Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 14, 2017; 23(22): 4064-4071
Published online Jun 14, 2017. doi: 10.3748/wjg.v23.i22.4064
Single-operator cholangioscopy for biliary complications in liver transplant recipients
Anna Hüsing-Kabar, Hauke Sebastian Heinzow, Hartmut Hans-Jürgen Schmidt, Carina Stenger, Hans Ulrich Gerth, Michele Pohlen, Gerold Thölking, Christian Wilms, Iyad Kabar
Anna Hüsing-Kabar, Hauke Sebastian Heinzow, Hartmut Hans-Jürgen Schmidt, Carina Stenger, Christian Wilms, Iyad Kabar, Department of Transplant Medicine, University Hospital Muenster, 48149 Muenster, Germany
Hans Ulrich Gerth, Gerold Thölking, Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Muenster, 48149 Muenster, Germany
Michele Pohlen, Department of Medicine A, Hematology and Oncology, University Hospital Muenster, 48149 Muenster, Germany
Author contributions: Hüsing-Kabar A, Heinzow HS and Kabar I designed the study; Hüsing-Kabar A, Heinzow HS and Kabar I performed the study; Hüsing-Kabar A, Heinzow HS, Stenger C, Wilms C and Kabar I collected the patients’ data; Hüsing-Kabar A, Heinzow HS, Schmidt HHJ, Stenger C, Gerth HU, Pohlen M, Thölking G, Wilms C and Kabar I analyzed the data; Hüsing-Kabar A, Heinzow HS, Schmidt HHJ, Gerth HU, Pohlen M, Thölking G and Kabar I wrote the manuscript; Hüsing-Kabar A and Heinzow HS contributed equally to this work and are co-first-authors.
Supported by Hüsing-Kabar A from the Dean’s Office of the Medical Faculty of the Westfälische-Wilhelms-University of Muenster.
Institutional review board statement: This observational study was approved by the Institution Review Board.
Informed consent statement: All patients gave written informed consent prior to intervention.
Conflict-of-interest statement: Hüsing-Kabar A received funding from the Dean’s Office of the Medical Faculty of the Westfälische-Wilhelms-University of Muenster. None of the other authors have conflicts of interest related to the subject of this manuscript.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Iyad Kabar, MD, Department of Transplant Medicine, University Hospital Muenster, Albert-Schweitzer-Campus 1, Gebäude A14, 48149 Muenster, Germany. iyad.kabar@ukmuenster.de
Telephone: +49-251-8344957 Fax: +49-251-8357771
Received: February 13, 2017
Peer-review started: February 14, 2017
First decision: March 3, 2017
Revised: March 20, 2017
Accepted: April 21, 2017
Article in press: April 21, 2017
Published online: June 14, 2017
Processing time: 120 Days and 13.6 Hours
Abstract
AIM

To evaluate cholangioscopy in addition to endoscopic retrograde cholangiopancreatography (ERCP) for management of biliary complications after liver transplantation (LT).

METHODS

Twenty-six LT recipients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between April and December 2016 at the university hospital of Muenster were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis and bile was collected during the intervention for microbial analysis and for antibiotic susceptibility testing.

RESULTS

Thirty-three biliary complications were found in a total of 22 patients, whereas four patients showed normal bile ducts. Anastomotic strictures were evident in 14 (53.8%) patients, non-anastomotic strictures in seven (26.9%), biliary cast in three (11.5%), and stones in six (23.1%). A benefit of cholangioscopy was seen in 12 (46.2%) patients. In four of them, cholangioscopy was crucial for selective guidewire placement prior to planned intervention. In six patients, biliary cast and/or stones failed to be diagnosed by ERCP and were only detectable through cholangioscopy. In one case, a bile duct ulcer due to fungal infection was diagnosed by cholangioscopy. In another case, signs of bile duct inflammation caused by acute cholangitis were evident. One patient developed post-interventional cholangitis. No further procedure-related complications occurred. Thirty-seven isolates were found in bile. Sixteen of these were gram-positive (43.2%), 12 (32.4%) were gram-negative bacteria, and Candida species accounted for 24.3% of all isolated microorganisms. Interestingly, only 48.6% of specimens were sensitive to prophylactic antibiotics.

CONCLUSION

Single-operator cholangioscopy can provide important diagnostic information, helping endoscopists to plan and perform interventional procedures in LT-related biliary complications.

Keywords: Cholangioscopy; Endoscopic retrograde cholangiopancreatography; Liver transplantation; Biliary complications; Biliary strictures

Core tip: Biliary complications represent a leading cause of morbidity and mortality in liver transplant recipients. To date, endoscopic retrograde cholangiopancreatography still remains the gold standard for diagnosing and treating such complications. The present study examined the benefit of complementary single-operator cholangioscopy. Our results are encouraging and demonstrate strong evidence for a diagnostic and therapeutic advantage of additional cholangioscopy for management of biliary disorders following liver transplantation.