Sherman S, Shaked A, Cryer H M, Goldstein L I, Busuttil R W
Department of Medicine, UCLA School of Medicine.
Ann Surg. 1993 Aug;218(2):167-75. doi: 10.1097/00000658-199308000-00008.
This study was undertaken to prospectively evaluate the efficacy and safety of endoscopic management of biliary fistulas complicating liver transplantation and other hepatobiliary operations.
Surgical therapy has been the traditional approach to large or unresolving biliary fistulas complicating liver transplantation. Although endoscopic management is rapidly becoming an acceptable alternative to surgery for the treatment of biliary fistulas complicating non-liver transplant hepatobiliary operations, it has received limited attention in the liver transplant setting.
During a 15-month period, 146 adults underwent liver transplantation with biliary reconstruction by end-to-end choledochocholedochostomy over a T-tube. Inadvertent T-tube migration or intentional T-tube removal resulted in bile peritonitis in 18 patients. The patients were treated with a nasobiliary tube (n = 13), internal stent plus endoscopic sphincterotomy (n = 3), or internal stent alone (n = 2). Thirteen patients had a biliary fistula after other hepatobiliary operations and underwent endoscopic therapy during a similar period. All 13 had an endoscopic sphincterotomy with removal of obstructing stones when present (n = 6). Twelve patients also had stents placed. All patients were prospectively followed after hospital discharge and assessed for recurrent symptoms suggestive of biliary tract disease and procedure-related complications.
Endoscopic retrograde cholangiopancreatography (ERCP) identified a biliary fistula at the T-tube insertion site into the bile duct in all 18 liver transplant patients. Seventeen patients had resolution of their symptoms within 12 hours of therapy. The fistula sealed in 94.4%. In the other hepatobiliary operation group, ERCP demonstrated contrast extravasation from the biliary tree in 12 of 13. The biliary fistula closure rate was 92.3%. The endoscopic complication rate for the two groups was 3.2%. During a mean follow-up of 9 months, recurrent biliary tract complications occurred in 11.1% of the liver transplant group and 0% in the other hepatobiliary operation group (p > 0.05). The 30-day mortality rate was 0%.
The results of this study support the application of endoscopic management of biliary fistulas complicating orthotopic liver transplantation and other hepatobiliary operations. This approach was relatively safe and obviated the need for surgical intervention.
本研究旨在前瞻性评估内镜治疗肝移植及其他肝胆手术并发胆瘘的疗效和安全性。
手术治疗一直是处理肝移植术后出现的较大或经久不愈胆瘘的传统方法。尽管内镜治疗正迅速成为非肝移植的肝胆手术并发胆瘘治疗中可接受的手术替代方案，但在肝移植领域其受到的关注有限。
在15个月期间，146例成人接受了肝移植，并通过在T管上进行端端胆管吻合术进行胆管重建。18例患者因T管意外移位或有意拔除导致胆汁性腹膜炎。这些患者接受了鼻胆管治疗（n = 13）、内置支架加内镜括约肌切开术（n = 3）或仅内置支架治疗（n = 2）。13例患者在其他肝胆手术后出现胆瘘，并在同一时期接受了内镜治疗。所有13例患者均接受了内镜括约肌切开术，如有阻塞性结石则予以取出（n = 6）。12例患者还放置了支架。所有患者出院后均进行前瞻性随访，并评估是否出现提示胆道疾病的复发症状及与手术相关的并发症。
内镜逆行胰胆管造影（ERCP）在所有18例肝移植患者中均发现T管插入胆管处存在胆瘘。17例患者在治疗后12小时内症状缓解。瘘口闭合率为94.4%。在其他肝胆手术组中，13例中有12例ERCP显示有造影剂从胆管树外渗。胆瘘闭合率为92.3%。两组的内镜并发症发生率为3.2%。在平均9个月的随访期间，肝移植组11.1%出现复发性胆道并发症，其他肝胆手术组为0%（p>0.05）。30天死亡率为0%。
本研究结果支持内镜治疗原位肝移植及其他肝胆手术并发胆瘘的应用。该方法相对安全，无需进行手术干预。
