Résumé
Objective To evaluate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-based comprehensive minimally invasive treatment for biliary anastomotic stenosis (BAS) after liver transplantation. Methods Clinical data of 60 BAS recipients after liver transplantation were retrospectively analyzed, 54 male and 6 female, aged (48±10) years. ERCP was initially carried out. If it succeeded, plastic or metallic stents were placed into the biliary tract. If it failed, percutaneous transhepatic cholangial drainage (PTCD) or single-operator cholangioscopy (SpyGlass) was adopted to pass through the stenosis. If all these procedures failed, magnetic anastomosis or other special methods were delivered. The incidence and treatment of BAS after liver transplantation were summarized. The efficacy, stent removal and recurrence were observed. Results The median time of incidence of BAS after liver transplantation was 8 (4, 13) months. Within postoperative 1 year, 1-2 years and over 2 years, 39, 16 and 5 recipients were diagnosed with BAS, respectively. All 60 BAS recipients after liver transplantation were successfully treated, including 56 cases initially receiving ERCP, and 41 completing BAS treatment, with a success rate of 73%. The failure of guide wire was the main cause of ERCP failure. The success rates of PTCD, SpyGlass and magnetic anastomosis were 5/9, 5/7 and 7/8, respectively. Two recipients were successfully treated by percutaneous choledochoscope-assisted blunt guide wire technique and stent placement in the biliary and duodenal fistula. After 3 (3, 4) cycles of ERCP and 13 (8, 18) months of stent indwelling, 38 recipients reached the stent removal criteria, including 25 plastic stents and 13 metallic stents. The indwelling time of plastic stents was longer than that of metallic stents (P < 0.05). Six cases suffered from stenosis recurrence at 12 (8, 33) months after stent removal, and the recurrence rate was 16%. Six patients were treated with ERCP, and 5 of them did not recur after the stents were successfully removed. Multivariate analysis showed that delayed diagnosis of stenosis and frequent ERCP before stent removal were the independent risk factors for BAS recurrence (both P < 0.05). Conclusions ERCP-based comprehensive minimally invasive treatment may improve the success rate of BAS treatment after liver transplantation and yield satisfactory long-term efficacy. Delayed diagnosis of BAS and high frequent ERCP required for stent removal are the independent risk factors for BAS recurrence.
Résumé
Objective To evaluate the clinical efficacy of early diagnosis by contrast-enhanced ultrasound (CEUS) combined with mesenchymal stem cell (MSC) therapy in the treatment of biliary ischemia after liver transplantation. Methods Clinical data of 9 recipients presenting with biliary ischemia detected by CEUS within 4 weeks after liver transplantation and diagnosed with non-anastomotic biliary stricture (NAS) within postoperative 1 year were retrospectively analyzed. In the conventional treatment group, 4 recipients were treated with conventional treatment including liver protection, cholagogic therapy and interventional therapy. In MSC treatment group, 5 recipients received intravenous infusion of MSC at 1, 2, 4, 8, 12 and 16 weeks after biliary ischemia detected by CEUS on the basis of conventional therapy. The interventional treatment and clinical prognosis within 1 year after liver transplantation were analyzed between two groups. Results Two recipients in the MSC treatment group required interventional therapy, which was initially given at 7-9 months after liver transplantation for 1-2 times. All recipients in the conventional treatment group required interventional therapy, which was initially delivered at postoperative 1-3 months for 2-6 times, earlier than that in the MSC treatment group. Within 1 year following liver transplantation, diffuse bile duct injury occurred in 2 recipients in MSC treatment group, and no graft dysfunction was observed. In the conventional treatment group, all recipients developed diffuse bile duct injury, and 2 recipients presented with graft dysfunction. Conclusions Early diagnosis of biliary ischemia after liver transplantation by CEUS combined with MSC therapy may delay and reduce the requirement of interventional therapy for NAS, and also improve clinical prognosis of the recipients.
Résumé
Objective To compare the clinical curative effect of endoscopic retrograde cholangio-pancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) in treatment of malignant obstructive jaundice. Methods Clinical data of 97 patients with malignant obstructive jaundice were collected and analyzed retrospectively, includs 54 patients in ERCP group and 43 patients in PTCD group. The clinical curative effect, postoperative complications, comfort score and hospitalization time and costs were compared between the two groups. Results The symptoms improved compared with preoperative. The total remission rate of jaundice in ERCP group and PTCD group was 77.78％ vs 79.07％, and the remission rate of high obstructive jaundice was 55.00％, vs 89.29％, and the remission rate of low obstruction jaundice was 91.18％, vs 60.00％.There was significant difference between the two groups (P < 0.05); The incidence of postoperative complications in ERCP group and PTCD group was 37.04％ vs 16.28％. There was significant difference between the two groups (P < 0.05); The comfort scale of ERCP group and PTCD group was (15.13 ± 3.89) points vs (16.60 ± 3.15) points. There was significant difference between the two groups (P < 0.05); The hospitalization time of ERCP group and PTCD group were (8.74 ± 4.94) days vs (11.12 ± 4.82) days, and the hospitalization costs were (22.70 ± 6.30) thousand yuan vs (21.90 ± 3.40) thousand yuan. Conclusion Satisfactory clinical curative effect for patients with malignant obstructive jaundice can be derived from both ERCP and PTCD. The treatment of ERCP has more advantages than PTCD in patients with low obstruction, while PTCD is better than ERCP in patients with high obstruction. But ERCP group is better than PTCD in comfort score and shorter in hospitalization time. There is no obvious difference on hospitalization costs.
Résumé
Objective To retrospectively study the clinical value and the advantages in " planned hepatectomy" for the "central type" intrahepatic and extrahepatic choledochal cysts.Methods The clinical data of 7 patients with the "central type" of intrahepatic and extrahepatic choledochal cysts which were treated with "planned hepatectomy" from January 2014 through April 2017 at the Department of Biliary Tract Surgery of the Eastern Hepatobiliary Surgery Hospital,Second Military Medical University were retrospectively analyzed.Results All the patients completed radical resection of the intrahepatic and extrahepatic choledochal cysts in accordance with the " planned hepatectomy".The operations included 6 patients who were treated with percutaneous transhepatic cholangial drainage (PTCD) and 5 patients with portal vein embolization (PVE) prior to the surgical excision.Combined right liver resection was performed in 6 patients,and combined left liver resection in one patient.All the 7 patients had a history of chronic cholangitis.Liver volume tests demonstrated that the hemiliver volume to be removed (the embolized hemiliver) significantly decreased after PVE,whereas the hemilivers to be persevered were remarkably enlarged.No complication associated with PTCD and PVE occurred.The mean postoperative hospitalization was 12 days.Liver function tests suggested all the patients recovered well.No postoperative complication of bleeding,infection or liver function failure was observed,except in one patient who experienced pleural and abdominal effusion.Conclusions Combined subtotal hepatectomy may increase the risk of complications associated with the "central type" intrahepatic and extrahepatic choledochal cysts.The surgical strategy in planned hepatectomy can be used effectively to treat the "central type" of intrahepatic and extrahepatic choledochal cysts,with improved surgical safety,decrease in incidences of postoperative liver function failure and residual choledochal cysts.