Pearson Terra, Zimmerman Michael A, Kim Joohyun, Palines Patrick A, Eriksen Calvin M, Wong Melissa, Selim Motaz A, Markovic Daniela, Hong Johnny C
Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
Medical College of Wisconsin Medical School, Milwaukee, WI.
Transplant Direct. 2019 Aug 8;5(9):e482. doi: 10.1097/TXD.0000000000000924. eCollection 2019 Sep.
Biliary complications (BC) following orthotopic liver transplantation (OLT) is strongly associated with inferior patient outcomes and increased healthcare cost. BC in high-acuity patients can be lethal. While the utility of staged biliary reconstruction after liver transplantation (SBRALT) has been reported in adult and pediatric OLT, biliary outcome data are scarce. We sought to evaluate the clinical utility and outcomes of SBRALT in high-acuity transplant recipients.
We conducted an analysis from our prospective database of 149 adult OLT between January 1, 2012, and September 30, 2017. Mean follow-up was 26 months. Variables were compared for Group I: one-stage OLT with biliary reconstruction (N = 58) versus Group II: SBRALT (N = 91).
Compared with Group I, patients in Group II had higher acuity of illness: median model for end-stage liver disease scores (19 vs 35 = 0.002), requirement for pretransplant intensive care unit (29.3% vs 54.9%, = 0.022), pretransplant renal replacement therapy (15.5% vs 48.4%), estimated blood loss (2000 vs 4750 mL, < 0.001), and intraoperative packed red blood cells transfusion (4 vs 10 units, < 0.001). For Group II, biliary reconstruction was performed between 1 and 6 days after OLT. Hepaticojejunostomy was performed in 8.6% (Group I) and 26.4% (Group II), = 0.010. For Groups I and II, BC rates (8.6% vs 7.7%, = 0.955) and 1-year graft failure-free survival rates (89.7% vs 88.2%, = 0.845) were comparable.
Graft failure-free survival and biliary outcomes of SBRALT in high-acuity recipients are excellent and comparable to one-stage OLT for low-risk patients. SBRALT is a practical surgical strategy in complex OLT.
原位肝移植（OLT）后的胆道并发症（BC）与患者预后较差及医疗成本增加密切相关。高 acuity 患者的 BC 可能致命。虽然肝移植后分期胆道重建（SBRALT）在成人和儿童 OLT 中的应用已有报道，但胆道结局数据稀缺。我们旨在评估 SBRALT 在高 acuity 移植受者中的临床应用和结局。
我们对 2012 年 1 月 1 日至 2017 年 9 月 30 日期间 149 例成人 OLT 的前瞻性数据库进行了分析。平均随访时间为 26 个月。对 I 组：一期 OLT 并进行胆道重建（N = 58）与 II 组：SBRALT（N = 91）的变量进行了比较。
与 I 组相比，II 组患者的病情 acuity 更高：终末期肝病评分中位数（19 对 35 = 0.002）、移植前重症监护病房需求（29.3%对 54.9%， = 0.022）、移植前肾脏替代治疗（15.5%对 48.4%）、估计失血量（2000 对 4750 mL， < 0.001）以及术中输注浓缩红细胞（4 对 10 单位， < 0.001）。对于 II 组，胆道重建在 OLT 后 1 至 6 天进行。肝空肠吻合术在 I 组为 8.6%，II 组为 26.4%， = 0.010。对于 I 组和 II 组，BC 发生率（8.6%对 7.7%， = 0.955）和 1 年无移植失败生存率（89.7%对 88.2%， = 0.845）相当。
高 acuity 受者中 SBRALT 的无移植失败生存率和胆道结局良好，与低风险患者的一期 OLT 相当。SBRALT 是复杂 OLT 中的一种实用手术策略。
