• 上海市器官移植臨床醫(yī)學中心,上海交通大學附屬第一人民醫(yī)院(上海200080);

膽道并發(fā)癥發(fā)生率的高低往往代表了一個肝移植中心的整體技術水平。歐美成熟的肝移植中心膽道并發(fā)癥發(fā)生率為7%~10%，1年生存率達到90%。來自中國肝移植登記注冊網（CTLR）的資料： 香港瑪麗醫(yī)院2006年統(tǒng)計了香港公民在大陸進行肝移植的148例患者，在長期隨訪中發(fā)現(xiàn)，有48%的受體發(fā)生了膽道并發(fā)癥，1年生存率只有59%； 說明目前肝移植膽道并發(fā)癥的防治仍然是亟待解決的難題。究其原因，還是對膽管微循環(huán)保護的研究不夠深入和并發(fā)癥發(fā)生的防治體系不夠完善，筆者就此談幾點體會。
1膽管微循環(huán)保護的理論
人體肝臟膽管及血管鑄型模型的研究顯示，膽管為動脈單一供血，肝固有動脈和胃十二指腸動脈終末支分出3點、9點動脈滋養(yǎng)肝外膽管，并構成肝門部膽管周圍血管叢(peribiliary vascular plexus,PVP)，膽管的動脈系統(tǒng)與門靜脈之間無明顯的交通血管，門靜脈在膽管的血液供應中作用有限 (圖1)。在動脈損傷時膽管很難從別的途徑獲得充分的血液供應，從而造成膽管的缺血性損傷。碳素墨汁灌注透明法顯示，肝門部每個肝葉膽管及其分叉部均有肝固有動脈的較大分支支配，肝動脈的分支與膽管壁微血管之間呈垂直的連接方式。膽管厚切片透明后可清楚地顯示出PVP的平面結構: 外層微血管直徑較粗，內層微血管象鏈條一樣排列，中層微血管連接在內、外層之間[３](圖2)。動脈血流從外層較粗大血管流入位于膽管黏膜下的內層微血管，它是膽管動脈的終末分支,由內層微血管滋養(yǎng)的膽管上皮細胞層是膽管最易受損的部位(Achilles heel)。所以，肝移植中膽管動脈灌洗非常重要，應盡可能選用能夠進入膽管黏膜內層血管網的低黏滯度灌注液。筆者研究證實了HCA液結合UW液灌注快速獲取無心跳供體（NHBD）的肝臟，其保存效果優(yōu)于單用UW液、Celsior液或HTK液，采用價廉低黏滯度HCA液聯(lián)合UW液灌注，既能防止膽管PVP微血栓形成，又能充分發(fā)揮UW液對肝細胞和膽管細胞的保護作用.............................

引用本文： 鐘林,彭志海. 肝移植后膽道并發(fā)癥防治的幾點體會. 中國普外基礎與臨床雜志, 2009, 16(3): 177-179. doi: 復制

1. Adam R, McMaster P, O’Grady JG, et al.　Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry [J]. Liver Transpl, 2003; 9(12):1231.
2. Li WG, Huang XQ, Li B, et al. Three dimensional reconstruction of hepatohilar peribiliary vascular plexus in rats and dogs [J]. Chin Med J (Engl), 2007; 120(12):1106.
3. Li WG, Hu SX, Xue BD, et al. Observation of hepatohilar peribiliary vascular plexus with complete absence of hepatic artery blood supply in rats [J]. Transplant Proc, 2007; 39(10):3424.
4. 戴學明, 彭志海, 陳國慶, 等. 供肝的獲取及修整技術規(guī)范與獲取器官質量之間的關系 [J]. 中國實用外科雜志, 2004; 24(1):54.
5. Lo CM. Complications and longterm outcome of living liver donors: a survey of 1 508 cases in five Asian centers [J]. Transplantation, 2003; 75(3 Suppl):S12.
6. Shah SA, Grant DR, McGilvray ID, et al. Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: results of a Western center [J]. Am J Transplant, 2007; 7(1):161.
7. Park JS, Kim MH, Lee SK, et al. Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation [J]. Gastrointest Endosc, 2003; 57(1):78.
8. Rerknimitr R, Sherman S, Fogel EL, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy [J]. Gastrointest Endosc, 2002; 55(2):224.
9. Gunsar F, Rolando N, Pastacaldi S, et al. Late hepatic artery thrombosis after orthotopic liver transplantation [J]. Liver Transpl, 2003; 9(6):605.
  1. 1. Adam R, McMaster P, O’Grady JG, et al.　Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry [J]. Liver Transpl, 2003; 9(12):1231.
  2. 2. Li WG, Huang XQ, Li B, et al. Three dimensional reconstruction of hepatohilar peribiliary vascular plexus in rats and dogs [J]. Chin Med J (Engl), 2007; 120(12):1106.
  3. 3. Li WG, Hu SX, Xue BD, et al. Observation of hepatohilar peribiliary vascular plexus with complete absence of hepatic artery blood supply in rats [J]. Transplant Proc, 2007; 39(10):3424.
  4. 4. 戴學明, 彭志海, 陳國慶, 等. 供肝的獲取及修整技術規(guī)范與獲取器官質量之間的關系 [J]. 中國實用外科雜志, 2004; 24(1):54.
  5. 5. Lo CM. Complications and longterm outcome of living liver donors: a survey of 1 508 cases in five Asian centers [J]. Transplantation, 2003; 75(3 Suppl):S12.
  6. 6. Shah SA, Grant DR, McGilvray ID, et al. Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: results of a Western center [J]. Am J Transplant, 2007; 7(1):161.
  7. 7. Park JS, Kim MH, Lee SK, et al. Efficacy of endoscopic and percutaneous treatments for biliary complications after cadaveric and living donor liver transplantation [J]. Gastrointest Endosc, 2003; 57(1):78.
  8. 8. Rerknimitr R, Sherman S, Fogel EL, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy [J]. Gastrointest Endosc, 2002; 55(2):224.
  9. 9. Gunsar F, Rolando N, Pastacaldi S, et al. Late hepatic artery thrombosis after orthotopic liver transplantation [J]. Liver Transpl, 2003; 9(6):605.