Darius Tom, Rivera Jairo, Fusaro Fabio, Lai Quirino, de Magnée Catherine, Bourdeaux Christophe, Janssen Magdalena, Clapuyt Philippe, Reding Raymond
Pediatric Surgery and Transplant Unit, Université Catholique de Louvain, Brussels, Belgium.
Liver Transpl. 2014 Aug;20(8):893-903. doi: 10.1002/lt.23910.
Biliary complications (BCs) still remain the Achilles heel of liver transplantation (LT) with an overall incidence of 10% to 35% in pediatric series. We hypothesized that (1) the use of alternative techniques (reduced size, split, and living donor grafts) in pediatric LT may contribute to an increased incidence of BCs, and (2) surgery as a first treatment option for anastomotic BCs could allow a definitive cure for the majority of these patients. Four hundred twenty-nine primary pediatric LT procedures, including 88, 91, 47, and 203 whole, reduced size, split, and living donor grafts, respectively, that were performed between July 1993 and November 2010 were retrospectively reviewed. Demographic and surgical variables were analyzed, and their respective impact on BCs was studied with univariate and multivariate analyses. The modalities of BC management were also reviewed. The 1- and 5-year patient survival rates were 94% and 90%, 89% and 85%, 94% and 89%, and 98% and 94% for whole, reduced size, split, and living donor liver grafts, respectively. The overall incidence of BCs was 23% (n = 98). Sixty were anastomotic complications [47 strictures (78%) and 13 fistulas (22%)]. The graft type was not found to be an independent risk factor for the development of BCs. According to a multivariate analysis, only hepatic artery thrombosis and acute rejection increased the risk of anastomotic BCs (P < 0.001 and P = 0.003, respectively). Anastomotic BCs were managed primarily with surgical repair in 59 of 60 cases with a primary patency rate of 80% (n = 47). These results suggest that (1) most of the BCs were anastomotic complications not influenced by the type of graft, and (2) the surgical management of anastomotic BCs may constitute the first and best therapeutic option.
胆道并发症（BCs）仍是肝移植（LT）的致命弱点，在儿童肝移植系列中总体发生率为10%至35%。我们推测：（1）小儿肝移植中使用替代技术（减体积、劈离式和活体供肝移植）可能会导致BCs发生率增加；（2）手术作为吻合口BCs的首选治疗方法可使大多数此类患者得到根治。回顾性分析了1993年7月至2010年11月期间进行的429例小儿初次肝移植手术，其中包括88例全肝、91例减体积肝、47例劈离式肝和203例活体供肝移植。分析了人口统计学和手术变量，并通过单因素和多因素分析研究了它们对BCs的各自影响。还回顾了BCs的处理方式。全肝、减体积肝、劈离式肝和活体供肝移植的1年和5年患者生存率分别为94%和90%、89%和85%、94%和89%、98%和94%。BCs的总体发生率为23%（n = 98）。60例为吻合口并发症[47例狭窄（78%）和13例瘘（22%）]。未发现移植类型是BCs发生的独立危险因素。根据多因素分析，只有肝动脉血栓形成和急性排斥反应会增加吻合口BCs的风险（分别为P < 0.001和P = 0.003）。60例吻合口BCs中有59例主要通过手术修复处理，初次通畅率为80%（n = 47）。这些结果表明：（1）大多数BCs是吻合口并发症，不受移植类型影响；（2）吻合口BCs的手术处理可能是首要且最佳的治疗选择。
