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肝移植术后早期并发消化道漏的临床特点和诊治分析

Clinical characteristics, diagnosis and treatment of digestive tract leakage after orthotopic liver transplantation

摘要:

目的 探讨肝移植患者术后早期并发消化道漏的临床特点和诊治经验.方法 2000年1月至2010年12月共完成1173例次尸体肝移植,61例术后早期并发消化道漏.其中男性55例,女性6例,年龄36 ~61岁,中位年龄45岁.包括胆漏46例,胃漏5例,十二指肠漏1例,空肠漏4例,回肠漏1例以及横结肠漏4例.其中10例胃肠道漏患者肝移植术前曾有过1~3次腹部外科手术史.28例胆漏行腹腔引流,其中8例还给予内镜逆行胰胆管造影、内镜鼻胆管引流术并放置支架;另外18例胆漏采用再次开腹行胆漏修补术.13例胃肠道漏采用单纯穿孔处修补术,1例十二指肠漏行憩室部位切除、修补术,1例严重空肠漏行空肠部分切除、吻合术.本组病例均给予充分的营养支持治疗.结果 本组消化道漏发生率为5.20%(61/1173).6例胃肠道漏患者肝移植术中有不同程度的胃肠道损伤.本组患者治疗后共有1 1例死于严重腹腔感染致多器官功能衰竭,病死率为18.0%(11/61);其中胆漏4例,病死率为8.6% (4/46);胃肠道漏7例,病死率为7/15.其余50例经过1~3个月的综合治疗,康复出院.随访6~ 84个月,无消化道漏再发.结论 肝移植术后早期消化道漏的发生率低,但病死率高,尤以胃肠道漏为著.大剂量糖皮质激素的使用、既往腹部手术史及术中医源性损伤可能是其发生的主要原因.综合治疗是治愈的关键.

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abstracts:

Objective To investigate the clinical characteristics,diagnosis and treatment of digestive tract leakage after orthotopic liver transplantation (OLT). Methods Sixty-one recipients had digestive tract leakage in early stage after OLT among 1173 cases from January 2000 to December 2010.There were 55 male and 6 female patients,aging fiom 36 to 61 years,with a median of 45 years.Digestive tract leakage included bile leakage (46 cases),gastric leakage (5 cases ),duodenal leakage ( 1 case),jejunal leakage (4 cases),ileal leakage (1 case) and colon transversum leakage (4 cases). Ten of recipients with gastrointestinal leakage had 1 to 3 times of abdominal surgery before OLT. Abdominal drainage was used in 28 cases with bile leakage, and additionally, endoscopic retrograde cholangiopancreatography,endoscopic nasobiliary drainage and stenting were performed for 8 of them,and surgical neoplasty for another 18 patients with bile leakage. Simple surgical neoplasty of perforation was performed for 13 patients with gastrointestinal leakage,and diverticulectomy and neoplasty for 1 case with duodenal leakage, and partial jejunectomy for one severe jejunal leakage. Nutritional support was administered for all of cases.Results The incidence rate of digestive tract leakage in early stage after OLT was 5.20% (61/1173). Intra-operative iatrogenic injury of gastrointestinal tract was occurred in 6 cases with gastrointestinal leakage.After treatment,11 cases died of multiple organ failure resulted from severe infection,with mortality of 18.0% ( 11/61 ),including 4 cases with bile leakage,with the mortality of 8.6% (4/46),and 7 cases with gastrointestinal tract leakage,with the mortality of 46.6% (7/15).The remanent 50 cases through comprehensive treatment with a span of 1 to 3 months recovered and discharged healthily.No digestive tract leakage reoccurred in the follow-up of 6 to 84 months. Conclusions The morbidity of digestive tract leakage in early stage after OLT is low,but its mortality is high,especially for gastrointestinal tract leakage. High dose corticosteroids therapy,history of abdominal operation and intraoperative iatrogenic injury may be high risk factor. Comprehensive treatment is crucial for improving prognosis.

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