成人肝移植术后良性胆管狭窄的诊断与管理
Diagnosis and management of benign biliary strictures post liver transplantation in adults.
作者信息
Keane Margaret G, Devlin John, Harrison Philip, Masadeh Maen, Arain Mustafa A, Joshi Deepak
机构信息
Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
出版信息
Transplant Rev (Orlando). 2021 Jan;35(1):100593. doi: 10.1016/j.trre.2020.100593. Epub 2020 Dec 25.
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
肝移植术后良性胆管狭窄很常见,可导致移植物功能障碍并降低患者生存率。移植后狭窄分为吻合口狭窄或非吻合口狭窄,对治疗的反应有所不同。移植后胆管狭窄的危险因素包括血供受损、手术因素和胆管异常。患者可能出现胆管梗阻,但大多数患者无症状,仅有移植物功能异常。磁共振胰胆管造影(MRCP)是诊断胆管并发症最敏感的非侵入性检查方法。在全球大多数中心,内镜检查是吻合口狭窄治疗的一线方法,不过所采用的内镜技术存在很大差异,包括扩张、放置单个或多个塑料支架、完全覆盖的金属支架,以及最近使用的导管内完全覆盖金属支架。随着完全覆盖金属支架的引入,患者所需的干预次数减少,总体而言,内镜治疗方法的临床成功率稳步提高。经皮治疗和手术治疗目前仅用于内镜治疗失败或接受了 Roux-en-Y 吻合术的患者。然而,即使在这些情况下,介入放射学联合手术、或实施小肠镜检查和超声内镜引导下的方法,现在意味着最终很少有患者需要进行手术修正。