患者和移植物存活率：肝移植术后胆道并发症。

Patient and Graft Survival: Biliary Complications after Liver Transplantation.

机构信息

Section of Transplant Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO.

出版信息

J Am Coll Surg. 2018 Apr;226(4):484-494. doi: 10.1016/j.jamcollsurg.2017.12.039. Epub 2018 Jan 31.

DOI:10.1016/j.jamcollsurg.2017.12.039

PMID:29360615

Abstract

BACKGROUND

Biliary complications (BCs) affect up to to 34% of liver transplant recipients and are a major source of morbidity and cost. This is a 13-year review of BCs after liver transplantation (LT) at a tertiary care center.

STUDY DESIGN

We conducted a single-center retrospective review of our prospective database to assess BCs in adult (aged 18 years or older) liver transplant recipients during a 13-year period (2002 to 2014). Biliary complications were divided into 3 subgroups: leak alone (L), stricture alone (S), and both leak and strictures (LS). Controls (no BCs) were used for comparison.

RESULTS

There were 1,041 adult LTs performed during the study period; BCs developed in 239 (23%) of these patients: 55 (23%) L, 148 (62%) S, and 36 (15%) LS. One hundred and two (43%) were early (less than 30 d). Surgical revision was required in 42 cases (17%) (30 L, 10 LS, and 2 S), while the remaining 197 (83%) were managed nonsurgically (25 L, 26 LS, and 146 S), with a mean of 4.2 interventions/patient. One-, 3-, and 5-year overall patient and graft survival was significantly reduced in patients with bile leaks (84%, 71%, and 68% and 76%, 67%, and 64%, respectively) compared with controls (90%, 84%, and 78% and 88%, 81%, and 76%, respectively [p < 0.05]). Patients with BCs had higher incidence of cholestatic liver disease, higher pre-LT bilirubin, higher use of T-tubes, higher use of donor after cardiac death grafts, and higher rates of acute rejection (p < 0.05). Patients with BCs had longer ICU and hospital stays and higher rates of 30- and 90-day readmissions (p < 0.01). Multivariate analysis identified cholestatic liver disease, Roux-en-Y anastomosis, donor risk index >2, and T-tubes as independent BC predictors.

CONCLUSIONS

Biliary complications after LT can significantly decrease patient and graft survival rates. Careful donor and recipient selection and attention to anastomotic technique can reduce BCs and improve outcomes.

摘要

背景

胆管并发症（BCs）影响高达 34%的肝移植受者，是发病率和费用的主要来源。这是对一家三级护理中心肝移植后 BCs 的 13 年回顾。

研究设计

我们对前瞻性数据库进行了单中心回顾性研究，以评估 13 年间（2002 年至 2014 年）成年（18 岁或以上）肝移植受者的 BCs。胆管并发症分为 3 个亚组：单纯漏（L）、单纯狭窄（S）和漏和狭窄均有（LS）。对照组（无 BCs）用于比较。

结果

研究期间共进行了 1041 例成人 LT，其中 239 例（23%）发生 BCs：55 例（23%）L、148 例（62%）S 和 36 例（15%）LS。102 例（43%）为早期（<30 d）。42 例（17%）需要手术修正（30 例 L、10 例 LS 和 2 例 S），而其余 197 例（83%）则接受非手术治疗（25 例 L、26 例 LS 和 146 例 S），平均每位患者有 4.2 次干预。与对照组相比，有胆漏的患者的 1、3 和 5 年总体患者和移植物存活率明显降低（分别为 84%、71%和 68%和 76%、67%和 64%）[p < 0.05]。有 BCs 的患者发生胆汁淤积性肝病的发生率较高，术前胆红素较高，T 管使用率较高，使用心脏死亡供体移植物的比例较高，急性排斥反应发生率较高（p < 0.05）。有 BCs 的患者 ICU 住院时间和住院时间较长，30 天和 90 天再入院率较高（p < 0.01）。多变量分析确定胆汁淤积性肝病、Roux-en-Y 吻合术、供体风险指数>2 和 T 管是 BC 的独立预测因素。