Ishiko T, Egawa H, Kasahara M, Nakamura T, Oike F, Kaihara S, Kiuchi T, Uemoto S, Inomata Y, Tanaka K
器官移植和免疫科，医学系，京都大学，京都，日本

目标：评价肝右叶活体肝移植（LDLT）中端端胆管吻合术的可行性和安全性。

背景资料：胆道并发症依然是肝移植术后最严重的问题之一。胆总管空肠Roux-en-Y吻合术已经成为LDLT部分肝移植中胆管重建的标准操作。但是胆总管端端吻合术是一项胆管重建技术，对胆肠连续性的要求比胆总管空肠Roux-en-Y吻合术所能达到的要更高。作者对肝右叶LDLT进行了端端胆管吻合术，同时本研究还回顾性评价了胆管重建术和胆道并发症之间的关系。

方法：在1999年7月至2000年12月，共有51名患者（年龄在11岁至67岁之间）使用端端胆管重建术进行了肝右叶LDLT，且所有患者的术后生存期均超过了一个月。其中24例移植手术中应用了间断性胆管吻合术，剩下28例则应用了连续性胆管吻合术。在16例移植手术中，胆管是通过受体的胆囊管向下插入胆总管内的（胆囊管引流）；在4例移植手术中，胆管支架是通过胆囊管向上推入吻合口的（胆囊架）；在31例移植手术中，胆管支架则是通过胆总管壁向上推入吻合口的（外支架）。

结果：胆管吻合术由34个单端吻合、11个双端吻合和7个单吻合组成。总之，5名患者出现了胆漏（9.6%），12例患者出现狭窄（23.0%）。对于间断性胆管吻合术来说，胆囊管引流组（53.3%，8/15）出现狭窄的发病率明显高于支架组（0%，0/8；包括胆囊架和外支架）。采用间歇性缝合的胆囊管引流（15例）中，胆漏和狭窄的发病率分别为20%和53.3%，而在连续性缝合的外支架（26例）中则分别为7.7%和15.4%。二者出现狭窄的发病率有明显的不同。

结论：联合外支架的连续性端端吻合术是肝右叶LDLT中一项很有用的技术，但是胆道并发症依然普遍存在。

Duct-to-duct biliary reconstruction in living donor liver transplantation utilizing right lobe graft
Ishiko T, Egawa H, Kasahara M, Nakamura T, Oike F, Kaihara S, Kiuchi T, Uemoto S, Inomata Y, Tanaka K
Department of Transplantation and Immunology, Faculty of Medicine, Kyoto University, Kyoto, Japan

OBJECTIVE: To assess the feasibility and safety of duct-to-duct biliary anastomosis for living donor liver transplantation (LDLT) utilizing the right lobe.

SUMMARY BACKGROUND DATA: Biliary tract complications remain one of the most serious problems after liver transplantation. Roux-en-Y hepaticojejunostomy has been a standard procedure for biliary reconstruction in LDLT with a partial hepatic graft. However, end-to-end choledochocholedochostomy is the technique of choice for biliary reconstruction and yields a more physiologic bilioenteric continuity than can be achieved with Roux-en-Y hepaticojejunostomy. The authors performed right lobe LDLT with end-to-end duct-to-duct biliary anastomosis, and this study assessed retrospectively the relation between the manner of reconstruction and complications.

METHODS: Between July 1999 and December 2000, 51 patients (11-67 years of age) underwent 52 right lobe LDLTs with duct-to-duct biliary reconstruction and remained alive more than 1 month after their transplantation. Interrupted biliary anastomosis was performed for 24 transplants and the continuous procedure was used for 28. A biliary tube was inserted downward into the common bile ducts through the recipient's cystic duct in 16 transplants (cystic drainage), or a biliary stent tube was pushed upward into the anastomosis through the cystic duct in four transplants (cystic stent), or upward into the anastomosis through the wall of the common bile duct in 31 transplants (external stent).

RESULTS: Biliary anastomotic procedures consisted of 34 single end-to-end anastomoses, 11 double end-to-end anastomoses, and 7 single anastomoses for double hepatic ducts. Overall, 5 patients developed leakage (9.6%) and 12 patients suffered stricture (23.0%). For biliary anastomosis with interrupted suture, the incidence of stricture was significantly higher in the cystic drainage group (53.3%, 8/15) than in the stent group consisting of cystic stent and external stent (0%, 0/8). While the respective incidences of leakage and stricture were 20% and 53.3% for intermittent suture with a cystic drainage tube (n = 15), they were 7.7% and 15.4% for a continuous suture with an external stent (n = 26). There was a significant difference in the incidence of stricture.

CONCLUSIONS: Duct-to-duct reconstruction with continuous suture combined with an external stent represents a useful technique for LDLT utilizing the right lobe, but biliary complications remain significant.

PMID: 12170029 [PubMed - indexed for MEDLINE]

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