Tsujino Takeshi, Isayama Hiroyuki, Kogure Hirofumi, Sato Tatsuya, Nakai Yousuke, Koike Kazuhiko
Miyuki Clinic, 1-8-3 Renko-ji, Tama, Tokyo, 2060021, Japan.
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Clin J Gastroenterol. 2017 Aug;10(4):297-311. doi: 10.1007/s12328-017-0754-z. Epub 2017 Jun 9.
Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.
活体肝移植（LDLT）是治疗终末期肝病的一种有效替代方法，可替代尸体肝移植（DDLT）。尽管手术技术、免疫抑制管理和移植后护理方面的进展改善了LDLT的总体疗效，但胆管狭窄仍然是主要的未解决问题。对于采用胆管对胆管重建的LDLT术后胆管狭窄，目前内镜逆行胰胆管造影（ERCP）被认为是一线治疗方法，经皮和手术干预则留给经ERCP治疗失败的患者。由于胆管吻合的复杂性以及胆管系统的迂曲和成角，LDLT中胆管狭窄的内镜管理在技术上比DDLT更具挑战性。球囊扩张后放置一个或多个塑料支架一直是LDLT术后狭窄的标准策略，但这需要多次更换支架以防止支架阻塞，直到狭窄解除。内置支架可能会防止十二指肠胆管反流，因此支架通畅时间更长，无需多次进行ERCP。新开发的带有抗迁移系统的覆膜自膨式金属支架是放置多个塑料支架的替代方法。随着深度肠镜检查的出现，接受Roux-en-Y肝空肠吻合术的LDLT患者的胆管狭窄现在可以通过内镜治疗。在这篇综述中，我们讨论了LDLT术后狭窄内镜管理的短期和长期疗效以及该领域的最新进展。
