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1
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Vernuccio F, Mercante I, Tong XX, Crimì F, Cillo U, Quaia E. Biliary complications after liver transplantation: A computed tomography and magnetic resonance imaging pictorial review. World J Gastroenterol 2023; 29:3257-3268. [PMID: 37377585 PMCID: PMC10292145 DOI: 10.3748/wjg.v29.i21.3257] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/23/2023] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
Biliary complications are the most common complications after liver transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are cornerstones for timely diagnosis of biliary complications after liver transplantation. The diagnosis of these complications by CT and MRI requires expertise, mainly with respect to identifying subtle early signs to avoid missed or incorrect diagnoses. For example, biliary strictures may be misdiagnosed on MRI due to size mismatch of the common ducts of the donor and recipient, postoperative edema, pneumobilia, or susceptibility artifacts caused by surgical clips. Proper and prompt diagnosis of biliary complications after transplantation allows the timely initiation of appropriate management. The aim of this pictorial review is to illustrate various CT and MRI findings related to biliary complications after liver transplantation, based on time of presentation after surgery and frequency of occurrence.
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Affiliation(s)
- Federica Vernuccio
- Department of Radiology, University Hospital of Padova, Padova 35128, Italy
| | - Irene Mercante
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Xiao-Xiao Tong
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Filippo Crimì
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Umberto Cillo
- Department of Surgery, Hepatobiliary Surgery and Liver Transplant Center, Oncology and Gastroenterology (DISCOG), University of Padova, Padova 35128, Italy
| | - Emilio Quaia
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
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2
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Fasullo M, Patel M, Khanna L, Shah T. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000778. [PMID: 35552193 PMCID: PMC9109012 DOI: 10.1136/bmjgast-2021-000778] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
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Affiliation(s)
- Matthew Fasullo
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Milan Patel
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lauren Khanna
- Gastroenterology, New York University Medical Center, New York, New York, USA
| | - Tilak Shah
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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3
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Fernandez-Simon A, Sendino O, Chavez-Rivera K, Córdova H, Colmenero J, Crespo G, Fundora Y, Samaniego F, Ruiz P, Fondevila C, Navasa M, Cárdenas A. The presence and outcome of biliary sphincter disorders in liver-transplant recipients according to the Rome IV classification. Gastroenterol Rep (Oxf) 2021; 9:299-305. [PMID: 34567561 PMCID: PMC8460114 DOI: 10.1093/gastro/goab025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/13/2021] [Accepted: 05/11/2021] [Indexed: 11/27/2022] Open
Abstract
Background Biliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria. Methods We reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP. Results Among the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up. Conclusions PS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.
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Affiliation(s)
- Alejandro Fernandez-Simon
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Oriol Sendino
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Karina Chavez-Rivera
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Henry Córdova
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jordi Colmenero
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Gonzalo Crespo
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Yilliam Fundora
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Franco Samaniego
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pablo Ruiz
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Constantino Fondevila
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Andrés Cárdenas
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
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4
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Hong SY, Hu XG, Lee HY, Won JH, Kim JW, Shen XY, Wang HJ, Kim BW. Longterm Analysis of Biliary Complications After Duct-to-Duct Biliary Reconstruction in Living Donor Liver Transplantations. Liver Transpl 2018; 24:1050-1061. [PMID: 29633539 DOI: 10.1002/lt.25074] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/22/2018] [Accepted: 05/20/2018] [Indexed: 02/07/2023]
Abstract
Biliary complication (BC) is still regarded as the Achilles' heel of a living donor liver transplantation (LDLT). This study aims to evaluate the longterm outcomes of the duct-to-duct (DD) biliary reconstruction using 7-0 suture and to identify the risk factors of BCs after LDLTs. Data of 140 LDLTs between 2006 and 2015 were analyzed. All biliary reconstructions were performed as DD anastomoses using 7-0 suture: 102 for the right lobe, 20 for the left lobe, and 18 for right posterior sector grafts. BC was defined as a bile leakage (BL) or a biliary stricture (BS), and the median follow-up time after LDLT was 65 months. A total of 19 recipients (13.5%) developed BCs (8 BLs and 16 BSs) after LDLT. The survival rates between recipients with and without BCs were 83% and 86.7%, respectively (P = 0.88). In univariate analyses, the risk factors for BC were small diameter of the graft's bile duct, long warm ischemic time, small graft-to-recipient weight ratio, and no use of external biliary stent (EBS). The graft's bile duct diameter ≤ 3 mm and no use of EBS were determined as independent risk factors (hazard ratios of 9.74 and 7.68, respectively) in multivariate analyses. The 116 recipients with EBS had no BL, 11 had BSs (9%), while 24 without EBS had 8 BLs (33%) and 5 BSs (21%). After a propensity score match between the recipients with and without EBS, the EBS group (24) developed only 1 BS (4%). In conclusion, DD anastomosis using 7-0 suture combined with EBS could provide favorable longterm outcomes after LDLT, which should thus be considered the surgical technique of choice for LDLTs.
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Affiliation(s)
- Sung Yeon Hong
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Xu-Guang Hu
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Hyun Young Lee
- Clinical Trial Center, Ajou University School of Medicine, Suwon, Korea
| | - Je Hwan Won
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Woo Kim
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Xue-Yin Shen
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Hee-Jung Wang
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
| | - Bong-Wan Kim
- Department of Hepatobiliary Surgery and Liver Transplantation, Ajou University School of Medicine, Suwon, Korea
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5
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Girotra M, Soota K, Klair JS, Dang SM, Aduli F. Endoscopic management of post-liver transplant biliary complications. World J Gastrointest Endosc 2015; 7:446-459. [PMID: 25992185 PMCID: PMC4436914 DOI: 10.4253/wjge.v7.i5.446] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/15/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.
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6
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Abstract
UNLABELLED Biliary complications (BCs) remain one of the most outstanding factors influencing long-term results after orthotopic liver transplantation. The authors carried out a systematic overview of 1720 papers since 2008, and focused on 45 relevant ones. Among 14,411 transplanted patients the incidence of BCs was 23%. Biliary leakage occurred in 8.5%, biliary stricture in 14.7%, mortality rate was 1-3%. RISK FACTORS preoperative sodium level; p = 0.037, model of end-stage liver disease score >25; p = 0.048, primary sclerosing cholangitis; p = 0.001, malignancy; p = 0.026, donor age >60, macrovesicular graft steatosis; p = 0.001, duct-to-duct anastomosis; p = 0.004, long anhepatic phase; p = 0.04, cold ischemic time >12 h; p = 0.043, use of T-tube; p = 0.032, insufficient flush of bile ducts; p = 0.001, acute rejection; p = 0.003, cytomegalovirus infection; p = 0.004 and hepatic artery thrombosis; p = 0.001. The management was surgical in case of biliary leakage, and interventional radiology or endoscopic retrograde cholangiopancreatography in case of biliary stricture. Mapping of miRNA profile is a new field of research. Nemes-Doros score is a useful tool in the estimation of hepatic artery thrombosis. Management of BCs requires a multidisciplinary expert team.
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Affiliation(s)
- Balázs Nemes
- Division of Transplantation, Institute of Surgery, Clinical Centre, University of Debrecen, Moricz Zs. krt. 22, Debrecen, H-4032, Hungary
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7
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Rai R. Liver transplantatation- an overview. Indian J Surg 2012; 75:185-91. [PMID: 24426424 DOI: 10.1007/s12262-012-0643-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 06/21/2012] [Indexed: 01/23/2023] Open
Abstract
Liver transplantation is a therapeutic option of choice for acute and chronic end-stage liver disease. Indications, contraindications, and surgical procedures for the liver transplantation have become well established. In most part of the world, the main source of liver for transplantation remains the donation after brain death (DBD), but in view of increasing death on the waiting list due to shortage of brain dead organs other options such as split liver transplantation, living donor liver transplantation (LDLT), and donation after cardiac death (DCD) have been used. In the pretransplantation era, liver failure was nearly universally fatal, with mortality from fulminant hepatic failure of 80-90 %, and 1-year mortality in decompensated cirrhosis of more than 50 %. In contrast, liver transplantation patient survival is presently more than 85 % at 1 year and more than 70 % at 5 years, emphasizing the clinical benefit of liver transplantation for either acute or chronic liver failure.
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Affiliation(s)
- Rakesh Rai
- Senior Consultant Surgeon HPB & Transplant Surgery, Fortis Hospital, Mulund (W), Mumbai, India
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8
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Biliary Dilatation and Strictures After Composite Liver–Small Bowel Transplantation in Children: Defining a Newly Recognized Complication. Transplantation 2011; 92:461-8. [DOI: 10.1097/tp.0b013e318225278e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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9
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Kothary N, Patel AA, Shlansky-Goldberg RD. Interventional radiology: management of biliary complications of liver transplantation. Semin Intervent Radiol 2011; 21:297-308. [PMID: 21331141 DOI: 10.1055/s-2004-861564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Major advances in the field of liver transplantation have led to an increase in both graft and patient survival rates. Despite increased graft survival rate, biliary complications lead to significant postoperative morbidity and even mortality. A multidisciplinary approach to these complications is critical. As part of the team approach, less invasive techniques used by the interventional radiologist have an increasing role in the management of complications after liver transplantation. This paper will review the current role of the interventionalist in management of biliary complications.
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Affiliation(s)
- Nishita Kothary
- Division of Vascular and Interventional Radiology, Columbia University Medical Center, New York, New York
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10
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Papachristou GI, Abu-Elmagd KM, Bond G, Costa G, Mazariegos GV, Sanders MK, Slivka A. Pancreaticobiliary complications after composite visceral transplantation: incidence, risk, and management strategies. Gastrointest Endosc 2011; 73:1165-73. [PMID: 21481866 DOI: 10.1016/j.gie.2011.01.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 01/10/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combined liver/small-bowel (L/SB) and multivisceral (MV) transplantation has been increasingly used with significant improvement in outcome. OBJECTIVE To report our experience with pancreaticobiliary (PB) complications in this unique population. DESIGN AND SETTING Single-center cohort study using a prospectively completed database. PATIENTS AND INTERVENTIONS From May 1990 to November 2008, records of 271 consecutive patients who received 289 composite visceral grafts were retrospectively reviewed; 151 of the allografts were L/SB (52%) and the remaining 138 were MV. MAIN OUTCOME MEASUREMENTS Type, incidence, risk factors, clinical features, and management of PB complications. RESULTS PB complications were diagnosed in 44 patients with an incidence of 16%. Biliary complications developed in 20 patients (ampullary stenosis in 9, bile duct casts/stones in 6, and bile duct leaks in 5), pancreatic complications occurred in 19 patients (necrotizing pancreatitis in 7, edematous pancreatitis in 6, and pancreatic duct fistulae in 6), and combined biliary and pancreatic complications occurred in 5 patients. The risk of PB complications was significantly higher in MV graft recipients compared with L/SB recipients with a rate of 25% compared with 9%, respectively. ERCP was instrumental in the diagnosis and/or treatment of ampullary stenosis, bile duct casts and stones, bile duct leaks, and recurrent acute pancreatitis. Combined endoscopic and surgical intervention was required in most cases of pancreatic duct fistulae. Surgical intervention was performed in patients with pancreatic allograft necrosis and complex anastomotic biliary leaks. LIMITATIONS Single-center study. CONCLUSIONS PB complications are common after composite visceral transplantation. Awareness of these complications is important to the transplantation team to ensure early diagnosis and appropriate intervention in an attempt to minimize morbidity and mortality.
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Affiliation(s)
- Georgios I Papachristou
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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11
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Abstract
After liver transplantation, the prevalence of complications related to the biliary system is 6-35%. In recent years, the diagnosis and treatment of biliary problems has changed markedly. The two standard methods of biliary reconstruction in liver transplant recipients are the duct-to-duct choledochocholedochostomy and the Roux-en-Y-hepaticojejunostomy. Biliary leakage occurs in approximately 5-7% of transplant cases. Leakage from the site of anastomosis, the T-tube exit site and donor or recipient remnant cystic duct is well described. Symptomatic bile leakage should be treated by stenting of the duct by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTCD). Biliary strictures can occur at the site of the anastomosis (anastomotic stricture; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). AS occur in 5-10% of cases and are due to fibrotic healing. Treatment by ERCP or PTCD with dilatation and progressive stenting is successful in the majority of cases. NAS can occur in the context of a hepatic artery thrombosis, or with an open hepatic artery (ischaemic type biliary lesions or ITBL). The incidence is 5-10%. NAS has been associated with various types of injury, e.g. macrovascular, microvascular, immunological and cytotoxic injury by bile salts. Treatment can be attempted with multiple sessions of dilatation and stenting of stenotic areas by ERCP or PTCD. In cases of localized diseased and good graft function, biliary reconstructive surgery is useful. However, a significant number of patients will need a re-transplant. When biliary strictures or ischaemia of the graft are present, stones, casts and sludge can develop.
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Affiliation(s)
- Robert C Verdonk
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, The Netherlands.
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12
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Safdar K, Atiq M, Stewart C, Freeman ML. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol Hepatol 2009; 3:183-95. [PMID: 19351288 DOI: 10.1586/egh.09.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Biliary tract complications are an important source of morbidity after liver transplantation, and present a challenge to all involved in their care. With increasing options for transplantation, including living donor and split liver transplants, the complexity of these problems is increasing. However, diagnosis is greatly facilitated by modern noninvasive imaging techniques. A team approach, including transplant hepatology and surgery, interventional endoscopy and interventional radiology, results in effective solutions in most cases, such that operative reintervention or retransplantation is rarely required.
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Affiliation(s)
- Kamran Safdar
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
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13
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Koffron A, Stein JA. Liver transplantation: indications, pretransplant evaluation, surgery, and posttransplant complications. Med Clin North Am 2008; 92:861-88, ix. [PMID: 18570946 DOI: 10.1016/j.mcna.2008.03.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver transplantation is the therapeutic option of choice for acute and chronic end-stage liver disease. The indications and contraindications to liver transplantation have become established, as has the operative and postoperative management. This article provides a practical clinical approach to the evaluation and management of patients with acute and chronic liver failure, with particular emphasis on liver transplant recipient selection, clinical management, and complications. The goal is to provide helpful guidelines to caregivers involved in the multidisciplinary care of these complex patients.
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Affiliation(s)
- Alan Koffron
- William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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14
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Scanga AE, Kowdley KV. Management of biliary complications following orthotopic liver transplantation. Curr Gastroenterol Rep 2007; 9:31-8. [PMID: 17335675 DOI: 10.1007/s11894-008-0018-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Biliary complications are a major cause of morbidity following orthotopic liver transplantation with an overall incidence between 11% and 25%. The most common complications are biliary leaks, strictures, and stones. These complications have an impact on graft survival, length of hospital stay, recovery, and overall cost of care. Therefore, knowledge of these complications and their management is important to the practicing gastroenterologist. Historically, biliary complications after liver transplantation have been managed surgically. However, with the growth of therapeutic endoscopic and percutaneous radiologic methods, most of these complications can now be managed less invasively. This article focuses on the incidence, timing, mechanism, and endoscopic management of biliary leak, strictures, stones, sludge, casts, and sphincter of Oddi dysfunction following liver transplantation.
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Affiliation(s)
- Andrew E Scanga
- Division of Gastroenterology, Department of Medicine, University of Washington Medical Center, Box 356174, 1959 NE Pacific Street, Seattle, WA 98195-6174, USA
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15
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Shastri YM, Hoepffner NM, Akoglu B, Zapletal C, Bechstein WO, Caspary WF, Faust D. Liver biochemistry profile, significance and endoscopic management of biliary tract complications post orthotopic liver transplantation. World J Gastroenterol 2007; 13:2819-25. [PMID: 17569117 PMCID: PMC4395633 DOI: 10.3748/wjg.v13.i20.2819] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy.
METHODS: Patients who developed biliary complications were analysed in detail for the clinical information, laboratory tests, treatment offered, response to it, follow up and outcomes. The profile of liver enzymes was determined. The safety, efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed.
RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be > 3 times (388.1 ± 70.9 U/mL vs 168.5 ± 34.2 U/L, P = 0.007) and SAP > 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L, P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic strictures in 28 (40%). Sustained success was achieved in 26 (81%) patients.
CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early, non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.
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Affiliation(s)
- Yogesh M Shastri
- Department of Medicine I, Goethe-University Hospital, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
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16
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Pascher A, Neuhaus P. Biliary complications after deceased-donor orthotopic liver transplantation. ACTA ACUST UNITED AC 2006; 13:487-96. [PMID: 17139421 DOI: 10.1007/s00534-005-1083-z] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Accepted: 11/25/2005] [Indexed: 12/29/2022]
Abstract
A wide range of potential biliary complications can occur after orthotopic liver transplantation (OLT). The most common biliary complications are bile leaks, anastomotic and intrahepatic strictures, stones, and ampullary dyfunction, which may occur in up to 20%-40% of OLT recipients. Leaks predominate in the early posttransplant period; stricture formation typically develops gradually over time. However, with the advent of new techniques, such as split-liver, reduced-size, and living-donor liver transplantation, the spectrum of biliary complications has changed. Risk factors for biliary complications comprise technical failure; T-tube or stent-related complications; hepatic artery thrombosis; bleeding; ischemia/reperfusion injury; and other immunological, nonimmunological, and infectious complications. Noninvasive diagnostic methods have been established and treatment modalities have been modified towards a primarily nonoperative, endoscopy-based strategy. Besides, the management of biliary complications after OLT requires a multidisciplinary approach, in which interventional and endoscopic treatment options have to be weighed up against surgical treatment options. The etiology and spectrum of bile duct complications, their diagnosis, and their treatment will be reviewed in this article.
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Affiliation(s)
- Andreas Pascher
- Department of General, Visceral, and Transplantation Surgery, Charité, Campus Virchow, Universitaetsmedizin Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany
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Abstract
Complications involving the biliary tract after orthotopic liver transplantation (OLT) have been a common problem since the early beginning of this technique. Biliary complications have been reported to occur at a relatively constant rate of approximately 10-15% of all deceased donor full size OLTs. There is a wide range of potential biliary complications which can occur after OLT. Their incidence varies according to the type of graft, type of donor, and the type of biliary anastomosis performed. The spectrum of biliary complications has changed over the past decade because of the establishment of split liver, reduced-size, and living donor liver transplantation. Apart from technical developments, novel diagnostic methods have been introduced and evaluated in OLT, the most prominent being magnetic resonance imaging (MRI). Treatment modalities have also changed over the past years towards a primarily nonoperative, endoscopy-based strategy, leaving the surgical intervention for lesions which otherwise are not curable. The management of biliary complications after OLT requires a multidisciplinary approach. Conservative, interventional, and endoscopic treatment options have to be weighed up against surgical re-intervention. In the following the spectrum of specific bile duct complications after OLT and their treatment options will be reviewed.
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Affiliation(s)
- Andreas Pascher
- Department of General, Visceral, and Transplantation Surgery, Universitätsmedizin Berlin, Berlin, Germany.
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Leonardi MI, Ataide EC, Boin IFSF, Leonardi LS. Role of Choledochojejunostomy in Liver Transplantation. Transplant Proc 2005; 37:1126-8. [PMID: 15848644 DOI: 10.1016/j.transproceed.2004.12.249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM This study analyzes the efficacy and rate of complications related to Roux-en-Y choledochojejunostomy need either as the primary biliary reconstruction during orthotopic liver transplantation (OLT) or to treat biliary complications. METHODS One hundred seventy-seven transplantation procedures were performed from September 1991 to December 2003 in recipients of mean age 51.9 years. Patients were reviewed for the type of biliary reconstruction, the prevalence of biliary complications, and the choice of treatment for these complications. Duct-to-duct anastomosis (group CDC) was performed in 153 patients (85.6%), and choledochojejunostomy (group CDJ) in 24 patients (14.4%). Biliary complications, including stenosis, bile leakage, calculosis, and extensive biliary necrosis, required hospitalization, surgical interventions or endoscopic approaches. Biliary complications in the CDC group first were addressed by endoscopic treatments. When endoscopic therapy failed, they were approached by surgical reintervention. All biliary complications in group CDJ were surgically treated, namely, revision of the Roux-en-Y choledochojejunostomy. The chi square test was used to compare frequencies, with Yates correction when necessary; P values were considered significant at <.05. The Mann-Whitney U test was used to evaluate survival. RESULTS Fifty-eight (32.8%) biliary complications in 47 patients required endoscopic or surgical approaches. In group CDJ, 1 patient had bile leakage requiring surgical treatment. The prevalence of biliary complications was lower in the CDJ group than the CDC group (P < .05). Endoscopic treatment applied in 23 patients, failed in 11. Surgical approaches were performed in 11 patients after endoscopic failure, and in 13 patients as the first option to treat biliary complications. No failure was observed with surgical treatment. Cholangitis occurred in 3 patients who received surgical treatment and 4 patients who received endoscopic treatment. There was no statistically significant difference when comparing the mortality rates of the 3 types of treatment for biliary complications: endoscopy, surgery, and endoscopy followed by surgery. Survival rates were similar for the 3 types of treatment of biliary complications. CONCLUSION Roux-en-Y choledochojejunostomy is a useful tool to treat biliary complications after OLT, especially when endoscopic treatment fails. In our experience, the rate of complications directly related to this technique is significantly lower than common duct anestomosis, whether used for biliary reconstruction during OLT or for posttransplantation biliary complications.
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Affiliation(s)
- M I Leonardi
- Unit of Liver Transplantation, University of Campinas Medical School, Campinas, São Paulo, Brasil.
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Gopal DV, Pfau PR, Lucey MR. Endoscopic Management of Biliary Complications After Orthotopic Liver Transplantation. ACTA ACUST UNITED AC 2003; 6:509-515. [PMID: 14585240 DOI: 10.1007/s11938-003-0053-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.
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Affiliation(s)
- Deepak V. Gopal
- Section of Gastroenterology & Hepatology, University of Wisconsin Hospital & Clinics, H6/516 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-5124, USA.
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Abstract
UNLABELLED Biliary complications following orthotopic liver transplantation (OLT) may be associated with significant morbidity and mortality. In this report, we reviewed our endoscopic experience of managing post OLT biliary complications in 79 patients over a 12-year period. METHODS OLT (n = 423) recipients between 10/86 and 12/98 were obtained from the transplant registry at the Johns Hopkins Hospital. OLT recipient who underwent at least one endoscopic retrograde cholangiography (ERC) were identified through a radiology database. Indications, findings and interventions performed were noted for each ERC report. Outpatient and inpatients medical records were reviewed for outcome and complications. RESULTS Seventy-nine (79/423, 18.7%) patients had at least one ERC for suspected biliary complication. Sixty-four (15.1%) patients had at least one or more biliary complications. The mean follow-up for patients with abnormal ERC was 33.9 months. Nineteen patients had bile leaks; 10 of these patients had leak at the exit site of the T-tube and five patients had at the anastomosis. Biliary stenting with or without endoscopic sphincterotomy led to resolution of bile leak in 16 patients. Three patients failed endoscopic therapy: one underwent surgery and two had percutaneous drainage. Twenty-five patients presented with biliary strictures. Nineteen strictures were at the anastomotic or just proximal to the anastomosis, one at the hilum (ischemic in nature) and three were at the distal, recipient common bile duct; one had strictures at the anastomosis as well as the distal recipient bile duct and another had diffuse intrahepatic strictures. Seventeen patients in the stricture group improved with endoscopic intervention. One patient was re-transplanted (diffuse intrahepatic strictures), but no patient underwent percutaneous drainage. CONCLUSIONS ERC is safe and effective in the diagnosis and management of biliary complications following liver transplantation with choledochocholedochal anastomosis and obviates the need for surgical or percutaneous transhepatic approaches in majority of cases.
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Affiliation(s)
- Paul J Thuluvath
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Abstract
Sphincter of Oddi dyskinesia (SOD) is a functional disorder of the papilla region that can lead to clinical symptoms and functional obstruction of biliary and pancreatic outflow. Based on the severity of the clinical symptoms, the disorder is classified as one of three types (biliary or pancreatic type I-III). Diagnosis of SOD is hampered by the relative risk of endoscopic sphincter manometry to cause pancreatitis. Manometrically, SOD is characterized by increased pressure in the biliary or pancreatic sphincter segment and can be treated with endoscopic papillotomy. This review is an attempt to balance the arguments for invasive diagnosis with a pragmatic clinical approach in which papillotomy is performed if clinical suspicion and patient presentation support a dysfunction of the papilla. For patients with biliary or pancreatic type I, endoscopic papillotomy is the treatment of choice. In biliary type II, SO manometry may be helpful for clinical decision making; however, the ratio of risks to benefits is difficult to assess based on the present data. In type III SOD, patient selection and the low predictive value of manometry for treatment success raise questions about the clinical usefulness of SO manometry.
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Affiliation(s)
- Hans-Dieter Allescher
- Department of Internal Medicine II, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany. hans.allescher.@lrz.tum.de
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Maguire D, Rela M, Heaton ND. Biliary complications after orthotopic liver transplantation. Transplant Rev (Orlando) 2002. [DOI: 10.1053/trte.2002.1296481] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Rerknimitr R, Sherman S, Fogel EL, Kalayci C, Lumeng L, Chalasani N, Kwo P, Lehman GA. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 2002; 55:224-31. [PMID: 11818927 DOI: 10.1067/mge.2002.120813] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. METHODS From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. RESULTS A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree. CONCLUSION When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures.
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Affiliation(s)
- Rungsun Rerknimitr
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202-5000, USA
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Abstract
1. Biliary complications of some type occur in approximately one of every eight liver transplant recipients. Although they are uncommon causes of mortality, they are significant sources of morbidity. 2. Leaks and strictures that occur early after transplantation have technical causes. Late strictures and obstruction are more likely to be complex and have multiple causes, including hepatic artery occlusion, preservation injury, rejection, and recurrent disease. 3. Diagnosis relies on abdominal imaging and cholangiographic studies. Patency of the hepatic artery must be proven when a complication of the donor biliary tree occurs. 4. Management of late complications is largely influenced by the nature and extent of strictures. Percutaneous and endoscopic treatment of anastomotic strictures offers a significant prospect of successful long-term management. 5. Nonsurgical management of more complex hilar and intrahepatic strictures is less successful, and surgical revision or retransplantation may be required for definitive treatment.
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Affiliation(s)
- M A Moser
- Multi-Organ Transplant Program, London Health Sciences Centre, London, Ontario, Canada
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Leonardi LS, Boin IDFSF, Callejas Neto F, Soares Júnior C. Complicações biliares do transplante hepático com o emprego ou não do tubo em T. Rev Col Bras Cir 2000. [DOI: 10.1590/s0100-69912000000400002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
O aperfeiçoamento da técnica operatória do transplante hepático reduziu o número de complicações biliares, mas os índices de morbidade e mortalidade relacionadas a estas complicações ainda preocupam os cirurgiões. Assim, é importante avaliar novas opções terapêuticas relativamente aos procedimentos operatórios convencionais. De setembro de 1991 a setembro de 1998, foram analisadas as complicações biliares observadas em 78 pacientes submetidos ao transplante hepático; anastomose coledococoledociana com emprego do tubo em T (CCT) foi praticada em 16 pacientes ou 20,5%, anastomose coledococoledociana sem a utilização do tubo em T (CC) em 50 ou 64,1% e anastomose coledocojejunal (CJ) em 12 ou 15,4%. Foram observadas 24 (31,2%) complicações biliares sendo 12 durante o 1º mês e as demais no pós-operatório tardio. Ocorreram 12/78 (15,6%) fístulas (CCT = 5, CC = 6, CJ = 1), 9/78 (11,7%) estenose (CCT = 1, CC = 8) e 3/78 calculose (CCT = 1, CC = 2). A colangiopancreatografia retrógrada endoscópica (CPRE) realizada em 19/78 pacientes ou 24,7% ofereceu resultados satisfatórios em 13 (61,9%). O tratamento endoscópico foi praticado em 11 casos de fístula biliar oferecendo bons resultados em quatro do grupo CCT e 5/6 do grupo CC; por outro lado, nos oito casos de estenose da anastomose (grupo CC) o tratamento endoscópico mostrou-se eficiente em 4/8 pacientes. Complicações biliares ocorreram em 7/16 casos ou 43,75% (grupo CCT) e 16/50 ou 32% do grupo CC, somente nove entre as 24 complicações biliares necessitaram de reoperações (CCT = 1, CC = 8). Além destas, entre os 78 , ocorreu trombose da artéria hepática (T.A.H.). Nesta casuística ocorreram 8/78 (10,4%) óbitos (5 T.A.H., 1 CCT e 2 CC). O tempo de seguimento médio pós-tratamento das complicações biliares foi de 14 meses variando de um a 6,8 anos. A incidência global das complicações biliares observadas nesta série consecutiva de 78 pacientes foi maior nos grupos CCT (7/16) CC (16/50) quando comparadas ao grupo CJ. Não houve diferenças significativa quanto à ocorrência de fístula e estenoses nos grupos CCT e CC, quando comparadas. A incidência de complicações biliares precoces e tardias foi semelhante em ambos os grupos CCT e CC. Estes resultados sugerem que a incidência de fístulas e estenoses biliares, não é significativamente pelo emprego do tubo em T. O tratamento endoscópico indicado em casos selecionados permite diagnóstico acurado apresentando-se como tratamento de primeira escolha frente a estas complicações.
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Pfau PR, Kochman ML, Lewis JD, Long WB, Lucey MR, Olthoff K, Shaked A, Ginsberg GG. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000; 52:55-63. [PMID: 10882963 DOI: 10.1067/mge.2000.106687] [Citation(s) in RCA: 172] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgery, percutaneous cholangiography, and endoscopic retrograde cholangiopancreatography (ERCP) have been used in the management of biliary complications after orthotopic liver transplantation with varied results. We assessed the role of ERCP in the diagnosis, treatment, and outcome of post-orthotopic liver transplantation biliary complications. METHODS We retrospectively reviewed the records of 260 patients who underwent orthotopic liver transplantation. We examined the number of patients referred for ERCP and the indication, diagnosis, therapeutic intervention, success, and complication rate of ERCP post orthotopic liver transplantation. We compared the survival and retransplantation rates of the patients who underwent ERCP with a control group of post-orthotopic liver transplantation patients not undergoing ERCP. RESULTS Of the 260 patients undergoing orthotopic liver transplantation, 64 (24.6%) underwent 137 ERCPs. Two categories of indications for ERCP were identified: bile leak (n = 31) and obstruction (n = 39). ERCP identified the site of the bile leak in 27 of 31 cases (87.1%) and the leak was treated by endoscopic means in 26 of 31 (83.9%). Treatment success differed significantly based on location of the leak (T tube, 95.2% vs. anastomosis, 42.9%; p = 0. 009). ERCP identified the site of obstruction in 37 of 39 cases (94. 9%) and obstruction was relieved by endoscopic means in 25 of 35 cases (71.4%). ERCP was significantly less successful in the treatment of biliary casts (25.0%, p = 0.048). There was no difference in survival or retransplantation between patients who did and did not undergo ERCP. CONCLUSION ERCP should be the primary method for diagnosis and treatment of post-orthotopic liver transplantation biliary complications. Endoscopic therapy is safe and effective for the majority of post-orthotopic liver transplantation complications and temporizes management for those complications that may require surgery.
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Affiliation(s)
- P R Pfau
- Departments of Medicine and Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia 19104-4283, USA
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Mosca S, Militerno G, Guardascione MA, Amitrano L, Picciotto FP, Cuomo O. Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol 2000; 15:654-60. [PMID: 10921420 DOI: 10.1046/j.1440-1746.2000.02198.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Biliary tract complications are frequent after orthotopic liver transplantation. Late biliary tract complications occurring after T-tube removal mostly include stones and strictures which may be associated with sepsis and worsening of the liver function. Endoscopic retrograde cholangiopancreatography (ERCP) has a role in the diagnosis and therapy of these complications. The aim of our study was to report our experience of endoscopic diagnosis and treatment of late biliary tract complications in liver-transplanted patients. METHODS AND RESULTS One hundred and thirty-six adult liver-transplanted patients have been followed since 1988. Seventeen patients (12.5%) needed a total of 30 ERCP because of evidence of clinical and/or biochemical cholestasis: eight with biliary stricture; six with biliary stones; one with both stricture and stones; and two with normal ERCP findings. Interventional endoscopic procedures included 14 sphincterotomies, six stone removals, seven biliary balloon dilatations, seven biliary stent placements, 11 biliary stent replacements, seven nasobiliary catheter placements and one mechanical lithotripsy. No complications were seen. In all cases, ERCP was able to identify the location, entity and dimension of the late biliary tract complication, thus allowing a therapeutic strategy to be used. Two patients had medical cholestasis. Forty-seven per cent of patients with late biliary tract complications could definitely be cured by ERCP alone. The ERCP improved the patients' condition to allow subsequent surgery in five patients (33%). CONCLUSIONS These results confirms that ERCP is a valuable diagnostic tool and should be considered as the first step in the non-surgical management of late biliary tract complications after orthotopic liver transplantation.
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Affiliation(s)
- S Mosca
- Department of Gastroenterology, A Cardarelli Hospital, Naples, Italy.
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Furukawa H. Role of endoscopic retrograde cholangiopancreatography in late biliary tract complications after orthotopic liver transplantation. J Gastroenterol Hepatol 2000; 15:577-8. [PMID: 10921407 DOI: 10.1046/j.1440-1746.2000.02218.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Davidson BR, Rai R, Kurzawinski TR, Selves L, Farouk M, Dooley JS, Burroughs AK, Rolles K. Prospective randomized trial of end-to-end versus side-to-side biliary reconstruction after orthotopic liver transplantation. Br J Surg 1999; 86:447-52. [PMID: 10215812 DOI: 10.1046/j.1365-2168.1999.01073.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary reconstruction is the Achilles heel of liver transplantation. Side-to-side anastomosis of donor and recipient bile duct has been claimed to be superior to end-to-end anastomosis in uncontrolled studies. METHODS A total of 100 consecutive patients undergoing orthotopic liver transplantation were randomized after commencement of the transplant procedure to end-to-end or side-to-side anastomosis. No T tube drainage was employed. Endoscopic retrograde cholangiography was performed 2 weeks after transplantation and findings were reported by an experienced endoscopist as normal, leak or stricture. Median follow-up was 53 (range 35-63) months. RESULTS Patient age, sex, the graft preservation time and indication for transplantation were similar in both groups. Sixty patients received end-to-end and 40 side-to-side anastomosis. Ten patients randomized to side-to-side anastomosis had an end-to-end procedure. The total number of biliary complications was similar in both groups (end-to-end 32 per cent versus side-to-side 30 per cent) as were the number of leaks (17 versus 18 per cent) and biliary strictures (15 versus 12 per cent). There was no difference in the number of biliary complications that required interventional treatment (22 per cent in both groups). CONCLUSION Side-to-side and end-to-end biliary anastomosis at liver transplantation are equally effective.
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Affiliation(s)
- B R Davidson
- Hepatobiliary and Liver Transplantation Unit, Royal Free Hospital and School of Medicine, London, UK
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Shuhart MC, Kowdley KV, McVicar JP, Rohrmann CA, McDonald MF, Wadland DW, Emerson SS, Carithers RL, Kimmey MB. Predictors of bile leaks after T-tube removal in orthotopic liver transplant recipients. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1998; 4:62-70. [PMID: 9457969 DOI: 10.1002/lt.500040109] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bile leaks after T-tube removal are a frequent cause of morbidity in orthotopic liver transplant recipients. The aim of this study was to determine factors that predict the development of these leaks in liver transplant recipients. Records of all patients who had undergone liver transplantation at the University of Washington Medical Center between January 1990 and September 1993 were reviewed. The following were excluded: patients with a Roux-en-Y anastomosis or inadvertent early T-tube removal and patients who died or underwent retransplantation before T-tube removal. All T-tube cholangiograms were reviewed blindly by two authors. Using logistic regression, several variables were assessed for possible association with bile leaks after T-tube removal; these included patient demographics, intraoperative variables, and clinical and cholangiographic variables related to T-tube removal. Of the 166 liver transplants performed in 150 patients, 99 transplants in 97 patients were evaluable for bile leak after T-tube removal. Thirty-three patients developed symptomatic bile leaks, and 21 underwent endoscopic or operative intervention for persistent symptoms. Only duct mural irregularities on the final cholangiogram were strongly associated with the development of a bile leak after T-tube removal (P = 0.001). In conclusion, bile leaks after T-tube removal occurred in one-third of patients undergoing orthotopic liver transplantation; the majority of these patients required some intervention. Duct mural irregularities were associated with bile leaks.
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Affiliation(s)
- M C Shuhart
- Department of Medicine, University of Washington, Seattle, USA
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Mirza DF, Neto BHF, McMaster P, Mayer AD. Management of the bile duct in liver transplantation. Transplant Rev (Orlando) 1996. [DOI: 10.1016/s0955-470x(96)80007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Gholson CF, Zibari G, McDonald JC. Endoscopic diagnosis and management of biliary complications following orthotopic liver transplantation. Dig Dis Sci 1996; 41:1045-53. [PMID: 8654132 DOI: 10.1007/bf02088217] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Nonoperative management of biliary complications (BC) with endoscopic retrograde cholangiopancreatography (ERCP) is a natural sequel to the emergence of choledochocholedochostomy as the preferred biliary reconstruction for orthotopic liver transplantation (OLT). Overall, therapeutic ERCP's efficacy for posttransplant BC is difficult to assess because most published data are retrospective, anecdotal, or in abstract form, and there are no prospective, randomized studies. Thus, endoscopic management of posttransplant BC must be individualized. While T-tube-related late bile leaks and ductal calculi are amenable to endoscopic therapy, its efficacy for strictures is more difficult to define. Refined surgical technique has prevented many unifocal anastomotic lesions, while multifocal strictures (for which endoscopic therapeutic experience is minimal) are increasingly prevalent. Whether endoscopic sphincterotomy is appropriate for posttransplant sphincter of Oddi dysfunction is controversial, because the disorder may be transient and the risk significant. Multicenter, prospective studies are needed to determine more accurately the optimal role of endoscopic therapy after OLT.
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Affiliation(s)
- C F Gholson
- Department of Medicine, Louisiana State University School of Medicine, Shreveport 71130-3932, USA
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Vallera RA, Cotton PB, Clavien PA. Biliary reconstruction for liver transplantation and management of biliary complications: overview and survey of current practices in the United States. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1995; 1:143-52. [PMID: 9346556 DOI: 10.1002/lt.500010302] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- R A Vallera
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Friend PJ. Overview: biliary reconstruction after liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1995; 1:153-5. [PMID: 9346557 DOI: 10.1002/lt.500010303] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- P J Friend
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, England
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