Current Opinion of Postoperative Bile Duct Complications in Liver Transplantation_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

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钟林 , 彭志海

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Keywords：

肝移植; 胆道并发症; 防治; 胆管周围血管丛

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胆道并发症发生率的高低往往代表了一个肝移植中心的整体技术水平。欧美成熟的肝移植中心胆道并发症发生率为7%~10%，1年生存率达到90%。来自中国肝移植登记注册网（CTLR）的资料：香港玛丽医院2006年统计了香港公民在大陆进行肝移植的148例患者，在长期随访中发现，有48%的受体发生了胆道并发症，1年生存率只有59%；说明目前肝移植胆道并发症的防治仍然是亟待解决的难题。究其原因，还是对胆管微循环保护的研究不够深入和并发症发生的防治体系不够完善，笔者就此谈几点体会。
1胆管微循环保护的理论
人体肝脏胆管及血管铸型模型的研究显示，胆管为动脉单一供血，肝固有动脉和胃十二指肠动脉终末支分出3点、9点动脉滋养肝外胆管，并构成肝门部胆管周围血管丛(peribiliary vascular plexus,PVP)，胆管的动脉系统与门静脉之间无明显的交通血管，门静脉在胆管的血液供应中作用有限 (图1)。在动脉损伤时胆管很难从别的途径获得充分的血液供应，从而造成胆管的缺血性损伤。碳素墨汁灌注透明法显示，肝门部每个肝叶胆管及其分叉部均有肝固有动脉的较大分支支配，肝动脉的分支与胆管壁微血管之间呈垂直的连接方式。胆管厚切片透明后可清楚地显示出PVP的平面结构: 外层微血管直径较粗，内层微血管象链条一样排列，中层微血管连接在内、外层之间[３](图2)。动脉血流从外层较粗大血管流入位于胆管黏膜下的内层微血管，它是胆管动脉的终末分支,由内层微血管滋养的胆管上皮细胞层是胆管最易受损的部位(Achilles heel)。所以，肝移植中胆管动脉灌洗非常重要，应尽可能选用能够进入胆管黏膜内层血管网的低黏滞度灌注液。笔者研究证实了HCA液结合UW液灌注快速获取无心跳供体（NHBD）的肝脏，其保存效果优于单用UW液、Celsior液或HTK液，采用价廉低黏滞度HCA液联合UW液灌注，既能防止胆管PVP微血栓形成，又能充分发挥UW液对肝细胞和胆管细胞的保护作用.............................

Citation： 钟林,彭志海. Current Opinion of Postoperative Bile Duct Complications in Liver Transplantation. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2009, 16(3): 177-179. doi: Copy

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7.	Park JS, Kim MH, Lee SK, et al. Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation [J]. Gastrointest Endosc, 2003; 57(1):78.
8.	Rerknimitr R, Sherman S, Fogel EL, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy [J]. Gastrointest Endosc, 2002; 55(2):224.
9.	Gunsar F, Rolando N, Pastacaldi S, et al. Late hepatic artery thrombosis after orthotopic liver transplantation [J]. Liver Transpl, 2003; 9(6):605.

1. Adam R, McMaster P, O’Grady JG, et al.　Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry [J]. Liver Transpl, 2003; 9(12):1231.
2. Li WG, Huang XQ, Li B, et al. Three dimensional reconstruction of hepatohilar peribiliary vascular plexus in rats and dogs [J]. Chin Med J (Engl), 2007; 120(12):1106.
3. Li WG, Hu SX, Xue BD, et al. Observation of hepatohilar peribiliary vascular plexus with complete absence of hepatic artery blood supply in rats [J]. Transplant Proc, 2007; 39(10):3424.
4. 戴学明, 彭志海, 陈国庆, 等. 供肝的获取及修整技术规范与获取器官质量之间的关系 [J]. 中国实用外科杂志, 2004; 24(1):54.
5. Lo CM. Complications and longterm outcome of living liver donors: a survey of 1 508 cases in five Asian centers [J]. Transplantation, 2003; 75(3 Suppl):S12.
6. Shah SA, Grant DR, McGilvray ID, et al. Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: results of a Western center [J]. Am J Transplant, 2007; 7(1):161.
7. Park JS, Kim MH, Lee SK, et al. Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation [J]. Gastrointest Endosc, 2003; 57(1):78.
8. Rerknimitr R, Sherman S, Fogel EL, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy [J]. Gastrointest Endosc, 2002; 55(2):224.
9. Gunsar F, Rolando N, Pastacaldi S, et al. Late hepatic artery thrombosis after orthotopic liver transplantation [J]. Liver Transpl, 2003; 9(6):605.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Current Opinion of Postoperative Bile Duct Complications in Liver Transplantation

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