Staged Biliary Reconstruction After Orthotopic Liver Transplantation: A Practical Surgical Strategy for High-Acuity Adult Recipients
Staged Biliary Reconstruction After Orthotopic Liver Transplantation: A Practical Surgical Strategy for High-Acuity Adult Recipients
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DOI：
10.1097/txd.0000000000000924
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发表时间：
2019-09-01
影响因子：
2.3
通讯作者：
Hong, Johnny C.
中科院分区：
文献类型：
--
作者：
Pearson, Terra;Zimmerman, Michael A.;Hong, Johnny C.
背景原位肝移植（奥尔特）后的胆道并发症（BC）与较差的患者结局和增加的医疗费用密切相关。高敏患者的BC可能是致命的。虽然在成人和儿童奥尔特中报告了肝移植后分期胆道重建（SBRALT）的效用，但胆道结局数据很少。我们试图评估SBRALT在高敏度移植受者中的临床效用和结局。方法.我们对2012年1月1日至2017年9月30日期间149例成人奥尔特的前瞻性数据库进行了分析。平均随访26个月。比较I组：一期奥尔特伴胆道重建（N = 58）与II组：SBRALT（N = 91）的变量。结果与I组相比，II组患者的病情严重程度更高：终末期肝病评分的中位数模型（19 vs 35 P = 0.002），需要移植前重症监护室（29.3% vs 54.9%，P = 0.022），移植前肾脏替代治疗（15.5% vs 48.4%）、估计失血量（2000 vs 4750 mL，P < 0.001）和术中浓缩红细胞输注（4 vs 10单位，P < 0.001）。对于第二组，在奥尔特后1至6天之间进行胆道重建。肝管空肠吻合术的发生率为8.6%（组I）和26.4%（组II），P = 0.010。对于I组和II组，BC率（8.6% vs 7.7%，P = 0.955）和1年移植物无衰竭生存率（89.7% vs 88.2%，P = 0.845）相当。结论. SBRALT在高敏度受者中的移植物无衰竭生存率和胆道结局非常好，与低风险患者的一期奥尔特相当。SBRALT是复杂奥尔特的一种实用的手术策略。
Background. Biliary complications (BC) following orthotopic liver transplantation (OLT) is strongly associated with inferior patient outcomes and increased healthcare cost. BC in high-acuity patients can be lethal. While the utility of staged biliary reconstruction after liver transplantation (SBRALT) has been reported in adult and pediatric OLT, biliary outcome data are scarce. We sought to evaluate the clinical utility and outcomes of SBRALT in high-acuity transplant recipients. Methods. We conducted an analysis from our prospective database of 149 adult OLT between January 1, 2012, and September 30, 2017. Mean follow-up was 26 months. Variables were compared for Group I: one-stage OLT with biliary reconstruction (N = 58) versus Group II: SBRALT (N = 91). Results. Compared with Group I, patients in Group II had higher acuity of illness: median model for end-stage liver disease scores (19 vs 35 P = 0.002), requirement for pretransplant intensive care unit (29.3% vs 54.9%, P = 0.022), pretransplant renal replacement therapy (15.5% vs 48.4%), estimated blood loss (2000 vs 4750 mL, P < 0.001), and intraoperative packed red blood cells transfusion (4 vs 10 units, P < 0.001). For Group II, biliary reconstruction was performed between 1 and 6 days after OLT. Hepaticojejunostomy was performed in 8.6% (Group I) and 26.4% (Group II), P = 0.010. For Groups I and II, BC rates (8.6% vs 7.7%, P = 0.955) and 1-year graft failure-free survival rates (89.7% vs 88.2%, P = 0.845) were comparable. Conclusions. Graft failure-free survival and biliary outcomes of SBRALT in high-acuity recipients are excellent and comparable to one-stage OLT for low-risk patients. SBRALT is a practical surgical strategy in complex OLT.