CAJ | 학술논문

目的探讨肝移植术后缺血型胆道病变（ITBL）并发门静脉高压症的发生、发展及其治疗、预后。方法回顾性分析2003年1月至2009年4月在中山大学附属第三医院肝移植中心行肝移植术且术后确诊为ITBL并发门静脉高压症的32例患者临床资料。所有患者均签署知情同意书，符合医学伦理学规定。其中男28例，女4例；平均年龄（46±14）岁。对患者进行定期随访，观察患者门静脉高压症发生、发展及其治疗和预后情况。结果 ITBL确诊时患者合并轻度脾肿大11例，中度脾肿大14例，重度脾肿大4例，无脾肿大3例。随访期间5例病情稳定，脾肿大保持在轻度或由中度转为轻度；余27例脾肿大等门静脉高压症状随着ITBL病变进展而加重，其中发展至重度脾肿大者11例。53%（17/32）患者出现食管胃底静脉曲张，其中食管下段轻度静脉曲张2例，食管下段胃底轻-中度静脉曲张8例、中-重度静脉曲张7例。所有患者均接受经内镜下逆行性胰胆管造影术（ERCP）或经皮经肝胆道造影术（PTC）途径介入治疗，行再次肝移植术11例、胆肠吻合术4例、胆总管切开取石+胆道探查术1例。患者存活18例，死亡14例，其中死于黄疸加深肝功能恶化4例、肝癌复发4例、上消化道大出血3例，再次肝移植术后重度感染1例、多器官功能衰竭1例、肾衰竭1例。结论大部分肝移植术后ITBL并发门静脉高压症患者随着ITBL进展而病情逐渐加重。治疗方式主要包括介入治疗、再次肝移植、胆肠吻合，患者预后极差。
목적탐토간이식술후결혈형담도병변（ITBL）병발문정맥고압증적발생、발전급기치료、예후。방법회고성분석2003년1월지2009년4월재중산대학부속제삼의원간이식중심행간이식술차술후학진위ITBL병발문정맥고압증적32례환자림상자료。소유환자균첨서지정동의서，부합의학윤리학규정。기중남28례，녀4례；평균년령（46±14）세。대환자진행정기수방，관찰환자문정맥고압증발생、발전급기치료화예후정황。결과 ITBL학진시환자합병경도비종대11례，중도비종대14례，중도비종대4례，무비종대3례。수방기간5례병정은정，비종대보지재경도혹유중도전위경도；여27례비종대등문정맥고압증상수착ITBL병변진전이가중，기중발전지중도비종대자11례。53%（17/32）환자출현식관위저정맥곡장，기중식관하단경도정맥곡장2례，식관하단위저경-중도정맥곡장8례、중-중도정맥곡장7례。소유환자균접수경내경하역행성이담관조영술（ERCP）혹경피경간담도조영술（PTC）도경개입치료，행재차간이식술11례、담장문합술4례、담총관절개취석+담도탐사술1례。환자존활18례，사망14례，기중사우황달가심간공능악화4례、간암복발4례、상소화도대출혈3례，재차간이식술후중도감염1례、다기관공능쇠갈1례、신쇠갈1례。결론대부분간이식술후ITBL병발문정맥고압증환자수착ITBL진전이병정축점가중。치료방식주요포괄개입치료、재차간이식、담장문합，환자예후겁차。
ObjectiveTo investigate the occurrence, development, treatments and prognosis of ischemic type biliary lesions (ITBL) complicated with portal hypertension after liver transplantation (LT). MethodsClinical data of 32 ITBL patients with portal hypertension after LT in Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University from January 2003 to April 2009 were analyzed retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. There were 28 males and 4 females with a mean age of (46±14) years old. The patients were followed up regularly and the occurrence, development, treatments and prognosis of portal hypertension were observed.ResultsWhen ITBL was diagnosed, mild splenomegaly was found in 11 cases, moderate splenomegaly in 14 cases and severe splenomegaly in 4 cases. Three cases were observed without splenomegaly. During the follow-up period, 5 cases were observed in stable states with mild splenomegaly or splenomegaly improving from moderate to mild. While for the other 27 cases, portal hypertension symptoms like splenomegalyetc. were observed becoming worse as ITBL developed including 11 cases with severe splenomegaly. Esophageal and gastric fundus varices were found in 53% (17/32) of the patients including 2 cases of lower esophagus mild varices, 8 cases of lower esophagus and gastric fundus mild to moderate varices, and 7 cases of moderate to severe varices. All the patients received intervention treatments via endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). Liver retransplantation was performed in 11 cases, choledochojejunostomy in 4 cases and choledocholithiasis + biliary tract exploration in 1 case. Eighteen cases survived and 14 cases died. Four cases died of aggravating jaundice and liver failure, 4 liver cancer recurrence, 3 massive hemorrhage in upper gastrointestinal tract, and 1 severe infection, 1 multiple organ failure, 1 renal failure after liver retransplantation.ConclusionsMost of ITBL patients with portal hypertension after LT gradually deteriorates with the progression of ITBL. The treatments mainly include intervention treatments, liver retransplantation, and choledochojejunostomy. The prognosis is very poor.