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Retrospective Analysis of Biliary Complications Afer Adult Liver Transplantation

Author: LuoZhenChao
Tutor: ZhouJie
School: Southern Medical University,
Course: General Surgery
Keywords: liver transplantation biliary complications postoperative complications diagnosis and treatment
CLC: R657.3
Type: Master's thesis
Year: 2013
Downloads: 12
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Abstract


[Subject background]In1963, the U.S. organ transplantation pioneer Starzl successfully implemented the first cases of orthotopic liver transplantation, liver transplantation surgery has gone through50years, significantly improved long-term survival of liver transplant patients. Surgical success rate of liver transplantation is more than90%in many center,5-year survival rate greater than70%, the effect of transplantation with the international advanced level, it has now become the only effective means of treatment of end-stage liver disease. Biliary complications, however, has been one of the important reason for long-term survival after liver transplantation recipients, because of the high frequency require long-term, repeated treatment, and potential adverse effects of graft and patient survival,it is called "Achilles’ heel" by Calne. Biliary complications after liver transplantation is the transplantation that leads to biliary complications after liver transplantation, affecting the normal function of the bile tract, and in turn affects the liver graft function. Foreign reports the incidence of biliary complications (Biliary complication BC) in10%-30%, the mortality rate of nearly10%, one of the major causes of death after liver transplantation. And the literature reported occurrence rate is still hovering at20%-34%, in the right lobe living donor liver transplant recipients is as high as15%to64%, of which6%to13%require liver retransplantation, the fatality rate can be as high as19%. Because of complex pathological mechanisms of biliary complications, difficult clinical treatment, seriously affect the quality of life and long-term survival of liver transplant patients, biliary complication has make the global liver transplantation sector attention.In recent years, research about BC has make some achievement, but In many ways yet to be. In order to explore biliary complications including bile leakage and bile duct stricture, also including biliary tract infection, bile duct stones, biliary tract bleeding, biliary sludge formation and so on. The reasons for the formation of biliary complications have different opinions, different literature report many possible causes including biliary reconstruction, biliary stent practical, liver transplantation surgery, organ preservation, chronic rejection, hepatic artery thrombosis, donor and recipient characteristics, cytomegalovirus infection, hepatitis C virus infection, autoimmune diseases. With the recent liver transplantation surgical techniques continue to improve, and the operation technology continues to skilled, the incidence of bile leakage and anastomotic stricture caused by operation present a downward trend, and the proportion of other complications gradually increased. In this sense, the key is to summarize and validate recent research on the settlement of biliary complications, in order to understand and reduce these complications.Therefore, in order to further deepen the understanding of the characteristics of adult liver transplantation postoperative biliary complications, explore the risk factors associated with postoperative biliary complications, and the comparison between the characteristics of different types of biliary complications, including location, time of occurrence, risk factors, and sampling history of hepatitis, the receptor blood type, biliary tract, preoperative and postoperative biochemical changes, hepatic artery suture reported in the literature to check how such factors be related to biliary complications, as clinical prevention and treatment reference, but due to bile duct injury regenerative capacity is relatively low, the treatment more difficult, how to prevent and treat biliary complications that to improve the efficacy of liver transplantation and to improve the quality of life of patients has important clinical significance.[Objective]In view of the diversity and complexity of biliary complications after liver transplantation, the liver transplantation center’s medical record to summarize, through scientific statistical analysis to analyze all relevant factors for biliary complications, some reference not only for the diagnosis and treatment of liver transplantation, they can still further deepen the understanding of liver transplantation and improve the therapeutic effect and long-term prognosis. Author retrospectively analyzed the clinical data of259cases of liver transplant patients by the center implemented from August2004to December2011, screening affect the main factors of biliary complications after liver transplantation patients, and biliary complications, diagnosis, treatment and prevention are discussed.[Materials and Methods]1. materials:retrospective analysis implemented in August2004to December2011,259cases of orthotopic liver transplantation (2cases of secondary liver transplantation) clinical data, the diagnosis of56cases of biliary complications and experience in the treatment were analyzed.2. the classification of biliary complications Biliary complications after liver transplantation, there is no uniform classification and standards,to sum up the to literatures at home and abroad, there are several common classification standards:2.1. according to the time of onset:(1) early complications occurred<30days;(2)≤30days late complications occurred<6months;(3) long-term complications occurred≥6months.2.2.causes:(1) surgical technical biliary complications;(2) ischemic biliary complications;(3) immune-related biliary complications;(4) infection-associated biliary complications;(5) physical and chemical factors related to biliary complications;(6) the functional relevance of biliary complications.2.3.according to the classification of the clinical manifestations:(1) bile leakage;(2) biliary obstruction.2.4.according to the diseased parts:(1) receptor (extrahepatic) biliary complications;(2) donor (intrahepatic) biliary complications;(3) biliary complications anastomotic complications;(4) drainage tube relative sinus-related complications.The statistical data of the subject of biliary complications after liver transplantation is counted by the above criteria.3. the diagnostic criteriaAccording to the patients clinical manifestations after liver transplantation such as chills, fever, jaundice, abdominal pain, pruritus, bilirubin, bile-like changes in drainage fluid and fluid drainage abnormally elevated bilirubin, serum transaminases and the abnormalities of liver enzyme, mainly by B ultrasound, CT and MRCP imaging and rely on ERCP, PTC or the T-tube cholangiography, if necessary, feasible liver biopsy to exclude acute and chronic rejection after transplantation; cholangiography as a diagnostic biliary complications after liver transplantation is the gold standard.4. Relevant factors to selectReview relevant literature,41factors may be associated with biliary complications (Biliary complication BC) for statistical analysis.Preoperative information:age, sex, history of hepatitis B infection, hepatitis B surface antigen, hepatitis C antibody, liver benign and malignant tumors, with or without cirrhosis, without history of abdominal surgery, radiofrequency ablation (RF) treatment history, the history of photons knife treatment, the history of the treatment of hepatic artery chemotherapy embolization (TACE), alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum total bilirubin (TBIL), albumin (ALB), prothrombin time (PT), international normalized ratio (INR), creatinine (CR), Child-Pugh score, MELD score.Surgery:surgical time, anhepatic phase, cold ischemia time, warm ischemia time, liver transplant, intraoperative blood loss and blood transfusion, the blood type of the donor and recipient matching or suture of the hepatic artery, the complex of hepatic artery agreement, whether to retain the receptor gastroduodenal artery (GDA), biliary suture, whether indwelling T-tube.Postoperative data:whether acute or chronic rejection, hepatic artery complications, complications of portal vein, inferior vena cava/hepatic vein complications, cytomegalovirus infection, and1postoperative day,1week,1month hepatic artery resistance index (RI).5. Statistical analysisAll data apply statistical software SPSS13.0for analysis, measurement data normality test using the the K-S Act (One-Sample Kolmogorov-Smirnov Test), measurement data meet the normality test was used to compare two independent samples t-test, the measurement data which does not meet the normality test were compared using the Wilcoxon rank sum test; count data were compared with chi-square test or exact test; multivariate analysis using logistic regression analysis, model selection using the stepwise regression method; P<0.05was statistically significant.[Results]56cases of receptor postoperative BC (22.13%,BC group), including biliary stricture30cases,24cases of bile leakage, simple biliary calculi/the biliary sludge1cases, simple biliary tract infection in1case;197cases found no BC (77.87%, Non-BC group). BC after liver transplantation in7years at2004-2011,the incidence of BC showed a downward trend, the highest incidence of50%in2004, BC,2005(2006) to2011BC incidence basically keep stable at20%-30%.1. BC distributionEarly biliary complications (<30days) in33cases, accounting for58.93%of the biliary complications. Bile leakage (including other types of biliary complications, the same below) in17cases, bile duct anastomotic stenosis in12cases, non-anastomotic biliary stricture in10cases, cholelithiasis/biliary sludge five cases,6cases of biliary tract infections, biliary tract bleeding1cases. A total of three cases of anastomotic complications, a total of13cases, the drainage tube-related complications.late biliary complications (≥30days) in23cases, accounting for41.07%of the biliary complications. Bile leakage, mainly due to the initial symptoms occult, T-tube delay extubation in patients with treatment delay causes; bile duct anastomotic stenosis in10cases, non-anastomotic biliary stricture in4cases, biliary stones/6cases of biliary sludge,5cases of biliary tract infections, biliary tract bleeding in1case. A total of12patients with anastomotic complications.2cases of24cases of bile leakage occurred in the receptor side,3cases occurred in the donor side,14cases occurred in the anastomosis (1case of formation of anastomotic duodenal fistula),2cases of postoperative hepatic artery embolism lead to local necrosis of the liver graft formation of bile Lake, Lake of bile rupture caused by bile leakage, and3cases of early postoperative mild bile leakage, self-healing after abdominal drainage, unable to determine the specific leakage area.22patients with bile duct stricture,12cases of bile duct anastomotic stricture, and the remaining10cases of non-anastomotic biliary stricture.2. BC group and non-BC group single factor comparative analysis of the incidence of the two groups were significantly different (P=0.007); between the two groups before surgery univariate comparison:the biliary reconstruction surgery technology improved, ie change bile Explorer end to end was sutured to the posterior wall of the continuous anterior wall was sutured to reduce the incidence of BC was statistically significant (P=0.0012); after1day,1week and1month hepatic artery resistance index (RI) abnormal (P=0.001), and the extension of the hepatic phase (P=0.0308), a significant increase in the incidence of BC. With univariate analysis feels that the the preoperative of TACE history and photon knife treatment history of increase in the incidence of BC. The surgery is not indwelling T tube, the improvement of vascular anastomosis technique can significantly reduce the incidence of BC.3. BC multivariate analysisAbnormal hepatic artery RI after1month (Hari),"T" indwelling vascular complications are an independent risk factor for BC. Non-hepatic phase extension will increase the incidence of BC is no clear conclusion. For non-anastomotic BC abnormal HARI after1month significantly increase in the incidence,multivariate analysis still think1postoperative days,l week HARI abnormal increase in the incidence of ischemic BC; for simple the anastomotic BC, primary disease (such as primary biliary cirrhosis), other vascular complications and postoperative1month HARI abnormalities which affect the incidence are the independent risk factor.[Conclusion]1.The biliary complications incidence:this group of patients which happened biliary complications after liver transplantation is overall incidence of22.13%.2.the main form of biliary complications including bile leakage and biliary obstruction, accounting for91.07%of the biliary complications, anastomotic complications (including anastomotic leakage, anastomotic stricture) more common, for a total of25cases, accounting for44.64%.3.the treatment of biliary complications:in most cases should first consider non-surgical treatment (including nasal biliary drainage or stenting), rather than surgical treatment in patients with poor reoperation bile duct exploration is necessary treatment for serious bile duct injury led to the loss of graft function, the secondary liver transplant is the only option.

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