Causes and consequences of ischemic-type biliary lesions after liver transplantation
Causes and consequences of ischemic-type biliary lesions after liver transplantation
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DOI：
10.1007/s00534-005-1080-2
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发表时间：
2006-11-01
期刊：
影响因子：
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通讯作者：
Porte, Robert J.
中科院分区：
文献类型：
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作者：
Buis, Carlijn I.;Hoekstra, Harm;Porte, Robert J.
胆道并发症是肝移植后发病、移植物丢失甚至死亡的主要原因。最麻烦的是所谓的缺血型胆道病变（ITBL），发病率在5%至15%之间。ITBL是一种放射学诊断，其特征是在没有肝动脉血栓形成的情况下，在胆管造影片上出现肝内狭窄和扩张。ITBL的几个风险因素已被确定，强烈建议多因素起源。ITBL的主要危险因素包括缺血相关损伤、免疫诱导损伤和胆盐诱导的细胞毒性损伤。然而，在许多情况下，无法确定具体的风险因素。缺血相关损伤包括缺血时间延长和通过胆管周围血管丛的血流障碍。基于ITBL与ABO血型不合、趋化因子基因编码多态性和既存免疫介导疾病（如原发性硬化性胆管炎和自身免疫性肝炎）的关系，免疫损伤被认为是一个风险因素。ITBL患者的临床表现通常没有特异性;症状可能包括发热、腹部不适和肝功能检查中胆汁淤积增加。诊断是通过胆管成像研究。治疗首先通过内镜逆行胰胆管造影术（ERCP）或经皮经鞘胆管引流术（PTCD）缓解胆汁淤积和扩张症状，然后在可能的情况下进行支架植入术。最终，高达50%的ITBL患者将需要再次移植或可能死亡。在选定的患者中，可以通过切除肝外胆管和肝管空肠吻合术避免或延迟再次移植。在制定更具体的预防或治疗策略之前，需要对ITBL的发病机制进行更多的研究。
Biliary complications are a major source of morbidity, graft loss, and even mortality after liver transplantation. The most troublesome are the so-called ischemic-type biliary lesions (ITBL), with an incidence varying between 5% and 15%. ITBL is a radiological diagnosis, characterized by intrahepatic strictures and dilatations on a cholangiogram, in the absence of hepatic artery thrombosis. Several risk factors for ITBL have been identified, strongly suggesting a multifactorial origin. The main categories of risk factors for ITBL include ischemia-related injury; immunologically induced injury; and cytotoxic injury, induced by bile salts. However, in many cases no specific risk factor can be identified. Ischemia-related injury comprises prolonged ischemic times and disturbance in blood flow through the peribiliary vascular plexus. Immunological injury is assumed to be a risk factor based on the relationship of ITBL with ABO incompatibility, polymorphism in genes coding for chemokines, and pre-existing immunologically mediated diseases such as primary sclerosing cholangitis and autoimmune hepatitis. The clinical presentation of patients with ITBL is often not specific; symptoms may include fever, abdominal complaints, and increased cholestasis on liver function tests. Diagnosis is made by imaging studies of the bile ducts. Treatment starts with relieving the symptoms of cholestasis and dilatation by endoscopic retrograde cholangiopancreaticography (ERCP) or percutaneous transhepatic cholangiodrainage (PTCD), followed by stenting if possible. Eventually up to 50% of the patients with ITBL will require a retransplantation or may die. In selected patients, a retransplantation can be avoided or delayed by resection of the extra-hepatic bile ducts and construction of a hepaticojejunostomy. More research on the pathogenesis of ITBL is needed before more specific preventive or therapeutic strategies can be developed.