝管血供并旨在避免危险因素。
总体并发症发生率从前37例患者的43%降至后37例患者的8%。第二组患者吻合口无漏液。经皮经肝胆道引流（PTBD）治疗胆管并发症导致4例患者右门静脉和肝动脉损伤，其中3例死亡。为避免PTBD的并发症，第二组中3例发生肝空肠吻合口狭窄的患者未进行术前PTBD而再次行肝空肠吻合术并康复。
通过识别危险因素并改良手术技术，可降低右半肝LDLT胆管重建的并发症发生率。一旦发生并发症，不进行术前PTBD而再次行肝空肠吻合术是首选方法。
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