Buis Carlijn I, Verdonk Robert C, Van der Jagt Eric J, van der Hilst Christian S, Slooff Maarten J H, Haagsma Elizabeth B, Porte Robert J
Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Liver Transpl. 2007 May;13(5):708-18. doi: 10.1002/lt.21166.
Nonanastomotic biliary strictures (NAS) are a serious complication after orthotopic liver transplantation (OLT). The exact pathogenesis is unclear. Purpose of this study was to identify risk factors for the development of NAS after OLT. A total of 487 adult liver transplants with a median follow-up of 7.9 years were studied. All imaging studies of the biliary tree were reviewed. Cholangiography was routinely performed between postoperative days 10-14 and later on demand. Localization of NAS at first presentation was categorized into 4 anatomical zones of the biliary tree. Severity of NAS was semiquantified as mild, moderate, or severe. Donor, recipient, and surgical characteristics and variables were analyzed to identify risk factors for NAS. NAS developed in 81 livers (16.6%). Thirty-seven (7.3%) were graded as moderate to severe. In 85% of the cases, anatomical localization of NAS was around or below the bifurcation of the common bile duct. A large variation was observed in the time interval between OLT and first presentation of NAS (median 4.1 months; range 0.3-155 months). NAS presenting early (< or =1 year) after OLT were associated with preservation-related risk factors. Cold and warm ischemia times were significantly longer in patients with early NAS compared with NAS presenting late (>1 year) after OLT (694 minutes vs. 490 minutes, P = 0.01, and 57 minutes vs. 53 minutes, P < 0.05, respectively), and early NAS were more frequently located in the central bile ducts. NAS presenting late (>1 year) after OLT were found more frequently in the periphery of the liver and were more frequently associated with immunological factors, such as primary sclerosing cholangitis, as the indication for OLT (24% vs. 45%, P < 0.05). By separating cases of NAS on the basis of the time of presentation after transplantation, we were able to identify differences in risk factors, indicating different pathogenic mechanisms depending on the time of initial presentation.
非吻合口胆管狭窄（NAS）是原位肝移植（OLT）后的一种严重并发症。确切的发病机制尚不清楚。本研究的目的是确定OLT后NAS发生的危险因素。共研究了487例成年肝移植患者，中位随访时间为7.9年。对所有胆管成像研究进行了回顾。术后第10 - 14天常规进行胆管造影，之后按需进行。首次出现时NAS在胆管树的定位分为4个解剖区域。NAS的严重程度半定量为轻度、中度或重度。分析供体、受体、手术特征及变量以确定NAS的危险因素。81例肝脏（16.6%）发生了NAS。37例（7.3%）为中度至重度。85%的病例中，NAS的解剖定位在胆总管分叉处周围或以下。OLT至NAS首次出现的时间间隔差异很大（中位时间4.1个月；范围0.3 - 155个月）。OLT后早期（≤1年）出现的NAS与保存相关危险因素有关。早期NAS患者的冷缺血和热缺血时间明显长于OLT后晚期（>1年）出现NAS的患者（分别为694分钟对490分钟，P = 0.01；57分钟对5分钟 < 0.05），且早期NAS更常位于中央胆管。OLT后晚期（>1年）出现的NAS在肝外周更常见，且更常与免疫因素相关，如作为OLT指征的原发性硬化性胆管炎（24%对45%，P < 0.05）。通过根据移植后出现时间对NAS病例进行分类，我们能够识别危险因素的差异，表明根据初始出现时间存在不同的致病机制。
