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Chen DX, Fang KX, Chen SX, Hou SL, Wen GH, Yang HK, Shi DP, Lu QX, Zhai YQ, Li MY. Optimal timing of endoscopic biliary drainage for bile duct leaks: A multicenter, retrospective, clinical study. World J Gastrointest Surg 2025; 17:99425. [PMID: 40162415 PMCID: PMC11948142 DOI: 10.4240/wjgs.v17.i3.99425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 01/14/2025] [Accepted: 02/05/2025] [Indexed: 02/24/2025] Open
Abstract
BACKGROUND Bile duct leaks (BDLs) are serious postsurgical adverse events. Typically, conservative management with abdominal drainage is the initial treatment option. However, prolonged abdominal drainage without improvement can lead to biliary stricture and delay the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP). AIM To identify the optimal timing for ERCP and the period during which clinical observation with conservative management is acceptable, balancing ERCP success and the risk of biliary strictures. METHODS We conducted a multicenter retrospective study involving 448 patients with BDLs between November 2002 and November 2022. The patients were divided into four groups based on the timing of ERCP: 3 days, 7 days, 14 days, and 21 days. The primary outcome was clinical success, defined as the resolution of BDL and related symptoms within 6 months without additional percutaneous drainage, surgery, or death. The secondary outcome was incidence of biliary strictures. Univariate and multivariate logistic regression analyses were performed to identify factors associated with ERCP success and biliary stricture occurrence. RESULTS In a cohort of 448 consecutive patients diagnosed with BDLs, 354 were excluded, leaving 94 patients who underwent ERCP. Clinical success was achieved in 84% of cases (79/94), with a median ERCP timing of 20 days (9.5-35.3 days). Biliary strictures were identified in 29 (30.9%) patients. Performing ERCP within 3 weeks, compared to after 3 weeks, was associated with higher success rates [92.0% (46/50) vs 75.0% (33/44), P = 0.032] and a lower incidence of biliary stricture incidence [18.0% (9/50) vs 45.5% (20/44), P = 0.005]. Subsequent multivariate analysis confirmed the association with higher success rates (odds ratio = 4.168, P = 0.045) and lower biliary stricture rates (odds ratio = 0.256, P = 0.007). CONCLUSION Performing ERCP for BDLs within 3 weeks may be associated with a higher success rate and a lower biliary stricture rate. If patients with BDLs do not respond to conservative treatment, ERCP is suggested to be performed within 3 weeks.
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Affiliation(s)
- De-Xin Chen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Graduate School, Chinese PLA General Hospital, Beijing 100853, China
| | - Kai-Xuan Fang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Graduate School, Chinese PLA General Hospital, Beijing 100853, China
- Department of Gastroenterology and Hepatology, The 960th Hospital of PLA, Jinan 050035, Shandong Province, China
| | - Sheng-Xin Chen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Sen-Lin Hou
- Department of Gastroenterology and Hepatology, The Second Hospital of Hebei Medical University, Hebei 050035, China
| | - Gui-Hai Wen
- Department of Gastroenterology and Hepatology, Handan Central Hospital, Hebei 056001, China
| | - Hai-Kun Yang
- Department of Gastroenterology and Hepatology, Shanxi Provincial People’s Hospital, Shanxi 030012, China
| | - Da-Peng Shi
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Army Medical University of PLA, Chongqing 400042, China
| | - Qing-Xin Lu
- Department of Gastroenterology and Hepatology, Second Affiliated Hospital of Army Medical University of PLA, Chongqing 400042, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ming-Yang Li
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
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Lodato F, Landi S, Bassi M, Ghersi S, Cennamo V. Urgent Endoscopic Biliary Procedures: "Run Like the Wind"? J Clin Med 2025; 14:1017. [PMID: 39941686 PMCID: PMC11818415 DOI: 10.3390/jcm14031017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 02/01/2025] [Accepted: 02/04/2025] [Indexed: 02/16/2025] Open
Abstract
Emergency endoscopy is an activity that must be guaranteed 7 days a week and 24 h a day. The pathologies of endoscopic interest that require emergency intervention are mainly hemorrhages of the upper digestive tract, the removal of foreign bodies, and the ingestion of caustics. The emergency endoscopist must therefore be experienced in the management of these pathologies. Nowadays, however, we know that even some biliary tract pathologies must be managed within a variable period between 12 and 72 h, in particular acute cholangitis (Ach), acute biliary pancreatitis (ABP), biliary duct leaks (BDLs), and acute cholecystitis (AC). If, on one hand, there is little awareness among doctors about which pathologies of the biliary tract really deserve urgent treatment, on the other, the international guidelines, although not uniformly, have acquired the results of the studies and have clarified that only severe Ach should be treated within 12 h; in other cases, endoscopic treatment can be delayed up to 72 h according to the specific condition. This obviously has a significant organizational implication, as not all endoscopists have training in biliary tract endoscopy, and guaranteeing the availability of a biliary endoscopist 24/7 may be incompatible with respecting the working hours of individual professionals. This review aims to evaluate which pathologies of the biliary tract really require an endoscopic approach in emergency or urgency and the organizational consequences that this can determine. Based on the guidelines, we can conclude that a daytime availability for urgent biliary tract procedures 7 days a week should be provided for the management of severe ACh. Patients with ABP, AC unfit for surgery, and not responsive to medical therapy or BDLs can be treated over a longer period, allowing its scheduling on the first available day of the week.
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Affiliation(s)
- Francesca Lodato
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital, 40133 Bologna, Italy; (S.L.); (M.B.); (S.G.); (V.C.)
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Vedamurthy A, Krishnamoorthi R, Irani S, Kozarek R. Endoscopic Management of Benign Pancreaticobiliary Disorders. J Clin Med 2025; 14:494. [PMID: 39860499 PMCID: PMC11766296 DOI: 10.3390/jcm14020494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 01/09/2025] [Accepted: 01/09/2025] [Indexed: 01/27/2025] Open
Abstract
Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications.
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Affiliation(s)
- Amar Vedamurthy
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
| | - Richard Kozarek
- Division of Gastroenterology and Hepatology, Center for Digestive Health, Virginia Mason, Franciscan Health, Seattle, WA 98101, USA
- Center for Interventional Immunology, Benaroya Research Institute, Virginia Mason, Franciscan Health, 1100 9th Avenue, G-250B, Seattle, WA 98101, USA
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Ni DJ, Yang QF, Nie L, Xu J, He SZ, Yao J. The past, present, and future of endoscopic management for biliary strictures: technological innovations and stent advancements. Front Med (Lausanne) 2024; 11:1334154. [PMID: 39669990 PMCID: PMC11634603 DOI: 10.3389/fmed.2024.1334154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/15/2024] [Indexed: 12/14/2024] Open
Abstract
Biliary stricture can be induced by intrinsic narrowing and extrinsic compression, with the majority of cases being malignant. Clinically, distinguishing between benign and malignant biliary strictures remains a considerable challenge, and the ongoing disagreement over the optimal choice of biliary stents significantly influences treatment strategies and impacts patients' survival and prognosis. The utilization and advancement of endoscopic techniques have heightened the diagnostic sensitivity for biliary strictures. Concurrently, innovative technologies such as endoscopic ultrasound and magnetic compression anastomosis emerge as viable alternatives when endoscopic retrograde cholangiopancreatography (ERCP) is not an option, providing fresh insights for the clinical management of these patients. Traditional plastic and metal stents, characterized by their complex application and limited scope, have been unable to fully satisfy clinical needs. The introduction of novel stent varieties has notably improved this scenario, marking a considerable progression towards precision medicine. However, the clinical validation of the diverse stent materials available is incomplete. Hence, a thorough discussion on the present state and evolving trends of biliary stents is warranted.
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Affiliation(s)
- Dong-Jin Ni
- Department of Gastroenterology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Qi-Fan Yang
- Department of Gastroenterology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Lu Nie
- Department of Intervention Vascular, Wujin Hospital Affiliated with Jiangsu University, Changzhou, China
| | - Jian Xu
- Department of Gastroenterology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
| | - Si-Zhe He
- Shanghai Academy of Fine Arts, Shanghai University, Shanghai, China
| | - Jun Yao
- Department of Gastroenterology, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, China
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Ding S, Dong S, Zhu H, Zheng S, Li Q. Does T-tube indwelling prolong the procedure of endoscopic retrograde cholangiopancreatography for healing duct-to-duct anastomotic bile leakage after liver transplantation? Medicine (Baltimore) 2024; 103:e40191. [PMID: 39470552 PMCID: PMC11521000 DOI: 10.1097/md.0000000000040191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 06/12/2024] [Accepted: 10/03/2024] [Indexed: 10/30/2024] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred treatment for duct-to-duct anastomotic bile leakage (D-D aBL) after liver transplantation (LT). This study aimed to compare the time required for ERCP and D-D aBL recovery in post-LT patients with and without T-tube drainage. A total of 40 patients (11 with T-tube drainage and 29 without T-tube drainage) with confirmed D-D aBLs treated successfully with ERCP from July 2016 to September 2021 were reviewed. The mean interval from LT to initial ERCP was significantly longer in patients with T-tube drainage than in those without T-tube drainage (41.9 vs 25.1 days, P < .05). However, there was no significant difference in the time required for ERCP to result in D-D aBL healing between patients with T-tube drainage and those without T-tubes (33.4 vs 23.0 days). T-tube indwelling did not significantly prolong the course required for ERCP to resolve D-D aBL in post-LT patients.
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Affiliation(s)
- Songming Ding
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Shanjie Dong
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Hengkai Zhu
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
| | - Qiyong Li
- Division of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, P.R. China
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Semash KO. Post-liver transplant biliary complications. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2024; 26:72-90. [DOI: 10.15825/1995-1191-2024-3-72-90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Biliary complications (BCs) are the most frequent complications following liver transplantation (LT). They are a major source of morbidity after LT. The incidence of BCs after LT is reported to range from 5% to 45%. The main post-LT biliary complications are strictures, biliary fistulas and bilomas, cholelithiasis, sphincter of Oddi dysfunction, hemobilia, and mucocele. Risk factors for biliary complications are diverse. In this article we seek to review the main types of biliary complications and modern approaches to their diagnosis and treatment.
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Chen DX, Chen SX, Hou SL, Wen GH, Yang HK, Shi DP, Lu QX, Zhai YQ, Li MY. A nomogram for prediction of ERCP success in patients with bile duct leaks: a multicenter study. Surg Endosc 2024; 38:2465-2474. [PMID: 38456946 DOI: 10.1007/s00464-024-10734-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Bile duct leaks (BDLs) are serious complications that occurs after hepatobiliary surgery and trauma, leading to rapid clinical deterioration. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for BDLs, but it is not clear which patients will respond to this therapy and which patients will require additional surgical intervention. The aim of our study was to explore the predictors of successful ERCP for BDLs. METHODS A retrospective analysis was conducted using data from six centers' databases. All consecutive patients who were clinically confirmed as BDLs were included in the study. Collected data were demographics, disease severity, and ERCP procedure characteristics. Univariate and multivariate analysis were used to select independent predictive factors that affect the outcome of ERCP for BDLs, and a nomogram was established. Calibration and ROC curves were used to evaluate the models. RESULTS Four hundred and forty-eight consecutive patients were clinically confirmed as BDLs and 347 were excluded. In the 101 patients included patients, clinical success was achieved in 78 patients (77.2%). In logistic multivariable regression, two independent factors were negatively associated with the success of ERCP: SIRS (OR, 0.183; 95% CI 0.039-0.864; P = 0.032) and high-grade leak (OR 0.073; 95% CI 0.010-0.539; P = 0.010). Two independent factors were positively associated with the success of ERCP: leak-bridging drainage (OR 4.792; 95% CI 1.08-21.21; P = 0.039) and cystic duct leak (OR 6.193; 95% CI 1.03-37.17; P = 0.046). The prediction model with these four factors was evaluated using a receiver-operating characteristic (ROC) curve, which demonstrated an area under the curve of 0.9351. The calibration curve showed that the model had good predictive accuracy. CONCLUSION Leak-bridging drainage and cystic duct leak are positive predictors for the success of ERCP, while SIRS and high-grade leak are negative predictors. This prediction model with nomogram has good predictive ability and practical clinical value, and may be helpful in clinical decision-making and prognostication.
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Affiliation(s)
- De-Xin Chen
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China
- Graduate School, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Sheng-Xin Chen
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Sen-Lin Hou
- Department of Gastroenterology and Hepatology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050035, China
| | - Gui-Hai Wen
- Department of Gastroenterology, Handan Central Hospital, Handan, 056001, China
| | - Hai-Kun Yang
- Department of Gastroenterology and Hepatology, Shanxi Provincial People's Hospital, Affiliate of Shanxi Medical University, Taiyuan, 030012, Shanxi, China
| | - Da-Peng Shi
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Army Medical University of PLA, Chongqing, 400042, China
| | - Qing-Xin Lu
- Department of Gastroenterology and Hepatology, Second Affiliated Hospital of Army Medical University of PLA, Chongqing, 400042, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Ming-Yang Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, The First Medical Center, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Bofill A, Cárdenas A. A practical approach to the endoscopic management of biliary strictures after liver transplantation. Ann Hepatol 2024; 29:101186. [PMID: 38035999 DOI: 10.1016/j.aohep.2023.101186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
Biliary tract complications are an important cause of morbidity and mortality after liver transplantation (LT) occurring in 5% to 25% of patients. The most common biliary complication in LT recipients are strictures representing approximately half of these biliary adverse events. Bile duct strictures can be divided into anastomotic biliary strictures (ABS) and non-anastomotic biliary strictures (NABS) depending on their location in the biliary tree, being ABS the most encountered type. Several risk factors identified in previous studies can predispose to the development of ABS and NABS, especially those related to surgical techniques and donor characteristics. Magnetic resonance cholangiopancreatography (MRCP) is the recommended noninvasive imaging test for detecting post-LT biliary strictures, given its high sensitivity and specificity. Once the diagnosis of a biliary stricture after LT has been made, endoscopic retrograde cholangiopancreatography (ERCP) is the preferred initial therapy with good short and long-term results. Biliary sphincterotomy plus balloon dilation (BD) with placement of multiple plastic stents (MPS) has been the classic endoscopic approach for treating ABS, although fully-covered metallic stents (FCSEMS) have emerged as an alternative thanks to shorter total duration of stenting and fewer endoscopic procedures compared to MPS. In this review, we provide a practical update on the management of biliary strictures after LT, focusing our attention on the available evidence in the endoscopic therapy.
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Affiliation(s)
- Alex Bofill
- GI Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain
| | - Andrés Cárdenas
- GI and Liver Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.
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Öztürk FU, Tezcan Ş, Soy EHA, Uslu N, Haberal M. Doppler ultrasonography blood flow changes of the hepatic artery in liver transplants complicated with cholangitis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:860-865. [PMID: 37029647 DOI: 10.1002/jcu.23466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Cholangitis after liver transplantation may lead to bile duct necrosis. Early diagnosis is essential to prevent graft loss. We aimed to investigate cholangitis related hepatic arterial Doppler ultrasonography findings in liver transplants. METHODS Patients complicated with biopsy proven cholangitis in grafts were prospectively evaluated. Vascular complications were excluded. Doppler ultrasonography parameters including hepatic arterial diameter, resistive index, volume flow, and portal vein maximum velocity were measured twice: first during cholangitis and after full recovery. Data of two groups were compared using paired samples t test and Mann-Whitney U test. RESULTS The mean hepatic arterial volume flow, resistive index, and diameter of 33 patients complicated with cholangitis was observed to decrease after recovery from 0.356 to 0.273 L/min (p = 0.007), from 0.64 to 0.60 (p < 0.001) and from 4.9 to 4.4 mm (p < 0.001), respectively. Portal vein maximum velocity alteration was not statistically significant (p = 0.6). CONCLUSION Ultrasound follow-ups after liver transplantation can give us the clue of cholangitis initiation through some altering hepatic arterial Doppler parameters. Even though these are nonspecific findings that can also be observed in vascular complications, baseline Doppler data should be saved for future comparison and considered to prevent biliary associated graft loss.
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Affiliation(s)
- Funda Ulu Öztürk
- Department of Radiology, Başkent University Medical Faculty, Ankara, Turkey
- Department of Radiology, Memorial Ankara Hospital, Ankara, Turkey
| | - Şehnaz Tezcan
- Department of Radiology, Başkent University Medical Faculty, Ankara, Turkey
- Department of Radiology, Koru Hospital, Ankara, Turkey
| | - Ebru Hatice Ayvazoğlu Soy
- Department of General Surgery, Başkent University Medical Faculty, Ankara, Turkey
- Department of General Surgery, Bayındır Söğütözü Hospital, Ankara, Turkey
| | - Nihal Uslu
- Department of Radiology, Başkent University Medical Faculty, Ankara, Turkey
| | - Mehmet Haberal
- Department of General Surgery, Başkent University Medical Faculty, Ankara, Turkey
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Gheorghe G, Diaconu CC, Bungau S, Bacalbasa N, Motas N, Ionescu VA. Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:850. [PMID: 37241082 PMCID: PMC10221850 DOI: 10.3390/medicina59050850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.
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Affiliation(s)
- Gina Gheorghe
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Internal Medicine Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department of Visceral Surgery, Center of Excellence in Translational Medicine “Fundeni” Clinical Institute, 022328 Bucharest, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
| | - Nicolae Bacalbasa
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Department of Visceral Surgery, Center of Excellence in Translational Medicine “Fundeni” Clinical Institute, 022328 Bucharest, Romania
| | - Natalia Motas
- Institute of Oncology “Profesor Doctor Alexandru Trestioreanu” Bucharest, 022328 Bucharest, Romania;
- Department of Thoracic Surgery, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania
| | - Vlad-Alexandru Ionescu
- Faculty of Medicine, University of Medicine and Pharmacy Carol Davila Bucharest, 050474 Bucharest, Romania; (G.G.); (N.B.); (V.-A.I.)
- Gastroenterology Department, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
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12
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Zhang CC, Rupp C, Exarchos X, Mehrabi A, Koschny R, Schaible A, Sauer P. Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after orthotopic liver transplantation. Gastrointest Endosc 2023; 97:42-49. [PMID: 36041507 DOI: 10.1016/j.gie.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/13/2022] [Accepted: 08/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Biliary strictures after liver transplantation are associated with significant morbidity and mortality. Although various endoscopic treatment strategies are available, consensus on a particular strategy is lacking. Moreover, the influence of endoscopic therapy on overall survival has not been studied. This retrospective study aimed to evaluate the impact of scheduled endoscopic dilatation of biliary strictures after orthotopic liver transplantation on therapeutic success, adverse events, and survival. METHODS Between 2000 and 2016, patients with post-transplant anastomotic and nonanastomotic strictures were treated with balloon dilatation at defined intervals until morphologic resolution and clinical improvement. The primary clinical endpoint was overall survival, whereas secondary outcomes were technical and sustained clinical success, adverse events, treatment failure, and recurrence. RESULTS Overall, 165 patients with a mean follow-up of 8 years were included; anastomotic and nonanastomotic strictures were diagnosed in 110 and 55 patients, respectively. Overall survival was significantly higher in patients with anastomotic strictures than in those with nonanastomotic strictures (median, 17.6 vs 13.9 years; log-rank: P < .05). Sustained clinical success could be achieved significantly more frequently in patients with anastomotic strictures (79.1% vs 54.5%, P < .001), and such patients showed significantly superior overall survival (19.7 vs 7.7 years; log-rank: P < .001). Sustained clinical success and the presence of nonanastomotic strictures were independently associated with better and worse outcomes (P < .05), respectively. CONCLUSIONS Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after liver transplantation is effective and safe, with high success rates. The implementation of this strategy controls symptoms and significantly improves survival.
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Affiliation(s)
| | - Christian Rupp
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Xenophon Exarchos
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ronald Koschny
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Sauer
- Interdisciplinary Center of Endoscopy, University Hospital Heidelberg, Heidelberg, Germany
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13
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Xu X, Guan L, Wu Y, Ke H, Zhao Y, Liu P. One hundred most cited articles related to Endoscopic retrograde cholangiopancreatography: A bibliometric analysis. Front Surg 2022; 9:1005771. [PMID: 36439532 PMCID: PMC9681810 DOI: 10.3389/fsurg.2022.1005771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has developed over the past few decades into a reliable technology for diagnostic and therapeutic purposes. Through a bibliometric analysis, this research attempted to evaluate the characteristics of the top 100 articles on ERCP that had the most citations. Methods We extracted pertinent publications from the Web of Science Core Collection (WoSCC) on July 9, 2022. The top 100 ERCP articles with the most citations were identified and analyzed. The following data were extracted: publication year, country/region, organization, total citation times, annual citation times, research type and research field, etc. To implement the network’s visual analysis, a bibliographic coupling network based on keywords was built using the VOSviewer 1.6.17 program. Results The journal with the most publications were GASTROINTESTINAL ENDOSCOPY, with 45 articles. Most of the top 100 articles came from the United States (n = 47) and Italy (n = 14). Indiana University and the University of Amsterdam were among the most important institutions in ERCP research. ML Freeman of the University of Minnesota contributed the highest number (n = 9) and the most highly cited paper. The age of the paper and article type is closely related to citation frequency. Of the 100 most-cited articles, clinical application in the field of ERCP has focused on three aspects: diagnosis, treatment, and complications. Clinical use of ERCP has shifted from diagnosis to treatment. Post-ERCP pancreatitis is the focus of attention, and the clinical application of technically complex therapeutic ERCP is the future development trend. Conclusion This study lists the most influential articles in ERCP by exposing the current state of the field, and showing the evolution of research trends to provide perspective for the future development of ERCP.
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Affiliation(s)
- Xuan Xu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Lulu Guan
- First Clinical Medical College, Nanchang University, Nanchang, China
| | - Yao Wu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuanbin Zhao
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Pi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Gastroenterology, The People’s Hospital of Longhua, Shenzhen, China
- Correspondence: Pi Liu
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14
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Sharma ZD, Karunakaran M, Bansal RK, Gandhi A, Singh MK, Soin AS, Puri R, Sud R. Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy. ANZ J Surg 2022; 93:911-917. [PMID: 36262090 DOI: 10.1111/ans.18123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/30/2022] [Accepted: 10/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis. METHODS A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up. RESULTS Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P = 0.002), longer duration for resolution (282.5 vs. 201.5 days, P = 0.095) and more number of stents. CONCLUSIONS Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.
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Affiliation(s)
- Zubin Dev Sharma
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Monish Karunakaran
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India.,Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.,College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon, India
| | - Ashish Gandhi
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Rajesh Puri
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Randhir Sud
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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15
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Donatelli G, Cereatti F, Dhumane P, Antonelli G, Dumont JL, De Palma GD, Dagher I, Derhy S. Long-term Outcomes of Combined Endoscopic-Radiological Approach for the Management of Complete Transection of the Biliary Tract. J Gastrointest Surg 2022; 26:1873-1880. [PMID: 35668228 DOI: 10.1007/s11605-022-05365-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/14/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Complete transection of the main bile duct (CTMD) is a major complication during hepato-bilio-pancreatic (HBP) surgery and is associated with high morbidity and mortality. In recent years, a combined endoscopic-radiological approach (CERA) for minimally invasive treatment of CTMD has been introduced, but evidence on its long-term outcomes is limited. Our aim is to report efficacy, safety, and long-term outcomes of CERA for the management of post-surgical CTMD in a tertiary referral center. METHODS All consecutive patients referred for CTMD after HBP surgery between February 2012 and January 2021 were included in this study. CERA was first performed to re-establish biliary tree continuity, and then multiple biliary plastic stents were deployed to guarantee biliary tree reconstruction. Anthropometric, clinical, procedural (endoscopic/radiologic/surgical), and follow-up data were collected and analyzed. Each lesion was classified according to Strasberg classification. RESULTS Overall, 60 patients (age 60.5 years, range 28-91), 38 F (61.7%), underwent CERA. Mean interval from surgery to endoscopic treatment was 13.2 days. Mean treatment duration was 526 days (SD ± 415) with a median number of 8 endoscopic sessions (range 1-33). Mean length of the biliary defect was 17.6 mm (SD ± 11.5). Long-term clinical success was achieved in 33/49 (67.3%) of patients. Treatment failure was experienced in 16/49 (32.7%) patients, while after an average follow-up of 41 months, stricture recurrence was observed in 3/36 (8.3%) patients. CONCLUSIONS CERA is a minimally invasive and effective technique to re-establish the continuity of the biliary tract after CTMD, achieving permanent restoration in over half of treated patients.
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Affiliation(s)
- Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France. .,Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy.
| | - Fabrizio Cereatti
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France.,Department of Gastroenterology and Digestive Endoscopy, Castelli Hospital, Ariccia (Rm), Italy
| | - Parag Dhumane
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France.,Department of General and Laparoscopic Surgery, Lilavati Hospital and Research Center, Bandra(w), Mumbai, India
| | - Giulio Antonelli
- Department of Gastroenterology and Digestive Endoscopy, Castelli Hospital, Ariccia (Rm), Italy.,Department of Anatomical, Forensic Medicine and Orthopedics Sciences, "Sapienza" University of Rome, HistologicalRome, Italy
| | - Jean-Loup Dumont
- Unité d'Endoscopie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, 8 Place de L'Abbé G. Hénocque, 75013, Paris, France
| | | | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Beclere Hospital, AP-HP, Clamart, France
| | - Serge Derhy
- Unité de Radiologie Interventionnelle, Hôpital Privé Des Peupliers, Ramsay Santé, Paris, France
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16
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Kirstein MM, Voigtländer T. Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie. Zentralbl Chir 2022; 147:398-406. [DOI: 10.1055/a-1857-5775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ZusammenfassungBiliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser
machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach
Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach
Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein
exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen
und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten
wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten
Verfahren.
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Affiliation(s)
| | - Torsten Voigtländer
- Gastroenterologie, Deutsches Rotes Kreuz Krankenhaus Clementinenhaus Hannover, Hannover, Deutschland
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17
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Schepis T, Boškoski I, Tringali A, Costamagna G. Role of ERCP in Benign Biliary Strictures. Gastrointest Endosc Clin N Am 2022; 32:455-475. [PMID: 35691691 DOI: 10.1016/j.giec.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Benign biliary strictures (BBS) can be associated with several causes, with postoperative and inflammatory strictures representing the most common ones. Endoscopy represents nowadays the first-line treatment in the management of BBS. Endoscopic balloon dilatation, plastic stents placement, fully covered metal stent placement, and magnetic compression anastomosis are the endoscopic techniques available for the treatment of BBS. The aim of this study is to perform a review of the literature to assess the role of endoscopy in the management of BBS and to evaluate the application of the different procedures in the different clinical settings.
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Affiliation(s)
- Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy.
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
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18
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Muniraj T. Post-liver transplantation bile leaks and strictures. Gastrointest Endosc 2022; 95:1233-1237. [PMID: 35124073 DOI: 10.1016/j.gie.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/23/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Thiruvengadam Muniraj
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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19
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Forde JJ, Bhamidimarri KR. Management of Biliary Complications in Liver Transplant Recipients. Clin Liver Dis 2022; 26:81-99. [PMID: 34802665 DOI: 10.1016/j.cld.2021.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.
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Affiliation(s)
- Justin J Forde
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA.
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20
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Pérez Lafuente M, Camacho Oviedo JA, Díez Miranda I, Tomasello A, Dot Bach J, Armengol Bertroli J, Gramegna LL, Molino Gahete JA, Bueno Recio FJ, Armengol Miró JR. Percutaneous or Endoscopic Treatment of Peripheral Bile Duct Leaks: Initial Experience with an Innovative Approach of Microcatheter-Delivered Argon Plasma Coagulation. Cardiovasc Intervent Radiol 2022; 45:365-370. [PMID: 35037087 DOI: 10.1007/s00270-021-03016-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/29/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Biliary ductal injuries are challenging to treat, and often lead to severe morbidity and mortality. The first-line approach involves endoscopic retrograde cholangiopancreatography with sphincterotomy and, in case of refractory leakage, long-lasting percutaneous transhepatic biliary drainage, endoscopic or percutaneous injection of sclerosing agents and/or coiling can be used. We describe a treatment procedure using microcatheter-mediated percutaneous or endoscopic argon plasma coagulation (APC). MATERIALS AND METHODS Three patients (7-year-old male, 14-year-old male, 81-year-old female) with refractory postsurgical and/or post-traumatic bile leaks underwent percutaneous (n = 2) or endoscopic (n = 1) APC through a detachable microcatheter. RESULTS The procedure was technically feasible in all patients. Postoperative imaging showed complete occlusion of biliary leakage. The technique was uneventful intraoperatively with no adverse events occurring during recovery or follow-up. CONCLUSION Our initial experience demonstrates that refractory bile duct leaks may be successfully treated with microcatheter-mediated APC endoscopically or percutaneously. Further research is needed to confirm the safety, efficacy, and clinical indications for this innovative technique.
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Affiliation(s)
- Mercedes Pérez Lafuente
- Department of Interventional Radiology, Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain.
| | - John Alexander Camacho Oviedo
- Department of Interventional Radiology, Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | - Iratxe Díez Miranda
- Department of Interventional Radiology, Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | - Alejandro Tomasello
- Interventional Neuroradiology Section, Department of Radiology, Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | - Joan Dot Bach
- Digestive Endoscopy Department, WIDER (World Institute for Digestive Endoscopy), Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | - Jordi Armengol Bertroli
- Digestive Endoscopy Department, WIDER (World Institute for Digestive Endoscopy), Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | | | - José Andrés Molino Gahete
- Pediatric Surgery Department, Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | - Francisco Javier Bueno Recio
- Pediatric Surgery Department, Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
| | - Josep Ramón Armengol Miró
- Digestive Endoscopy Department, WIDER (World Institute for Digestive Endoscopy), Hospital Vall d'Hebron, Passeig de la Vall d´Hebron 119-129, 08035, Barcelona, Spain
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21
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Fasullo M, Kandakatla P, Amerinasab R, Kohli DR, Shah T, Patel S, Bhati C, Bouhaidar D, Siddiqui MS, Vachhani R. Early laboratory values after liver transplantation are associated with anastomotic biliary strictures. Ann Hepatobiliary Pancreat Surg 2022; 26:76-83. [PMID: 35013006 PMCID: PMC8901979 DOI: 10.14701/ahbps.21-103] [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: 07/06/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims The aim of this study was to evaluate longitudinal changes of post-liver transplantation (LT) biliary anatomy and to assess the association of increased laboratory values after LT with the development of post-LT anastomotic biliary stricture (ABS). Methods Adult deceased donor LT recipients from 2008 and 2019 were evaluated. ABS was defined after blinded review of endoscopic cholangiograms. Controls were patients who underwent LT for hepatocellular carcinoma who did not have any clinical or biochemical concerns for ABS. Results Of 534 patients who underwent LT, 57 patients had ABS and 57 patients served as controls. On MRI, ABS patients had a narrower anastomosis (2.47 ± 1.32 mm vs. 3.38 ± 1.05 mm; p < 0.01) and wider bile duct at 1-cm proximal to the anastomosis (6.73 ± 2.45 mm vs. 5.66 ± 1.95 mm; p = 0.01) than controls. Association between labs at day 7 and ABS formation was as follows: aspartate aminotransferase hazard ratio (HR): 1.014; 95% confidence interval (CI): 1.008–1.020, p = 0.001; total bilirubin HR: 1.292, 95% CI: 1.100–1.517, p = 0.002; and conjugated bilirubin HR: 1.467, 95% CI: 1.216–1.768, p = 0.001. Corresponding analysis results for day 28 were alanine aminotransferase HR: 1.004, 95% CI: 1.002–1.006, p = 0.001; alkaline phosphatase HR: 1.005, 95% CI: 1.003–1.007, p = 0.001; total bilirubin HR: 1.233, 95% CI: 1.110–1.369, p = 0.001; and conjugated bilirubin HR: 1.272, 95% CI: 1.126–1.437, p = 0.001. Conclusions Elevation of laboratory values early after LT is associated with ABS formation.
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Affiliation(s)
- Matthew Fasullo
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Priyanush Kandakatla
- Department of Radiology, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Reza Amerinasab
- Department of Radiology, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Divyanshoo Rai Kohli
- Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO, United States
| | - Tilak Shah
- Division of Gastroenterology and Hepatology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, United States
| | - Samarth Patel
- Division of Gastroenterology and Hepatology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, United States
| | - Chandra Bhati
- Department of Transplant Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Doumit Bouhaidar
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Mohammad S Siddiqui
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA, United States
| | - Ravi Vachhani
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, VA, United States
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22
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Lam R, Muniraj T. Fully covered metal biliary stents: A review of the literature. World J Gastroenterol 2021; 27:6357-6373. [PMID: 34720527 PMCID: PMC8517778 DOI: 10.3748/wjg.v27.i38.6357] [Citation(s) in RCA: 14] [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: 03/30/2021] [Revised: 07/09/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.
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Affiliation(s)
- Robert Lam
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
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23
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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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24
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Jarlot-Gas C, Muscari F, Mokrane FZ, Del Bello A, Culetto A, Buscail E, Péré G, Fares N, Péron JM, Cuellar E, Barange K, Kamar N, Suc B, Maulat C. Management of anastomotic biliary stricture after liver transplantation and impact on survival. HPB (Oxford) 2021; 23:1259-1268. [PMID: 33423950 DOI: 10.1016/j.hpb.2020.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic biliary strictures (AS) is the main surgical complication after liver transplantation. The aims of this study are to investigate the risk factors of AS, its management and its impact on overall survival and survival of the graft. METHODS All patients who had received a liver transplantation with duct-to-duct anastomosis at Toulouse University Hospital between 2010 and 2016 were included. RESULTS Of 225 included patients, 56 (24.9%) presented with AS. The median time to discovery of AS was 83 days and 69.6% of the AS appeared within 6 months. Transplantation in critically ill patients, with a liver score >800 points, was an independent predictive factor of survival (P = 0.003). The first-line treatment was endoscopic (87.5%), with a success rate of 79.6% and a median of 4 procedures per patient in 12 months. In cases of failure of endoscopic therapy, percutaneous treatment had a high failure rate (50%). AS had no impact in terms of overall survival or in terms of graft survival. CONCLUSION AS do not have any repercussions on patient or graft survival, requiring long endoscopic treatment with multiple procedures. In the event of failure of this first-line endoscopic treatment, it seems preferable to turn directly towards surgical repair.
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Affiliation(s)
- Cécile Jarlot-Gas
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Fabrice Muscari
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | | | - Arnaud Del Bello
- Department of Nephrology and Transplantation, Toulouse University Hospital, Toulouse, France
| | - Adrian Culetto
- Department of Gastroenterology, Toulouse University Hospital, Toulouse, France
| | - Etienne Buscail
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Guillaume Péré
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Nadim Fares
- Department of Digestive Oncology, Toulouse University Hospital, Toulouse, France
| | - Jean-Marie Péron
- Department of Hepatology, Toulouse University Hospital, Toulouse, France
| | - Emmanuel Cuellar
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Karl Barange
- Department of Gastroenterology, Toulouse University Hospital, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Transplantation, Toulouse University Hospital, Toulouse, France
| | - Bertrand Suc
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Charlotte Maulat
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France.
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25
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Yoon SB, Kim J, Paik CN, Jang DK, Lee JK, Yoon WJ, Kim JW, Lee TH, Jang JY. Endoscopic and Percutaneous Biliary Interventions after Liver Transplantation: Nationwide Data in Korea. Gut Liver 2021; 16:300-307. [PMID: 34238768 PMCID: PMC8924799 DOI: 10.5009/gnl20379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/13/2021] [Accepted: 04/21/2021] [Indexed: 01/18/2023] Open
Abstract
Background/Aims Biliary complications including biliary strictures and bile leaks are the most common complications that occur after liver transplantation (LT). Endoscopic treatment with endoscopic retrograde cholangiography (ERC) is considered the first-line treatment, and percutaneous transhepatic cholangiography (PTC) can serve as an alternative or rescue therapy. However, nationwide clinical data on the frequency of ERC and PTC following LT have not yet been investigated. Methods Using the nationwide claims database, we investigated patients who underwent LT between 2012 and 2014 in Korea and followed them until 2015. We analyzed the prevalence and characteristics of patients and biliary procedures, including ERC and PTC implemented after LT. Results A total of 3,481 patients underwent LT during the 3-year study period. Among them, 3.0% of patients underwent biliary intervention postoperatively during the same hospitalization period, and 21.4% of patients received biliary intervention later on after initially being discharged from the hospital following LT. A total of 16.9% and 12.1% of patients underwent ERC and PTC after LT, respectively. The median period from LT to the first biliary intervention was 7.8 months (interquartile range, 3.5 to 14.6 months), and these patients underwent an average of 3.2±2.8 biliary procedures during the follow-up period. Patients undergoing living donor LT were more than twice as likely to undergo biliary procedures as those undergoing deceased donor LT (25.5% vs 12.1%). Conclusions Approximately one-fourth of patients in Korea who underwent LT subsequently underwent ERC or PTC. Compared with deceased donor LT patients, those undergoing living donor LT underwent more biliary interventions and were more difficult to treat.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jungmee Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Nyol Paik
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Won Jae Yoon
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jung-Wook Kim
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae-Young Jang
- Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
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26
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Barbaro F, Tringali A, Larghi A, Baldan A, Onder G, Familiari P, Boškoski I, Perri V, Costamagna G. Endoscopic management of non-anastomotic biliary strictures following liver transplantation: Long-term results from a single-center experience. Dig Endosc 2021; 33:849-857. [PMID: 33080081 DOI: 10.1111/den.13879] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Studies on endoscopic treatment of non-anastomotic biliary strictures (NABS) following orthotopic liver transplantation (OLT) are scanty and with a short follow-up. The long-term results of endoscopic treatment with plastic stents of NABS following OLT were analyzed. METHODS Retrospective analysis of consecutive enrolled patients who underwent endoscopic treatment for NABS after OLT between 1997 and 2015. Endoscopic treatment success was defined as stricture resolution, without recurrence. RESULTS During the study period, 33 patients with NABS underwent endoscopic retrograde cholangiopancreatography (ERCP) in our center. A total of 68 ERCP were performed with a 4.4% of procedure-related adverse events. Mortality related to cholangitis secondary to endoscopic procedures was 12%. After median follow-up of 70.3 months from stents removal, NABS resolution was obtained in 12 out of 24 (50%) patients. Only one case of late NABS recurrence was observed which was successfully retreated endoscopically. According to our data analysis NABS occurring <12 months from OLT showed a worse prognosis (P < 0.04). CONCLUSIONS The follow-up of this study confirms that endoscopic treatment of NABS is unsatisfactory. However, patients who respond to endoscopic treatment maintain the response over time. Prompt treatment of acute cholangitis due to stents occlusion is advised in these patients to avoid high mortality rates.
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Affiliation(s)
- Federico Barbaro
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Baldan
- Gastroenterology and Transplant Hepatology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Graziano Onder
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
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27
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Sung MJ, Jo JH, Lee HS, Park JY, Bang S, Park SW, Song SY, Joo DJ, Chung MJ. Optimal drainage of anastomosis stricture after living donor liver transplantation. Surg Endosc 2021; 35:6307-6317. [PMID: 33796905 DOI: 10.1007/s00464-021-08456-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/17/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Endoscopic biliary stenting (EBS) with a fully covered, self-expandable metallic stent (FC-SEMS) and plastic stent (PS) is safe and efficient for biliary anastomotic strictures (ASs) after a deceased donor liver transplantation. Limited studies have investigated the use of FC-SEMSs for biliary strictures post-living donor liver transplantation (LDLT). We compared the resolution rate of biliary ASs post-LDLT and the 12-month recurrence rates post-stent removal between EBS with an FC-SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). METHODS Patients with biliary ASs after an LDLT (mean age: 57.3 years, 76.1% men) hospitalized between 2014 and 2017 were enrolled. Endoscopic retrograde cholangiopancreatography (ERCP) was repeated every 3-4 months. Patients were followed-up for at least 1-year post-stent removal. RESULTS Of the 75 patients enrolled, 16, 20, and 39 underwent EBS with an FC-SEMS, PS, and PTBD, respectively. Median follow-up period was 39.2 months. Fewer ERCP procedures were needed in the FC-SEMS group than in the PS group (median, 2 vs. 3; P = 0.20). Median stent indwelling periods were 4.7, 9.3, and 5.4 months in the FC-SEMS, PS, and PTBD groups, respectively (P = 0.006). The functional resolution rate was lower in the PS group (16/20) than in the FC-SEMS (16/16) or PTBD (39/39) group (P = 0.005). The radiologic resolution rate was higher in the FC-SEMS group (16/16) than in the PS group (14/20) (P = 0.07). The 12-month recurrence rates showed no significant differences (FC-SEMS, 4/16; PS, 3/16; PTBD, 6/39; P = 0.66). The rates of complications during treatment differed significantly between the groups (P = 0.04). Stent migration occurred in 1 (6.3%) and 5 (25.0%) patients in the FC-SEMS and PS groups, respectively (P = 0.59). CONCLUSIONS EBS with an FC-SEMS is comparable with EBS with a PS or PTBD in terms of biliary stricture resolution and 12-month recurrence rates. The use of FC-SEMSs is potentially effective and safe for biliary AS resolution after LDLT.
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Affiliation(s)
- Min Je Sung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Division of Gastroenterology, Department of Internal Medicine CHA Bundang Medical Center, CHA University, Gyeonggi-do, Republic of Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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28
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One-step percutaneous transhepatic cholangioscopic lithotripsy in patients with choledocholithiasis. Clin Res Hepatol Gastroenterol 2021; 45:101477. [PMID: 33744724 DOI: 10.1016/j.clinre.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) may be inappropriate for most patients with choledocholithiasis. This study aimed to evaluate one-step percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in the treatment of patients with choledocholithiasis who could not undergo ERCP (e.g., failed ERCP, altered anatomy, and/or contra-indications). METHOD This was a retrospective single-centre series of 67 patients who underwent choledocholithiasis between November 2015 and March 2018: 35 with one-step PTCSL (Group A) and 32 with laparoscopic common bile duct (CBD) exploration (Group B). RESULTS Compared with Group B, Group A showed shorter duration of operation, length of stay in the hospital, postoperative hospital stay, postoperative drainage time, and time to oral intake (all P<0.05). Intraoperative blood loss, costs, conversion to open surgery (one in group A vs. seven in group B; P=0.023), and bile leakage (none in group A vs. four in group B; P=0.047) were lower in Group A than in Group B. There were no significant differences between the two groups regarding the intraoperative clearance rate, ultimate clearance rate, and several postoperative complications. CONCLUSION One-step PTCSL could be an alternative for patients with choledocholithiasis, especially when ERCP is not feasible.
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29
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Magro B, Tacelli M, Mazzola A, Conti F, Celsa C. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr 2021; 10:76-92. [PMID: 33575291 DOI: 10.21037/hbsn.2019.09.01] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
Importance Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation. Objective The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT. Evidence Review a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment. Findings Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks. Conclusions and Relevance BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.
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Affiliation(s)
- Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Filomena Conti
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
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30
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Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J Hepatol 2021; 13:66-79. [PMID: 33584987 PMCID: PMC7856868 DOI: 10.4254/wjh.v13.i1.66] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/01/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation is the current standard of care for end-stage liver disease and an accepted therapeutic option for acute liver failure and primary liver tumors. Despite the remarkable advances in the surgical techniques and immunosuppressive therapy, the postoperative morbidity and mortality still remain high and the leading causes are biliary complications, which affect up to one quarter of recipients. The most common biliary complications are anastomotic and non-anastomotic biliary strictures, leaks, bile duct stones, sludge and casts. Despite the absence of a recommended treatment algorithm many options are available, such as surgery, percutaneous techniques and interventional endoscopy. In the last few years, endoscopic techniques have widely replaced the more aggressive percutaneous and surgical approaches. Endoscopic retrograde cholangiography is the preferred technique when duct-to-duct anastomosis has been performed. Recently, new devices and techniques have been developed and this has led to a remarkable increase in the success rate of minimally invasive procedures. Understanding the mechanisms of biliary complications helps in their early recognition which is the prerequisite for successful treatment. Aggressive endoscopic therapy is essential for the reduction of morbidity and mortality in these cases. This article focuses on the common post-transplant biliary complications and the available interventional treatment modalities.
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Affiliation(s)
- Irina Boeva
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Petko Ivanov Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda Hospital, Sofia 1407, Bulgaria
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31
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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Kim GE, Lo DYA. Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report. World J Surg Proced 2020; 10:3-8. [DOI: 10.5412/wjsp.v10.i2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/23/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cholangioscopy has been described in case reports and series to facilitate guidewire placement in difficult benign biliary strictures. Specifically, it has been infrequently used in difficult benign anastomotic liver transplant biliary strictures to visualize the stricture orifice for guidewire placement. Here we describe a case of guidewire placement through a difficult malignant biliary stricture using single operator cholangioscopy.
CASE SUMMARY A 74-year-old female presented with jaundice and weight loss. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) by other endoscopists demonstrated pancreatic adenocarcinoma with a dilated cystic duct (CD) and proximal common bile duct (CBD). The associated distal CBD stricture was dilated and stented with a plastic stent. However she subsequently developed cholangitis, prompting referral for a repeat ERCP. The stent was found to have migrated distally to the confluence of the dilated CD and CBD stricture. Despite using multiple hydrophilic guidewires, the stricture could not be traversed due to preferential wire passage into the dilated CD. SpyGlass DS (Boston Scientific Corp, Marlborough, MA, United States) was then used to visualize the orifices of the CD and CBD stenosis, enabling the guidewire to be placed directly through the stricture into the proximal CBD. A WallFlex covered metal stent (Boston Scientific Corp, Marlborough, MA, United States) was successfully placed, resulting in resolution of her cholangitis.
CONCLUSION To our knowledge, this is one of the first cases to describe successful cholangioscopic guidewire placement for malignant biliary strictures.
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Affiliation(s)
- Grace E Kim
- Internal Medicine, University of Maryland Medical Center, Baltimore, MD 21201, United States
| | - David Yung-An Lo
- Department of Medicine, The Ohio State University College of Medicine, Ohio Gastroenterology Group, Inc, Columbus, OH 43214, United States
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Abstract
INTRODUCTION Liver transplantation is a life-changing event for patients and survival following transplantation has improved significantly since the first transplantation in 1967. Following liver transplantation, patients face a unique set of healthcare management decisions including transplantation-specific complications, recurrence of primary liver disease, as well as metabolic and malignancy concerns related to immunosuppression. As more patients with liver disease receive transplantation and live longer, understanding and managing these patients will require not only transplant specialist but also local subspecialist and primary care physicians. AREAS COVERED This review covers common issues related to the management of patients following liver transplantation including immunosuppression, liver allograft dysfunction, metabolic complications, as well as routine health maintenance such as immunizations and cancer screening. EXPERT OPINION Optimizing medical care for patients following liver transplant will benefit from ensuring all providers, not just transplant specialist, have a basic understanding of the common issues encountered in the post-transplant patient. This review provides an overview of common healthcare concerns and management options for patients following liver transplantation.
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Affiliation(s)
- Nicholas Hoppmann
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham , Birmingham, Alabama, USA
| | - Omar Massoud
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham , Birmingham, Alabama, USA
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Neuberger M, Sommerer C, Böhnisch S, Metzendorf N, Mehrabi A, Stremmel W, Gotthardt D, Zeier M, Weiss KH, Rupp C. Effect of mycophenolic acid on inosine monophosphate dehydrogenase (IMPDH) activity in liver transplant patients. Clin Res Hepatol Gastroenterol 2020; 44:543-550. [PMID: 31924555 DOI: 10.1016/j.clinre.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to the development of immunosuppressants, the focus in transplanted patients has shifted from short-term to long-term survival as well as a better adjustment of these drugs in order to prevent over- and under-immunosuppression. Mycophenolic acid (MPA) is a noncompetitive inhibitor of inosine monophosphate dehydrogenase (IMPDH) and approved for prophylaxis of acute rejection after kidney, heart, and liver transplantation, where it has become a part of the standard therapy. Targeting inosine monophosphate IMPDH activity as a surrogate pharmacodynamic marker of MPA-induced immunosuppression may allow a more accurate assessment of efficacy and aid in limiting toxicity in liver transplanted patients. AIM Assess IMPDH-inhibition in liver transplant recipients and its impact on biliary/infectious complications, acute cellular rejection (ACR) and liver dependent survival. METHODS This observational cohort study comprises 117 liver transplanted patients that were treated with mycophenolate mofetil (MMF) for at least 3 months. Blood samples (BS) were collected and MPA serum level and IMPDH activity were measured before (t(0)), 30minutes (t(30)) and 2h after (t(120)) MMF morning dose administration. Regarding MPA, we assessed the area under the curve (AUC). Patients were prospectively followed up for one year and assessed for infectious and biliary complications, episodes of ACR and liver dependent survival. RESULTS The MPA levels showed a broad interindividual variability at t(0) (2.0±1.8ng/ml), t(30) (12.7±9.0ng/ml) and t(120) (7.5±4.3ng/ml). Corresponding IMPDH activity was at t(o) (23.2±9.5 nmol/h/mg), at t(30) (16.3±8.8 nmol/h/mg) and t(120) (18.2±8.7 nmol/h/mg). With regard to MPA level we found no correlation with infectious or biliary complications within the follow-up period. Patients with baseline IMPDH(a) below the median had significant more viral infections (6 (10.2%) vs. 17 (29.3%); P=0.009) with especially more cytomegalovirus (CMV) infections (1 (3.4%) vs. 6 (21.4%); P=0.03)). Furthermore, patients with baseline IMPDH(a) above the median developed more often non-anastomotic biliary strictures (8 (13.6%) vs. 1 (1.7%), P=0.03). We found the group reaching the combined clinical endpoint of death and re-transplantation showing significantly lower MPA baseline values (t(0) 0.9±0.7 vs. 2.1±1.8μg/ml Mann-Whitney-U: P=0.02). We calculated a simplified MPA(AUC) with the MPA level at baseline, 30 and 120minutes after MPA administration. Whereas we found no differences with regard to baseline characteristics at entry into the study patients with MPA (AUC) below the median experienced significantly more often the combined clinical endpoint (12.1% (7/58) vs. 0.0% (0/57); P=0.002) and had a reduced actuarial re-transplantation-free survival (1.0 year vs. 0.58 years; Log-rank: P=0.007) during the prospective one-year follow-up period. In univariate and multivariate analysis including gender, age, BMI, ACR, MPA (AUC) and IMPDH(a) only BMI, MPA (AUC) and IMPDH(a) were independently associated with reduced actuarial re-transplantation-free survival. CONCLUSION MPA-levels and IMPDH-activity in liver transplanted patients allows individual risk assessment. Patients with higher IMPDH inhibition acquire more often viral infections. Insufficient IMPDH inhibition is associated with development of non-anastomotic bile duct strictures and reduced re-transplantation-free survival.
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Affiliation(s)
- M Neuberger
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Sommerer
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - S Böhnisch
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - N Metzendorf
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - A Mehrabi
- University of Heidelberg, Department of General, Visceral, and Transplantation Surgery, 69120 Heidelberg, Germany
| | - W Stremmel
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - D Gotthardt
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - M Zeier
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - K H Weiss
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Rupp
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany.
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Choi JH, Paik WH. Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture. Clin Endosc 2020; 53:255-260. [PMID: 32438779 PMCID: PMC7280849 DOI: 10.5946/ce.2020.079] [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: 03/28/2020] [Accepted: 04/27/2020] [Indexed: 11/14/2022] Open
Abstract
Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Risk of biliary tract disease in living liver donors: A population-based cohort study. PLoS One 2020; 15:e0230840. [PMID: 32226025 PMCID: PMC7105125 DOI: 10.1371/journal.pone.0230840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 02/25/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND & AIMS Whether living liver donors have a higher risk of biliary tract disease compared with non-donors remains unknown. METHODS Data were collected from the Taiwan Longitudinal Health Insurance Database for the 2003-2011 period. The study cohort comprised 1,446 patients aged ≥ 18 years who had served as living liver donors. The primary outcome was the incidence of biliary tract disease. Cox proportional hazards modeling was used to determine the hazard ratios. RESULTS The incidence density rate of biliary tract disease was 13.9-fold higher in the liver donor (LD) cohort than in the non-LD cohort (10.2 vs. 0.71 per 1,000 person-years), with an adjusted hazard ratio (HR) of 14.2 (95% confidence interval [CI] = 7.73-26.1). Stratified by comorbidity, the relative risk of biliary tract disease was higher in the LD cohort than in the non-LD cohort for both patients with or without comorbidity. The incidence density rate of biliary tract disease was significantly higher in the first 3 years (13.5 per 1,000 person-years in the LD cohort). The highest adjusted HR of biliary tract disease for LD patients compared with the non-LD cohort was 22.4 (95% CI = 10.8-46.1) in the follow-up ≤ 3 years. CONCLUSION Living liver donors had a higher risk of biliary tract disease compared with non-donors.
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Haidar H, Manasa E, Yassin K, Suissa A, Kluger Y, Khamaysi I. Endoscopic treatment of post-cholecystectomy bile leaks: a tertiary center experience. Surg Endosc 2020; 35:1088-1092. [PMID: 32107631 DOI: 10.1007/s00464-020-07472-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Post-cholecystectomy bile leak is relatively a well-known surgical complication. Several potential treatment modalities for such leaks are used. The early use of ERCP to exclude significant bile duct injury and to treat the leak by various endoscopic means is supported by a large bulk of data. However, there is no consensus as to the optimal endoscopic intervention. METHODS A retrospective review of ERCP database was done to identify all cases of bile leak related to cholecystectomy. Patient records including surgical and endoscopic reports were reviewed, and telephone interviews were conducted to collect data. RESULTS During the period 2004-2016, 100 patients (53 men, 47 women; mean age, 55 years) with post-cholecystectomy bile leak were referred for ERCP. Cholecystectomy was done laparoscopically in 82 patients (with an open conversion rate of 13%). In the majority of cases (77%), the leak was diagnosed by ongoing bile flow from the drains. The most common symptoms were pain (17%) and fever (4%). The most common site of the leak was the cystic duct stump (79%) followed by subvesical ducts (7%). Low grade leaks were seen in 84% of cases. Treatment included stent insertion alone (9%), sphincterotomy alone (11%), combination stent/sphincterotomy (76%) and others (1%). Failed ERCP was encountered in 3%. Endoscopic therapy was successful in 90 patients (90%). In subgroup analysis, success rate of procedures with stent insertion (with or without sphincterotomy) is significantly higher compared to procedures without stent insertion (95.3% vs 72.7%, p < 0.05). The failure rate of sphincterotomy alone procedures (3/11, 27%) is much higher compared to procedures with stent insertion (4/85, 5%) with p < 0.05. Four patients (4%) developed post-ERCP pancreatitis (mild to moderate) and one patient (1%) suffered from retroperitoneal perforation. CONCLUSION The optimal endoscopic intervention for post-cholecystectomy bile leak should include temporary insertion of a biliary stent.
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Affiliation(s)
- Hoda Haidar
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, POB 9602, 31096, Haifa, Israel
| | - Elias Manasa
- Department of Surgery, Rambam Medical Center, Haifa, Israel
| | - Kamel Yassin
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, POB 9602, 31096, Haifa, Israel
| | - Alain Suissa
- Invasive Endoscopy Unit, Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yoram Kluger
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, POB 9602, 31096, Haifa, Israel.,Department of Surgery, Rambam Medical Center, Haifa, Israel
| | - Iyad Khamaysi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, POB 9602, 31096, Haifa, Israel. .,Invasive Endoscopy Unit, Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.
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Ardalan ZS, Chandran S, Vasudevan A, Angus PW, Grigg A, He S, Macdonald GA, Strasser SI, Tate CJ, Kennedy GA, Testro AG, Gow PJ. Management of Patients With Erythropoietic Protoporphyria-Related Progressive Liver Disease. Liver Transpl 2019; 25:1620-1633. [PMID: 31469227 DOI: 10.1002/lt.25632] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/10/2019] [Indexed: 12/23/2022]
Abstract
Erythropoietic protoporphyria (EPP) is an inherited metabolic disorder of heme synthesis resulting from overproduction of protoporphyrin IX (PPIX), which can lead to progressive liver disease characterized by recurrent EPP crises and end-stage liver disease. We used the Australian Transplant Registry to identify 5 patients referred for liver transplantation between 2008 and 2017. A total of 4 patients had EPP secondary to ferrochelatase deficiency, and 1 patient had X-linked EPP. No patient had follow-up with a specialist prior to the diagnosis of progressive liver disease. There were 3 patients who underwent orthotopic liver transplantation, whereas 2 died while on the transplant waiting list. Parenteral PPIX-lowering therapy was used in 4 patients and was effective in 3 patients, although 2 of these had rebound porphyria and worsening liver function following a decrease in the intensity of therapy. Early disease recurrence in the allograft following transplantation occurred in 2 patients requiring red cell exchange (RCE) to successfully attain and maintain low PPIX levels, but RCE was associated with hemosiderosis in 1 patient. Allogeneic stem cell transplantation (AlloSCT) was performed in 2 patients. One failed engraftment twice, whereas the second rejected the first graft but achieved full donor chimerism with a second graft and increased immunosuppression. In conclusion, our observations suggest that progressive liver disease needs parenteral PPIX-lowering treatment with the intensity adjusted to achieve a target Erc-PPIX level. Because EPP liver disease is universally recurrent, AlloSCT should be considered in all patients with adequate immunosuppression to facilitate engraftment. RCE appears to be effective for recurrent EPP liver disease but is associated with an increased risk of iron overload.
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Affiliation(s)
- Zaid S Ardalan
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia.,Department of Gastroenterology, Alfred Hospital, Melbourne, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia
| | - Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Australia
| | - Peter W Angus
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia.,Melbourne University, Melbourne, Australia
| | - Andrew Grigg
- Department of Clinical Hematology, Austin Hospital, Melbourne, Australia
| | - Simon He
- Department of Clinical Hematology, Austin Hospital, Melbourne, Australia
| | - Graeme A Macdonald
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Courtney J Tate
- Department of Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Glen A Kennedy
- Department of Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Adam G Testro
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia
| | - Paul J Gow
- Department of Gastroenterology and Liver Transplant, Austin Hospital, Melbourne, Australia
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Endoscopic treatment of biliary complications after duct-to-duct biliary anastomosis in pediatric liver transplantation. Langenbecks Arch Surg 2019; 404:875-883. [DOI: 10.1007/s00423-019-01804-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
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40
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Akhter A, Pfau P, Benson M, Soni A, Gopal D. Endoscopic management of biliary strictures post-liver transplantation. World J Meta-Anal 2019; 7:120-128. [DOI: 10.13105/wjma.v7.i4.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Biliary complications play a significant role in morbidity of liver transplant recipients. Biliary strictures occur between 10%-25% of patients with a higher incidence in living donor recipients compared to deceased donors. Strictures can be classified as either anastomotic or non-anastomotic and may be related to ischemic events. Endoscopic management of biliary strictures in the post-transplant setting has become the preferred initial approach due to adequate rates of resolution of anastomotic and non-anastomotic strictures (NAS). However, several factors may increase complexity of the endoscopic approach including surgical anatomy, location, number, and severity of bile duct strictures. Many endoscopic tools are available, however, the approach to management of anastomotic and NAS has not been standardized. Multi-disciplinary techniques may be necessary to achieve optimal outcomes in select patients. We will review the risk factors associated with the development of bile duct strictures in the post-transplant setting along with the efficacy and complications of current endoscopic approaches available for the management of bile duct strictures.
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Affiliation(s)
- Ahmed Akhter
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Patrick Pfau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Mark Benson
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Anurag Soni
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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Tringali A, Tarantino I, Barresi L, Traina M, Bonato G, Cintolo M, Hassan C, Mutignani M, Adler DG. Multiple plastic versus fully covered metal stents for managing post-liver transplantation anastomotic biliary strictures: a meta-analysis of randomized controlled trials. Ann Gastroenterol 2019; 32:407-415. [PMID: 31263364 PMCID: PMC6595920 DOI: 10.20524/aog.2019.0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/23/2019] [Indexed: 12/15/2022] Open
Abstract
Background Anastomotic biliary strictures (ABS) following liver transplantation (LT) are one of the most common complications, occurring in 4.5-32% of patients. Multiple plastic stenting (MPS) requires multiple sessions, with the associated risk, cost and patient discomfort. Fully covered self-expandable metal stents (FC-SEMS) have increasingly been used in this setting. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs), comparing the role of FC-SEMS and MPS in the treatment of ABS post-LT. Methods We conducted a bibliographic search using PubMed and EMBASE, aimed at identifying available RCTs that compared MPS to FC-SEMS in patients with ABS post LT from January 2000 to October 2017. Primary outcomes were ABS resolution and recurrence, while secondary outcomes were adverse events and number of procedures performed. Pooled estimates were calculated using random-effects models. Results Four RCTs (205 patients) were included. ABS resolution and recurrence did not differ significantly between the groups (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.43-2.56, P=0.92; and OR 2.37, 95%CI 0.54-10.38, P=0.25). The same was true for adverse events (OR 0.91, 95%CI 0.84-3.48, P=0.86) and migration rate (OR 1.31, 95%CI 0.46-3.71, P=0.61). The mean number of endoscopic retrograde cholangiopancreatography procedures was lower for FC-SEMS (mean difference [MD] -2.08). Conclusions FC-SEMS and MPS had equal ABS resolution and recurrence, although there was a trend towards a higher recurrence rate in FC-SEMS that disappeared when trials with a shorter stent indwelling time were excluding. No difference was found in overall adverse events or migration rate.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Ilaria Tarantino
- Endoscopy Unit, IRCCS ISMETT, Palermo Italy (Ilaria Tarantino, Luca Barresi, Mario Traina)
| | - Luca Barresi
- Endoscopy Unit, IRCCS ISMETT, Palermo Italy (Ilaria Tarantino, Luca Barresi, Mario Traina)
| | - Mario Traina
- Endoscopy Unit, IRCCS ISMETT, Palermo Italy (Ilaria Tarantino, Luca Barresi, Mario Traina)
| | - Giulia Bonato
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Marcello Cintolo
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy (Cesare Hassan)
| | - Massimiliano Mutignani
- Endoscopy Unit, Ospedale Ca' Granda Niguarda, Milan, Italy (Alberto Tringali, Giulia Bonato, Marcello Cintolo, Massimiliano Mutignani)
| | - Douglas G Adler
- Division of Gastroenterology & Hepatology University of Utah, Salt Lake City, Utah, USA (Douglas G. Adler)
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Raza A, Omer A, Iqbal S, Gudsoorkar V, Koduru P, Krishnan K. Efficacy of Nasobiliary Tubes and Biliary Stents in Management of Patients with Bile Leak after Liver Transplantation: A Systematic Review. Clin Endosc 2019; 52:159-167. [PMID: 30959587 PMCID: PMC6453846 DOI: 10.5946/ce.2018.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/06/2010] [Indexed: 02/07/2023] Open
Abstract
Background/Aims Bile leak is one of the most common complications of liver transplantation. The treatment options for bile leaks include conservative management, surgical re-intervention, percutaneous drainage and endoscopic drainage. We aimed to perform a systematic review to identify the efficacy of endoscopic treatment in the resolution of post-transplant bile leaks. Methods Two independent reviewers performed systematic literature search in PubMed, ISI Web of Science, grey literature and relevant references in May 2017. Human studies in English with documented post-liver transplant bile leaks were included. Results Thirty-four studies were included in the final analysis. The pooled efficacy of biliary stents for the resolution of post-transplant bile leaks was 82.43% compared with 87.15% efficacy of nasobiliary tubes. The efficacy of biliary stents was lower for anastomotic leaks (69.23%) compared to T-tube (90.9%) or cut-surface/ cystic duct stump related leaks (92.8%). Similarly, the efficacy of nasobiliary tube was also lower for anastomotic leaks (58.33%) compared to T-tube or cut-surface related leaks (100%). Conclusions In this systematic review, the overall efficacy was 82.43% in biliary stent group, and 87.15% in nasobiliary tube group. Both biliary stent and nasobiliary tube were more effective in managing non-anastomotic leaks compared to anastomotic leaks.
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Affiliation(s)
- Ali Raza
- Division of Gastroenterology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA.,Division of Gastroenterology, Department of Medicine, The University of Texas-Houston, McGovern Medical School, Houston, TX, USA
| | - Anam Omer
- Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Sara Iqbal
- Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Vineet Gudsoorkar
- Division of Gastroenterology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Pramoda Koduru
- Division of Gastroenterology, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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43
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Crismale JF, Ahmad J. Endoscopic Management of Biliary Issues in the Liver Transplant Patient. Gastrointest Endosc Clin N Am 2019; 29:237-256. [PMID: 30846151 DOI: 10.1016/j.giec.2018.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Biliary complications remain a common problem after liver transplantation (LT). The therapeutic endoscopist encounters a variety of situations in LT including strictures at the duct-to-duct biliary anastomosis, strictures elsewhere in the biliary tree caused by an ischemic injury, and bile leaks at the anastomosis or from the cut surface and stone disease. Biliary complications lead to significant morbidity and occasionally reduced graft and patient survival. Several factors increase the risk of strictures and leaks. Endoscopic intervention in experienced hands is successful in the management of biliary complications following LT and percutaneous or surgical correction should seldom be required.
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Affiliation(s)
- James F Crismale
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Jawad Ahmad
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
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44
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Moy BT, Birk JW. A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. J Clin Transl Hepatol 2019; 7:61-71. [PMID: 30944822 PMCID: PMC6441650 DOI: 10.14218/jcth.2018.00028] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.
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Affiliation(s)
- Brian T. Moy
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- *Correspondence to: John W. Birk, Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT 06030, USA. E-mail:
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45
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Lee DW, Han J. Endoscopic management of anastomotic stricture after living-donor liver transplantation. Korean J Intern Med 2019; 34:261-268. [PMID: 30840808 PMCID: PMC6406087 DOI: 10.3904/kjim.2019.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 12/14/2022] Open
Abstract
The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.
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Affiliation(s)
- Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Correspondence to Jimin Han, M.D. Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Namgu, Daegu 42472, Korea Tel: +82-53-650-3442 Fax: +82-53-624-3281 E-mail:
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46
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Long-term Outcome of Endoscopic and Percutaneous Transhepatic Approaches for Biliary Complications in Liver Transplant Recipients. Transplant Direct 2019; 5:e432. [PMID: 30882037 PMCID: PMC6411220 DOI: 10.1097/txd.0000000000000869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/27/2018] [Indexed: 02/07/2023] Open
Abstract
Background Biliary complications occur in 6% to 34% of liver transplant recipients, for which endoscopic retrograde cholangiopancreatography has become widely accepted as the first-line therapy. We evaluated long-term outcome of biliary complications in patients liver transplanted between 2004 and 2014 at Karolinska University Hospital, Stockholm. Methods Data were retrospectively collected, radiological images were analyzed for type of biliary complication, and graft and patient survivals were calculated. Results In 110 (18.5%) of 596 transplantations, there were a total of 153 cases of biliary complications: 68 (44.4%) anastomotic strictures, 43 (28.1%) nonanastomotic strictures, 24 (15.7%) bile leaks, 11 (7.2%) cases of stone- and/or sludge-related problems, and 7 (4.6%) cases of mixed biliary complications. Treatment success rates for each complication were 90%, 73%, 100%, 82% and 80%, respectively. When the endoscopic approach was unsatisfactory or failed, percutaneous transhepatic cholangiography or a combination of treatments was often successful (in 18 of 24 cases). No procedure-related mortality was observed. Procedure-related complications were reported in 7.7% of endoscopic retrograde cholangiopancreatography and 3.8% of percutaneous transhepatic cholangiography procedures. Patient survival rates, 1, 3, 5, and 10 years posttransplant in patients with biliary complications were 92.7%, 80%, 74.7%, and 54.1%, respectively, compared with 92%, 86.6%, 83.7%, and 72.8% in patients free from biliary complications (P < 0.01). Similarly, long-term graft survival was lower in the group experiencing biliary complications (P < 0.0001). Conclusions Endoscopic and percutaneous approaches for treating biliary complications are safe and efficient and should be considered complementing techniques. Despite a high treatment success rate of biliary complications, their occurrence still has a significant negative impact on patient and graft long-term survivals.
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47
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Larghi A, Tringali A, Rimbaş M, Barbaro F, Perri V, Rizzatti G, Gasbarrini A, Costamagna G. Endoscopic Management of Benign Biliary Strictures After Liver Transplantation. Liver Transpl 2019; 25:323-335. [PMID: 30329213 DOI: 10.1002/lt.25358] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023]
Abstract
Biliary strictures represent some of the most frequent complications encountered after orthotopic liver transplantation. They comprise an array of biliary abnormalities with variations in anatomical location, clinical presentation, and different pathogenesis. Magnetic resonance cholangiography represents the most accurate noninvasive imaging test that can provide detailed imaging of the whole biliary system-below and above the anastomosis. It is of particular value in those harboring complex hilar or intrahepatic strictures, offering a detailed roadmap for planning therapeutic procedures. Endoscopic therapy of biliary strictures usually requires biliary sphincterotomy plus balloon dilation and stent placement. However, endoscopic management of nonanastomotic biliary strictures is much more complex and challenging as compared with anastomotic biliary strictures. The present article is a narrative review presenting the results of endoscopic treatment of biliary strictures occurring after liver transplantation, describing the different strategies based on the nature of the stricture and summarizing their outcomes.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Mihai Rimbaş
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Federico Barbaro
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Instituts Hospitalo-Universitaires - University of Strasbourg Institute of Advanced Study, Strasbourg, France
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48
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Verma R, Satapathy SK. Medical Course and Complications After Liver Transplantation. PSYCHOSOCIAL CARE OF END-STAGE ORGAN DISEASE AND TRANSPLANT PATIENTS 2019:169-179. [DOI: 10.1007/978-3-319-94914-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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49
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Kimura K, Kudo K, Kurihara T, Yoshiya S, Mano Y, Takeishi K, Itoh S, Harada N, Ikegami T, Yoshizumi T, Ikeda T. Rendezvous Technique Using Double Balloon Endoscope for Removal of Multiple Intrahepatic Bile Duct Stones in Hepaticojejunostomy After Living Donor Liver Transplant: A Case Report. Transplant Proc 2018; 51:579-584. [PMID: 30879594 DOI: 10.1016/j.transproceed.2018.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/09/2018] [Indexed: 02/08/2023]
Abstract
Cholangitis is a major complication following transplantation. We report a living donor liver transplant (LDLT) patient with cholangitis due to multiple stones in the intrahepatic bile duct during hepaticojejunostomy anastomosis, who was successfully treated with the rendezvous technique using double balloon endoscope. A 64-year-old woman underwent LDLT with right lobe graft and hepaticojejunostomy for Wilson disease. There was bile leakage with biliary peritonitis, which was treated conservatively after transplant. Two years after surgery, she developed reiterated cholangitis due to stenosis of hepaticojejunostomy anastomosis and multiple stones in the intrahepatic bile ducts. Percutaneous transhepatic biliary drainage was performed. The size of the drainage tube was increased, and the anastomotic area was dilated in a stepwise manner using a balloon catheter. The stones were crushed and lithotomy was performed using electronic hydraulic lithotripsy through cholangioscopy. Finally, lithotomy was performed for the remaining stones through endoscopic retrograde cholangiography with the rendezvous technique using the double balloon endoscope. Rendezvous approach with percutaneous transhepatic biliary drainage and double balloon endoscopic retrograde cholangiography was an effective treatment for the multiple intrahepatic stones in hepaticojejunostomy following LDLT with right lobe graft.
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Affiliation(s)
- K Kimura
- Department of Endoscopy and Endoscopic Surgery, Fukuoka Dental College, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - K Kudo
- Department of Endoscopy and Endoscopic Surgery, Fukuoka Dental College, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Kurihara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - S Yoshiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y Mano
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Takeishi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - S Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Ikeda
- Department of Endoscopy and Endoscopic Surgery, Fukuoka Dental College, Fukuoka, Japan; Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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50
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González-Sánchez MR, Cascales-Campos PA, López-Espín JJ, Febrero B, Pons JA, Vargas Acosta A, Ros J, Sánchez-Bueno F, Robles R, Sáenz L, Ramírez P, Parilla P. Donors Older Than 75 Years Do Not Influence the Appearance of Biliary Complications After Liver Transplantation. Transplant Proc 2018; 50:640-643. [PMID: 29579875 DOI: 10.1016/j.transproceed.2017.11.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/21/2017] [Accepted: 11/11/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND In recent years, several studies have shown that the age of the donor may be related to an increase in the occurrence of biliary complications (BCs), which remain the main cause of morbidity after liver transplantation. This study analyzed the type and management of these BCs, the impact of BCs on graft and patient survival rates, and the influence of some characteristics of donors and recipients on BC appearance in patients transplanted with donors 75 years of age or older. PATIENTS AND METHODS From 2003 to 2016, 100 liver transplantations with donors 75 years of age or older (15.6%) were performed in our hospital. The data were compared with a control group of 400 patients with younger donors (case-control 1:4 per chronology). RESULTS The BC rate in the group of patients transplanted with organs from elderly donors was 18%, compared to 21.5% in the control group. Specifically, in the immediate post-transplantation period, 14% of the elderly donor group and 13.8% of the control group presented some BCs, with no statistically significant differences in the incidence, type, and treatment of BCs between the two groups. The occurrence of BCs was not a factor associated with graft and patient survival rates. In the global population, donor death by cerebral vascular accident and male donors have influenced the occurrence of BCs. CONCLUSIONS The advanced age of the donor has not influenced BC rates after transplantation.
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Affiliation(s)
- M R González-Sánchez
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain.
| | - P A Cascales-Campos
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - J J López-Espín
- Operation Research Institute, University of Miguel Hernández, Elche, Spain
| | - B Febrero
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - J A Pons
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - A Vargas Acosta
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - J Ros
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - F Sánchez-Bueno
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - R Robles
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - L Sáenz
- Clinical Analysis Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - P Ramírez
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
| | - P Parilla
- Transplant Unit, General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas (IMIB), Murcia, Spain
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