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原位肝移植术后胆道狭窄的危险因素及预后分析

孔德财 张小静 员阳光 段昊雨 叶军锋

引用本文:
Citation:

原位肝移植术后胆道狭窄的危险因素及预后分析

DOI: 10.12449/JCH241119
基金项目: 

吉林省医疗卫生人才专项项目 (JLSWSRCZX2021-074)

伦理学声明:本研究方案于2024年1月24日经由吉林大学第一医院伦理委员会审批,批号:2024-034,患者均签署知情同意书。
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:孔德财负责设计论文框架,起草论文;孔德财、张小静、员阳光和段昊雨负责研究过程的实施,数据收集,统计学分析,绘制图表;叶军锋负责论文修改,拟定写作思路,指导撰写文章并最后定稿。
详细信息
    通信作者:

    叶军锋, yejunfeng@jlu.edu.cn (ORCID: 0000-0001-5330-9712)

Risk factors for biliary stricture and prognosis after orthotopic liver transplantation

Research funding: 

Jilin Province Medical and Health Talents Special Project (JLSWSRCZX2021-074)

More Information
  • 摘要:   目的  探讨原位肝移植术后2年内发生胆道狭窄的危险因素并进行生存分析。  方法  回顾性分析吉林大学第一医院肝移植中心2014年1月—2022年1月495例实施的肝移植手术患者的资料。根据肝移植术后两年内是否发生胆道狭窄,将495例患者分为胆道狭窄组(n=89)和非胆道狭窄组(n=406),进行胆道狭窄的危险因素和预后分析。正态分布的计量资料两组间比较采用成组t检验;偏态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ2检验。应用Cox单因素和多因素回归分析进行危险因素分析。应用Kaplan-Meier法进行生存分析。  结果  受体性别(HR=1.808,95%CI:1.055~3.098,P=0.031)、受体术前总胆红素(HR=1.002,95%CI:1.001~1.003,P=0.001)、冷缺血时间(HR=1.003,95%CI:1.001~1.005,P=0.007)、受体既往腹部手术史(HR=3.851,95%CI:2.273~6.524,P<0.001)和供体受体胆管不匹配(HR=1.962,95%CI:1.041~3.698,P=0.037)是移植术后2年内发生胆道狭窄的独立危险因素。通过中位随访期为4.09年的随访,肝移植术后患者的1、3和5年生存率分别为92.7%、80.5%和75.4%。肝移植术后2年内发生的胆道狭窄对原位肝移植患者的生存影响无统计学意义。  结论  受体性别、受体术前总胆红素、冷缺血时间、受体既往腹部手术史和供体受体胆管不匹配是移植术后2年内发生胆道狭窄的独立危险因素。肝移植术后2年内发生的胆道狭窄并不影响肝移植患者的生存期。

     

  • 图  1  受体既往腹部手术史对肝移植术后BS的累积风险

    Figure  1.  Cumulative risk of the recipients with previous abdominal surgical history for the biliary stricture after OLT

    图  2  肝移植术后2年内发生BS的独立危险因素列线图

    Figure  2.  The nomogram of independent risk factors for biliary stricture within two years after liver transplantation

    图  3  肝移植术后BS组与非BS组生存分析

    Figure  3.  Survival analysis between the stricture and non-stricture groups after liver transplantation

    图  4  肝移植术后吻合口狭窄组与非吻合口狭窄组生存分析

    Figure  4.  Comparing survival analysis between the anastomotic stenosis group and non-anastomotic stenosis group

    表  1  两组患者的临床特征比较

    Table  1.   Comparison of clinical features between two groups of patients

    因素 非BS组(n=406) BS组(n=89) 统计值 P
    受体性别(例) χ2=5.529 0.019
    93 31
    313 58
    年龄(岁) 51.78±9.58 51.36±9.63 t=-0.371 0.711
    手术日期(例) χ2=3.003 0.083
    2020年以前 238 61
    2020年及以后 168 28
    肝硬化(例) χ2=3.854 0.050
    50 18
    356 71
    乙型肝炎(例) χ2=0.179 0.672
    168 39
    238 50
    丙型肝炎(例) χ2=0.001 0.975
    379 83
    27 6
    恶性肿瘤(例) χ2=0.000 0.997
    251 55
    155 34
    既往腹部手术史(例) χ2=22.250 <0.001
    314 47
    92 42
    缝线(例) χ2=0.159 0.690
    聚丙烯缝线 269 57
    其他类型缝线 137 32
    缝合方式(例) χ2=1.086 0.581
    后连续前间断 290 62
    前后均间断 76 15
    前后均连续 40 12
    供体受体胆管不匹配(例) χ2=5.835 0.016
    355 69
    51 20
    白蛋白(g/L) 33.20±5.68 33.03±5.88 t=-0.256 0.798
    INR 1.53±0.58 1.62±0.69 t=1.331 0.184
    术前总胆红素(µmol/L) 53.8(24.1~164.6) 100.2(32.3~338.3) Z=5.147 0.002
    肌酐(µmol/L) 63.2(51.6~75.9) 60.7(53.1~70.8) Z=4.114 0.356
    Child-Pugh分级(例) χ2=0.403 0.818
    A级 85 16
    B级 307 70
    C级 14 3
    MELD评分(分) 10.52(7.03~15.63) 11.31(6.75~17.43) Z=0.150 0.699
    热缺血时间(s) 62.0(43.0~88.0) 81.0(61.5~105.0) Z=7.107 0.008
    冷缺血时间(min) 364.99±109.39 408.06±115.48 t=3.330 0.001
    手术时间(min) 485.42±91.90 514.89±109.39 t=2.644 0.008
    出血量(mL) 2 500(1 500~4 000) 3 000(1 450~5 300) Z=2.840 0.094
    下载: 导出CSV

    表  2  肝移植术后BS的Cox单因素和多因素分析

    Table  2.   Univariate and multivariate Cox analysis of the biliary stricture after liver transplantation

    因素 单因素分析 多因素分析
    HR(95%CI P HR(95%CI P
    受体性别(女/男) 1.669(1.079~2.581) 0.021 1.808(1.055~3.098) 0.031
    年龄 0.997(0.976~1.019) 0.789
    手术日期(2020年以前/2020年及以后) 1.487(0.951~2.326) 0.082
    肝硬化(否/是) 0.595(0.355~1.000) 0.051
    乙型肝炎(否/是) 0.937(0.616~1.424) 0.761
    丙型肝炎(否/是) 1.092(0.477~2.502) 0.834
    恶性肿瘤(否/是) 1.071(0.698~1.643) 0.753
    既往腹部手术史(否/是) 2.787(1.837~4.227) <0.001 3.851(2.273~6.524) <0.001
    缝线(聚丙烯缝线/其他类型缝线) 1.112(0.722~1.715) 0.629
    缝合方式(后连续前间断/前后均间断/前后均连续) 1.098(0.816~1.476) 0.537
    供体受体胆管不匹配(否/是) 1.785(1.085~2.937) 0.023 1.962(1.041~3.698) 0.037
    白蛋白 0.997(0.961~1.034) 0.858
    INR 1.225(0.906~1.658) 0.188
    术前总胆红素 1.001(1.000~1.002) 0.013 1.002(1.001~1.003) 0.001
    肌酐 0.995(0.987~1.002) 0.158
    Child-Pugh分级(A/B/C级) 1.107(0.699~1.752) 0.664
    MELD评分 1.005(0.979~1.032) 0.699
    热缺血时间 1.002(1.000~1.004) 0.047
    冷缺血时间 1.003(1.001~1.005) 0.001 1.003(1.001~1.005) 0.007
    手术时间 1.002(1.001~1.004) 0.008
    出血量 1.000(1.000~1.000) 0.075
    下载: 导出CSV

    表  3  肝移植术后患者的预后生存分析表

    Table  3.   Prognostic survival analysis table for patients after liver transplantation

    因素 例数 术后1年生存率(%) 术后3年生存率(%) 术后5年生存率(%) χ2 P
    BS 0.629 0.430
    89 96.6 76.6 70.3
    406 91.9 81.4 76.7
    原发病为恶性 49.920 <0.001
    189 85.7 66.8 56.5
    306 97.1 89.8 87.2
    既往腹部手术史 2.413 0.120
    134 91.0 78.3 70.3
    361 93.4 81.3 77.2
    供受体胆管匹配 0.104 0.747
    424 92.2 80.7 75.6
    71 95.8 79.3 74.5
    下载: 导出CSV

    表  4  肝移植术后发生BS患者的预后生存分析表

    Table  4.   Prognostic survival analysis table for patients with biliary stricture after liver transplantation

    因素 例数 术后1年生存率(%) 术后3年生存率(%) 术后5年生存率(%) χ2 P
    BS类型 4.26 0.039
    非吻合口狭窄 16 87.5 74.0 63.5
    吻合口狭窄 73 98.6 85.6 75.2
    最窄宽度 0.289 0.591
    ≤50% 56 93.9 87.9 82.7
    >50% 33 98.2 80.5 66.8
    狭窄长度 1.616 0.204
    ≤10 mm 62 96.8 86.4 80
    >10 mm 27 96.2 70.6 55.6
    下载: 导出CSV
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