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Mouchli MA, Osman MK, Busebee B, Taner T, Heimbach JK, Eaton J, Mousa O, Cole K, Watt KD. Long-term (15 y) complications and outcomes after liver transplantation for primary sclerosing cholangitis: Impact of donor and recipient factors. Liver Transpl 2024:01445473-990000000-00502. [PMID: 39451100 DOI: 10.1097/lvt.0000000000000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 10/11/2024] [Indexed: 10/26/2024]
Abstract
With longer survival of patients with primary sclerosing cholangitis (PSC) undergoing liver transplantation (LT), the frequency and risk factors associated with vascular and biliary complications in the allograft and the impact on long-term outcomes are poorly understood. To assess frequency and risk factors for long-term outcomes in patients after LT for PSC. All recipients of LT for advanced stage PSC for a non-cholangiocarcinoma indication from 1984 to 2012, with follow-up through March 2022 (>10+ y follow-up), were identified. One-, 5-, and 10-year cumulative risks of complications were estimated using the Aalen-Johansen method, where death was considered a competing risk. Two hundred ninety-three patients (mean age, 47.3 ± 12 y) formed our study cohort. One hundred and thirty-four patients received LT before 1995, and 159 were transplanted after 1995. Over a median (IQR) follow-up of 15.0 (10.3-22.1) years, LT was complicated by hepatic artery thrombosis (N = 30), portal vein stenosis/thrombosis (N = 48), biliary leak (N = 47), biliary strictures (N = 87), recurrent PSC (N=107), and graft failure (N=70). The 1-, 5-, 10-, and 15-year cumulative incidence of recurrent PSC was 1.0%, 8.0%, 23.5%, and 34.3%, respectively. The type of donor and older donor age were associated with an increased risk of biliary strictures. Donor age >60 years was associated with an increased risk of recurrent PSC. Long-term patient and graft survival have not changed significantly for patients transplanted for PSC. Controlling transplant-related factors, such as donor age, prompt identification of vascular and biliary complications early, and long-term rigorous follow-up, is recommended to continue to improve on these outcomes.
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Affiliation(s)
- Mohamad A Mouchli
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Fisher Titus Medical Center, Norwalk, Ohio, USA
| | - Mohamed K Osman
- Division of Gastroenterology, Department of Internal Medicine, Columbia University Irving Medical Center, New York, USA
| | - Bradley Busebee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Timucin Taner
- Department of Surgery, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie K Heimbach
- Department of Surgery, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - John Eaton
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Surgery, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Mousa
- Department of Surgery, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic Health System, Mankato, Minnesota, USA
| | - Kristin Cole
- Division of Biomedical Statistics and Informatics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Surgery, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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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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3
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Mishra S, Taneja S. Algorithmic Approach to Deranged Liver Functions After Transplantation. J Clin Exp Hepatol 2024; 14:101317. [PMID: 38264576 PMCID: PMC10801315 DOI: 10.1016/j.jceh.2023.101317] [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: 08/06/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector 22, Panchkula, Haryana 134109, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Harputluoglu M, Calgin MZ, Ataman E, Tikici D, Kutluturk K, Kutlu R, Efe CS, Yilmaz S. Outcomes of patients with primary sclerosing cholangitis after liver transplantation in a predominantly living donor liver transplant center. JOURNAL OF LIVER TRANSPLANTATION 2023; 12:100186. [DOI: 10.1016/j.liver.2023.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2025] Open
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Taniai T, Furukawa K, Haruki K, Yanagaki M, Hamura R, Akaoka M, Tsunematsu M, Onda S, Shirai Y, Uwagawa T, Ikegami T. Multimodal Management for Refractory Biliary Stricture After Living Donor Liver Transplantation. Transplant Proc 2023:S0041-1345(23)00249-X. [PMID: 37105831 DOI: 10.1016/j.transproceed.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/18/2023] [Accepted: 04/01/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Biliary stricture is a common complication of living donor liver transplantation (LDLT). Endoscopic retrograde biliary drainage (ERBD) is the primary treatment of biliary stricture, which is sometimes refractory. This study aimed to evaluate the risk factors for biliary stricture after LDLT and present successful management for refractory biliary stricture. METHODS Data from 26 patients who underwent LDLT were retrospectively analyzed. The relationship between the incidence of biliary strictures and clinical variables, including pre/intra/postoperative factors, was assessed. RESULTS Univariate analysis showed that ABO incompatibility (P = .037) was a significant risk factor for biliary strictures. Case 1 was a 57-year-old woman who underwent LDLT using a left-lobe graft for primary biliary cholangitis (PBC) and developed a biliary stricture 1 month after surgery. Percutaneous transhepatic cholangiodrainage (PTCD) and embolization of the portal vein and hepatic artery were performed. Thereafter, ethanol was injected into the biliary duct, and the intervention was successfully completed. Case 2 was a 54-year-old woman who underwent LDLT using a right-lobe graft and duct-to-duct biliary reconstruction for PBC. Internal plastic stent insertion by ERBD was unsuccessful due to the significantly bending bile duct. After PTCD, the gun-site technique for the posterior branch and dual hepatic vascular embolization of the anterior branch was performed. The patient was followed up without an external fistula tube. CONCLUSION ABO incompatibility was a risk factor for refractory biliary stricture. Appropriate procedures should be chosen based on stricture types.
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Affiliation(s)
- Tomohiko Taniai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuru Yanagaki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoga Hamura
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Munetoshi Akaoka
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Uwagawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Khot R, Morgan MA, Nair RT, Ludwig DR, Arif-Tiwari H, Bhati CS, Itani M. Radiologic findings of biliary complications post liver transplantation. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:166-185. [PMID: 36289069 DOI: 10.1007/s00261-022-03714-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/08/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
Liver transplantation is a potentially curative treatment for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy. Despite tremendous advancements in surgical techniques and immunosuppressive management, there remains a high rate of post-transplant complications, with one of the main complications being biliary complications. In addition to anastomotic leak and stricture, numerous additional biliary complications are encountered, including ischemic cholangiopathy due to the sole arterial supply of the bile ducts, recurrence of primary biliary disease, infections, biliary obstruction from stones, cast, or hemobilia, and less commonly cystic duct remnant mucocele, vanishing duct syndrome, duct discrepancy and kinking, post-transplant lymphoproliferative disorder, retained stent, and ampullary dysfunction. This article presents an overview of biliary anatomy and surgical techniques in liver transplantation, followed by a detailed review of post-transplant biliary complications with their corresponding imaging findings on multiple modalities with emphasis on magnetic resonance imaging and MR cholangiopancreatography.
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Affiliation(s)
- Rachita Khot
- Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.
| | - Matthew A Morgan
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Rashmi T Nair
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Hina Arif-Tiwari
- Department of Medical Imaging, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Chandra S Bhati
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Malak Itani
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, 63110, USA
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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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8
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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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Recent Advances in Pancreato-Biliary Endoscopic Intervention: How to Resolve Unmet Needs in Pancreato-Biliary Diseases Endoscopically. J Clin Med 2022; 11:jcm11133637. [PMID: 35806922 PMCID: PMC9267574 DOI: 10.3390/jcm11133637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
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10
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Eslami O, Moazzami B, Zabala ZE, Roushan N, Dashti H, Fakhar N, Saberi H, Jafarian A, Toosi MN. Anastomotic biliary stricture following liver transplantation and management analysis: 15 years of experience at a high-volume transplant center. Indian J Gastroenterol 2022; 41:231-239. [PMID: 35838868 DOI: 10.1007/s12664-022-01245-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/18/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The occurrence of anastomotic biliary stricture (BS) remains an essential issue following liver transplantation (LT). The present study aimed to compare our findings regarding the incidence of anastomotic BS to what is known. METHODS The present study is a single-center, retrospective cohort study of a total number of 717 consecutive patients (426 men and 291 women) who had undergone LT from January 2001 to March 2016. Multivariable Cox regression analysis was conducted to evaluate the risk factors associated with anastomotic BS development. RESULTS Post-transplant anastomotic BS developed in 70 patients (9.8%). In the Cox multivariate analysis (a stepwise forward conditional method), factors including biliary leak (hazard ratio [HR]: 6.61, 95% confidence interval [CI]: 3.08-17.58, p < 0.001), hepatic artery thrombosis (HR: 2.29, 95% CI: 1.03-5.88; p = 0.003), and acute rejection (HR: 2.18, 95% CI: 1.16-3.37; p = 0.006) were identified as independent risk factors for the development of anastomotic BS. Surgery in 6 cases (66.7%), followed by endoscopic retrograde cholangiopancreatography (ECRP) with a metal stent in 18 cases (62.1%), percutaneous transhepatic biliary drainage in 9 (20.9%), and ERCP with a single plastic stent in 8 (18.2%), had the highest effectiveness rates in the management of BS, respectively. CONCLUSIONS Risk factors including biliary leak, hepatic artery thrombosis, and acute rejection were independently associated with an anastomotic BS. ERCP with a metal stent may be considered as an effective treatment procedure with a relatively low complication rate in the management of benign post-LT anastomotic BS.
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Affiliation(s)
- Omid Eslami
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Gastroenterology and Hepatology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Bobak Moazzami
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA.
| | - Zohyra E Zabala
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Nader Roushan
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Habibollah Dashti
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasir Fakhar
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hazhir Saberi
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Jafarian
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohssen Nassiri Toosi
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Liver Transplantation, Imam Khomeini Hospital, Tehran University of Medical Science, Keshavarz Blvd, Tehran, Iran.
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Yu JF, Zhang DL, Wang YB, Hao JY. Digital single-operator cholangioscopy for biliary stricture after cadaveric liver transplantation. World J Gastrointest Oncol 2022; 14:1037-1049. [PMID: 35646282 PMCID: PMC9124986 DOI: 10.4251/wjgo.v14.i5.1037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/08/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Biliary strictures after liver transplantation (LT) remain clinically arduous and challenging situations, and endoscopic retrograde cholangiopancreatography (ERCP) has been considered as the gold standard for the management of biliary strictures after LT. Nevertheless, in the treatment of biliary strictures after LT with ERCP, many studies show that there is a large variation in diagnostic accuracy and therapeutic success rate. Digital single-operator peroral cholangioscopy (DSOC) is considered a valuable diagnostic modality for indeterminate biliary strictures.
AIM To evaluate DSOC in addition to ERCP for management of biliary strictures after LT.
METHODS Nineteen patients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between March 2019 and March 2020 at Beijing Chaoyang Hospital, Capital Medical University, 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. Biliary strictures after LT were classified according to the manifestations of choledochoscopic strictures and the manifestations of transplanted hepatobiliary ducts.
RESULTS Twenty-one biliary strictures were found in a total of 19 patients, among which anastomotic strictures were evident in 18 (94.7%) patients, while non-anastomotic strictures in 2 (10.5%), and space-occupying lesions in 1 (5.3%). Stones were found in 11 (57.9%) and loose sutures in 8 (42.1%). A benefit of cholangioscopy was seen in 15 (78.9%) patients. Cholangioscopy was crucial for selective guidewire placement prior to planned intervention in 4 patients. It was instrumental in identifying biliary stone and/or loose sutures in 9 patients in whom ERCP failed. It also provided a direct vision for laser lithotripsy. A space-occupying lesion in the bile duct was diagnosed by cholangioscopy in one patient. Patients with biliary stricture after LT displayed four types: (A) mild inflammatory change (n = 9); (B) acute inflammatory change edema, ulceration, and sloughing (n = 3); (C) chronic inflammatory change; and (D) acute suppurative change. Complications were seen in three patients with post-interventional cholangitis and another three with hyperamylasemia.
CONCLUSION DSOC can provide important diagnostic information, helping plan and perform interventional procedures in LT-related biliary strictures.
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Affiliation(s)
- Jian-Feng Yu
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Dong-Lei Zhang
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yan-Bin Wang
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jian-Yu Hao
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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12
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Fasullo M, Patel M, Khanna L, Shah T. Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000778. [PMID: 35552193 PMCID: PMC9109012 DOI: 10.1136/bmjgast-2021-000778] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease. Long-term survival is excellent, yet LT recipients are at risk of significant complications. Biliary complications are an important source of morbidity after LT, with an estimated incidence of 5%-32%. Post-LT biliary complications include strictures (anastomotic and non-anastomotic), bile leaks, stones, and sphincter of Oddi dysfunction. Prompt recognition and management is critical as these complications are associated with mortality rates up to 20% and retransplantation rates up to 13%. This review aims to summarise our current understanding of risk factors, natural history, diagnostic testing, and treatment options for post-transplant biliary complications.
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Affiliation(s)
- Matthew Fasullo
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Milan Patel
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lauren Khanna
- Gastroenterology, New York University Medical Center, New York, New York, USA
| | - Tilak Shah
- Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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13
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Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease with excellent long-term survival; however, LT recipients are at risk of significant complications. Among these complications are biliary complications with an incidence ranging from 5 to 32% and associated with significant post-LT morbidity and mortality. Prompt recognition and management are critical as these complications have been associated with mortality rates up to 19% and retransplantation rates up to 13%. An important limitation of published studies is that a large proportion does not discriminate between anastomotic strictures and nonanastomotic strictures. This review aims to summarize our current understanding of risk factors and natural history, diagnostic testing, and treatment options for post-LT biliary strictures.
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Affiliation(s)
- Matthew Fasullo
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Tilak Shah
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Huiping Zhou
- Department of Microbiology and Immunology, VCU and McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mohammad S Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia
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14
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Parlak E, Simsek C, Koksal AS, Eminler AT, Unal E, Ciftci TT, Akinci D, Yilmaz S. The Classification of Biliary Strictures in Patients With Right-Lobe Liver Transplant Recipients and Its Relation to Traversing the Stricture With a Guidewire. Transplantation 2022; 106:328-336. [PMID: 33724243 DOI: 10.1097/tp.0000000000003738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traversing the stricture with a guidewire is a prerequisite for the endoscopic treatment of biliary strictures after living donor liver transplantation. We aimed to evaluate the effect of variations in the biliary anastomosis and strictures on the success of endoscopic treatment and suggest a cholangiographic classification. METHODS The 125 strictures among the 104 patients with right-lobe living donor liver transplantation were reviewed. The strictures were classified by the anastomosis pattern according to the number (1, 2, or >2), location (common bile, hepatic, or cystic duct), the angle between the proximal and distal sites of the anastomosis, and the contrast enhancement pattern. The relationship between the success rate of traversing the anastomosis and the classification was evaluated. RESULTS Of the 125 biliary strictures, 86 (68.8%) could be passed via endoscopically. Thirty-three strictures were managed either percutaneously (n = 13) or by magnetic compression anastomosis (n = 20). Compared with the round, the triangular (odds ratio [OR], 6.5), the intermediate form (OR, 17.7), and the end-to-side anastomosis (OR, 5.1) were associated with an increased chance of traversing. The contrast enhancement pattern of the strictures and the bile ducts was also related to the successful rate of the endoscopic treatment (P < 0.001). The success rate was higher in the patients with the angle between the proximal and distal sites of the anastomosis approximated was small (0°-30° = 74%, 30°-60° = 69%, 60°-90° = 63%, >90° = 41%). CONCLUSIONS The type of biliary anastomoses and stricture affect the success rate of endoscopic treatment. These data may play role in making decision about the type of anastomosis during the surgery.
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Affiliation(s)
- Erkan Parlak
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Cem Simsek
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Aydin Seref Koksal
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Emre Unal
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Turkmen Turan Ciftci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Devrim Akinci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sezai Yilmaz
- Department of Surgery, Faculty of Medicine, Liver Transplant Institute, Inonu University, Malatya, Turkey
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15
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Kwon CI, Choi SH, Kim KS, Moon JP, Park S, Jeon J, Kim G, Jang JY, Sung MJ, Ko KH, Son JS. Preventive effect of biodegradable stents on biliary stricture and fibrosis after biliary anastomosis in a porcine model. Ann Surg Treat Res 2022; 102:90-99. [PMID: 35198512 PMCID: PMC8831087 DOI: 10.4174/astr.2022.102.2.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/29/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The current drain tubes for preventing surgically biliary anastomotic stricture are not naturally and easily removed. If a drain tube using biodegradable material is easily available and the degradation time of the tube is well controlled, surgical anastomotic stricture and fibrosis could be prevented. The aim of this animal study was to evaluate the preventive effect of novel biodegradable stents (BS) on biliary stricture and fibrosis after duct-to-duct (DD) biliary anastomosis. Methods Ten mini-pigs were allocated to the control group (n = 5) and or the stent group (n = 5). The common bile duct was exposed through surgical laparotomy and then resected transversely. In the stent group, a 4-mm or 6-mm polydioxanone/magnesium sheath-core BS was inserted according to the width of the bile duct, followed by DD biliary anastomosis. In the control group, DD biliary anastomosis was performed without BS insertion. Results In the stent group, stents were observed without deformity for up to 4 weeks in all animals. Eight weeks later, histopathologic examination revealed that the common bile duct of the anastomosis site was relatively narrower in circumference in the control group compared to the stent group. The degree of fibrosis in the control group was more marked than in the stent group (3.84 mm vs. 0.68 mm, respectively; P < 0.05). Conclusion Our study showed that novel BS maintained their original shape and radial force for an adequate time and then disappeared without adverse events. The BS could prevent postoperative complications and strictures after DD biliary anastomosis.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kyu Seok Kim
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jong Pil Moon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Sehwan Park
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jinkyung Jeon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Young Jang
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Je Sung
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jun Sik Son
- Korea Textile Development Institute, Daegu, Korea
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16
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Shimatani M, Mitsuyama T, Tokuhara M, Masuda M, Miyamoto S, Ito T, Nakamaru K, Ikeura T, Takaoka M, Naganuma M, Okazaki K. Recent advances of endoscopic retrograde cholangiopancreatography using balloon assisted endoscopy for pancreaticobiliary diseases in patients with surgically altered anatomy: Therapeutic strategy and management of difficult cases. Dig Endosc 2021; 33:912-923. [PMID: 32981141 DOI: 10.1111/den.13848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 09/17/2020] [Indexed: 12/17/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic modality established for diagnosis and treatment of pancreaticobiliary diseases. However ERCP in patients with surgically altered anatomy (SAA) has been difficult, and more invasive therapies have been primarily selected. The development of balloon assisted endoscopes (BAEs) innovatively facilitated ERCP in such patients. Recent advances of BAEs and other devices greatly contributed to increasing success of ERCP using BAEs (BAE-ERCP). Furthermore, interventions using Endoscopic Ultrasound (EUS-intervention) have been reported to be useful for pancreaticobiliary diseases in patients with SAA, which provide more options for endoscopic therapies and are also expected as a rescue therapy for difficult cases of BAE-ERCP. In order to thoroughly complete endoscopic treatment for pancreaticobiliary diseases with SAA, it is important to standardize the BAE-ERCP procedures based on the features of respective endoscopes and to establish a strategy for endoscopic treatment which includes analysis of BAE-ERCP difficult cases and selection of cases for rescue therapy. In addition, it is essential to be acquainted with the characteristics of possible adverse events of the procedure and to be able to deal with them for safe accomplishment of endoscopic treatment.
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Affiliation(s)
- Masaaki Shimatani
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan.,Division of Gastroenterology and Hepatology, Kansai Medical University Medical Center, Osaka, Japan
| | - Toshiyuki Mitsuyama
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Mitsuo Tokuhara
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Masataka Masuda
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Sachi Miyamoto
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Takashi Ito
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Koh Nakamaru
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Tsukasa Ikeura
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Makoto Takaoka
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, The Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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17
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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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18
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Kogure H, Kato H, Kawakubo K, Ishiwatari H, Katanuma A, Okabe Y, Ueki T, Ban T, Hanada K, Sugimori K, Nakai Y, Isayama H. A Prospective Multicenter Study of "Inside Stents" for Biliary Stricture: Multicenter Evolving Inside Stent Registry (MEISteR). J Clin Med 2021; 10:jcm10132936. [PMID: 34208969 PMCID: PMC8268973 DOI: 10.3390/jcm10132936] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Endoscopic biliary stent placement is the standard of care for biliary strictures, but stents across the papilla are prone to duodenobiliary reflux, which can cause stent occlusion. Preliminary studies of “inside stents” placed above the papilla showed encouraging outcomes, but prospective data with a large cohort were not reported. Methods: This was a prospective multicenter registry of commercially available inside stents for benign and malignant biliary strictures. Primary endpoint was recurrent biliary obstruction (RBO). Secondary endpoints were technical success of stent placement and removal, adverse events, and stricture resolution. Results: A total of 209 inside stents were placed in 132 (51 benign and 81 malignant) cases with biliary strictures in 10 Japanese centers. During the follow-up period of 8.4 months, RBO was observed in 19% of benign strictures. The RBO rate was 49% in malignant strictures, with the median time to RBO of 4.7 months. Technical success rates of stent placement and removal were both 100%. The adverse event rate was 8%. Conclusion: This prospective multicenter study demonstrated that inside stents above the papilla were feasible in malignant and benign biliary strictures, but a randomized controlled trial is warranted to confirm its superiority to conventional stents across the papilla.
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Affiliation(s)
- Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (H.K.); (Y.N.)
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo 060-8648, Japan;
| | - Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, Sapporo Medical University School of Medicine, Sapporo 060-8543, Japan;
| | - Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo 006-0811, Japan;
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University of Medicine, Kurume 830-0011, Japan;
| | - Toru Ueki
- Department of Internal Medicine, Fukuyama City Hospital, Fukuyama 721-8511, Japan;
| | - Tesshin Ban
- Department of Gastroenterology, Nagoya Daini Red Cross Hospital, Nagoya 466-8650, Japan;
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi 722-8508, Japan;
| | - Kazuya Sugimori
- Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan;
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (H.K.); (Y.N.)
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (H.K.); (Y.N.)
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo 113-8431, Japan
- Correspondence: ; Tel.: +81-3-3813-3111; Fax: +81-3-3813-8862
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19
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The role of stent placement above the papilla (inside-stent) as a bridging therapy for perihilar biliary malignancy: an initial experience. Surg Today 2021; 51:1795-1804. [PMID: 33835263 DOI: 10.1007/s00595-021-02268-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/21/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Although endoscopic naso-biliary drainage (ENBD) is a popular preoperative biliary drainage (PBD) method for patients with perihilar biliary malignancy (PHBM), patient discomfort caused by the nasal tube remains a problem. This study aimed to analyze the safety and efficacy of PBD with the placement of a plastic stent above the papilla [inside-stent (IS)] as a bridging therapy. METHODS The outcomes of 78 patients with potentially resectable PHBM, of whom 29 underwent IS placement and 49 underwent ENBD were evaluated. RESULTS The stent-associated complication rates were not different between the two groups (7% in the IS group and 10% in the ENBD group, P = 0.621). Catheter dislocation occurred less frequently (0% vs. 22%, P = 0.016), and the median time to recurrent biliary obstruction was longer (not reached vs. 32 days, P = 0.039) in the IS group than in the ENBD group. Among the patients who underwent resection, their postoperative severe complication rates were not substantially different (26% vs. 25%, P = 0.923). CONCLUSION IS placement is a possible alternative to ENBD as a bridge to a definitive operation for patients with resectable PHBM and a prospective trial to prove its feasibility and safety is therefore warranted.
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20
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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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21
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Park JK, Yang JI, Lee JK, Park JK, Lee KH, Lee KT, Joh JW, Kwon CHD, Kim JM. Long-term Outcome of Endoscopic Retrograde Biliary Drainage of Biliary Stricture Following Living Donor Liver Transplantation. Gut Liver 2020; 14:125-134. [PMID: 30970446 PMCID: PMC6974332 DOI: 10.5009/gnl18387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.
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Affiliation(s)
- Jae Keun Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Il Yang
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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22
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Wang CK, Cheng YF, Chen CL, Ou HY. Imaging Diagnosis of Biliary Complications of ABO Incompatibility in Living Donor Liver Transplantation. Transplant Proc 2020; 52:1833-1837. [DOI: 10.1016/j.transproceed.2020.02.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/06/2020] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
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23
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Jang SI, Cho JH, Lee DK. Magnetic Compression Anastomosis for the Treatment of Post-Transplant Biliary Stricture. Clin Endosc 2020; 53:266-275. [PMID: 32506893 PMCID: PMC7280848 DOI: 10.5946/ce.2020.095] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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24
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Kim KS, Kim JM, Lee JS, Choi GS, Joh JW. Long-term Outcome of the Rendezvous Technique in Patients With Severe Biliary Anastomotic Stricture That Cannot Cannulate After Liver Transplant. Transplant Proc 2020; 52:1812-1817. [PMID: 32482445 DOI: 10.1016/j.transproceed.2020.02.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nearly all publications related to endoscopic treatment of biliary anastomotic stricture after liver transplant have reported cases that can be cannulated. However, very few publications discuss endoscopic treatment of biliary anastomotic stricture (BAS) in which the guide wire does not pass through the stricture site. The purpose of this article is to analyze the long-term outcome of the Rendezvous technique in severe strictures through which guide wires cannot cannulate. METHODS Between 2010 and 2017, a total of 29 patients who underwent Rendezvous technique because of severe BAS after liver transplant were included in the study. RESULTS Twenty-nine patients who underwent the Rendezvous technique showed a 100% technical success rate. Ten patients (34.4%) required stent removal; the mean stenting period was 14.9 (SD, 5.6) months (range, 6.65-24.14 months). A total of 19 patients were maintained without stent removal; the stent-maintaining period was 13.1 (SD, 8.4) months (range, 3.48-38.61 months). Two patients receiving left lobe grafts maintained the stents for 27.1 (SD, 16.2) months. In left lobe graft, the duct anastomosis position moves to the right posteroinferior side of the patient. CONCLUSIONS Our results suggest that the stenting period of the Rendezvous technique was longer in severe BAS than in cannulated endoscopic retrograde cholangiopancreatography cases. Especially in the left liver, the position of the duct anastomosis changed to the right posteroinferior of the patient. Thus, the donor duct and the recipient duct are angulated, kinking worsens, and the stenting period becomes longer.
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Affiliation(s)
- Kyeong Sik Kim
- Department of Surgery, Soon Chun Hyang University Seoul Hospital, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery-Transplantation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Ji Soo Lee
- Department of Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Gyu Sung Choi
- Department of Surgery-Transplantation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Won Joh
- Department of Surgery-Transplantation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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25
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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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26
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Wong MY, Saxena P, Kaffes AJ. Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options. Diagnostics (Basel) 2020; 10:diagnostics10040221. [PMID: 32326542 PMCID: PMC7235774 DOI: 10.3390/diagnostics10040221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/02/2020] [Accepted: 04/14/2020] [Indexed: 01/18/2023] Open
Abstract
Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures.
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Affiliation(s)
- May Y.W. Wong
- Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia; (M.Y.W.W.); (P.S.)
| | - Payal Saxena
- Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia; (M.Y.W.W.); (P.S.)
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, Australia
- Department of Medicine, University of Sydney, Camperdown 2050, Australia
| | - Arthur J. Kaffes
- Interventional Endoscopy, Chris O Brien Lifehouse, Missenden Road, Camperdown 2050, Australia; (M.Y.W.W.); (P.S.)
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Missenden Road, Camperdown 2050, Australia
- Department of Medicine, University of Sydney, Camperdown 2050, Australia
- Correspondence:
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27
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Mukund A, Choudhury A, Das S, Pamecha V, Sarin SK. Salvage PTBD in post living donor liver transplant patients with biliary complications-a single centre retrospective study. Br J Radiol 2020; 93:20191046. [PMID: 31971831 DOI: 10.1259/bjr.20191046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To study the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in complex and technically challenging post-liver transplant (LT) biliary complications and analyse the reason for failure of endoscopic retrograde cholangiopancreatography (ERCP). METHODS AND MATERIALS Hospital data were searched for all LT patients with biliary complications requiring salvage PTBD (upon failure of ERCP) from January 2010 to May 2017. Patients who underwent primary PTBD were excluded. Patients clinical and biochemical parameters were analysed for clinical, biochemical and imaging response, stent-free survival and the reason for ERCP failure. RESULTS Salvage PTBD was performed in 32 patients with post-LT biliary stricture/bile leak presenting with deranged liver function in 12 (37.5%), cholangitis in 12 (37.5%) and cholangitis with cholangitic abscess in remaining 8 (25%) patients. Of 32 patients, 20 (62.5%) already had plastic biliary stent placed by ERCP, while in remaining (n = 12, 37.5%) a wire could not be negotiated across stricture by ERCP. These patients were found to have long/tortuous stricture (n = 18, 56.3%) and multiple duct disconnection at anastomosis (n = 14, 43.7%). Immediate as well as sustained (persisting for a year or more) clinical and biochemical improvement was seen in 26 (81.3%) patients, while failure of resolution of sepsis and death occurred in remaining 6 (18.8%). CONCLUSION Salvage PTBD is an effective treatment in difficult-to-treat post-LT biliary strictures with deranged liver functions with or without cholangitis/cholangitic abscess. It can reduce graft loss with improved clinical outcome. Post-LT ductal anatomy at anastomosis is important to decide the appropriate approach (ERCP/PTBD). ADVANCES IN KNOWLEDGE (1). PTBD as a salvage procedure in difficult anatomy or upon failure of ERCP-based intervention is effective and a good alternative strategy. (2). Postoperative surgical anatomy (type & length of stricture, number of ductanastomosis, location and graft-recipient duct alignment) is the key factor indeciding the appropriate therapeutic procedure.
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Affiliation(s)
- Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Swati Das
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobiliary Pancreatic surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
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28
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Kim YM, Chung TR, Lee DK. High-Level Biliary Strictures After Living-Donor Liver Transplantation. ADVANCED ERCP FOR COMPLICATED AND REFRACTORY BILIARY AND PANCREATIC DISEASES 2020:1-16. [DOI: 10.1007/978-981-13-0608-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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29
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Creation of a Robotically Assisted Terminal Jejunogastrostomy Is Safe and Effective in Regaining Antegrade Enteral Bile Duct Access After Live Donor Liver Transplant With Roux Limb. Transplant Direct 2019; 5:e476. [PMID: 31576372 PMCID: PMC6708632 DOI: 10.1097/txd.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 11/26/2022] Open
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30
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Sato T, Kogure H, Nakai Y, Hamada T, Takahara N, Mizuno S, Kawaguchi Y, Akamatsu N, Kaneko J, Hasegawa K, Tada M, Tsujino T, Isayama H, Koike K. Long-term outcomes of endoscopic treatment for duct-to-duct anastomotic strictures after living donor liver transplantation. Liver Int 2019; 39:1954-1963. [PMID: 31436017 DOI: 10.1111/liv.14219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The anastomotic biliary stricture is a clinically important complication after living donor liver transplantation (LDLT) with a duct-to-duct anastomosis. Although endoscopic management of post-LDLT biliary strictures using balloon dilation (BD) and plastic stents (PSs) has provided acceptable short-term outcomes, long-term outcomes and prognostic factors for treatment success remain unclear. METHODS We included 96 patients with post-LDLT biliary strictures who were endoscopically managed between 2003 and 2016. BD was utilized as a first-line treatment strategy, and PS placement was carried out for refractory cases. Potential prognostic factors for biliary stricture resolution were analysed using logistic regression analyses. RESULTS Endoscopic treatment was technically successful in 84 patients (87.5%). The overall rate of biliary stricture resolution was 44.8% (43 of 96 patients) with a median follow-up duration of 90.9 months (interquartile range, 30.9-122.3 months). Bile duct kinking was associated with a lower rate of biliary stricture resolution (odds ratio, 0.33; 95% confidence interval, 0.13-0.87). After successful endoscopic treatment, biliary strictures recurred in 22 patients (57.9%) after BD, and in one patient (4%) after PS treatment. CONCLUSIONS Despite a high technical success rate, endoscopic treatment only provided a low rate of resolution of anastomotic biliary strictures among LDLT patients and required prolonged treatment duration. Alternative strategies including the use of a covered metal stent should be evaluated to further improve the treatment outcomes of post-LDLT biliary strictures, particularly in those accompanied by the bile duct kinking.
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Affiliation(s)
- Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Miyuki clinic, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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31
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Menon S, Holt A. Large-duct cholangiopathies: aetiology, diagnosis and treatment. Frontline Gastroenterol 2019; 10:284-291. [PMID: 31288256 PMCID: PMC6583582 DOI: 10.1136/flgastro-2018-101098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/06/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Cholangiopathies describe a group of conditions affecting the intrahepatic and extrahepatic biliary tree. Impairment to bile flow and chronic cholestasis cause biliary inflammation, which leads to more permanent damage such as destruction of the small bile ducts (ductopaenia) and biliary cirrhosis. Most cholangiopathies are progressive and cause end-stage liver disease unless the physical obstruction to biliary flow can be reversed. This review considers large-duct cholangiopathies, such as primary sclerosing cholangitis, ischaemic cholangiopathy, portal biliopathy, recurrent pyogenic cholangitis and Caroli disease.
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Affiliation(s)
- Shyam Menon
- Department of Hepatology and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Department of Gastroenterology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Andrew Holt
- Department of Hepatology and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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32
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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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33
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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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34
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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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35
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Jang SI, Lee DK. Anastomotic stricture after liver transplantation: It is not Achilles' heel anymore! INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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36
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Chantarojanasiri T, Kogure H, Hamada T, Nakai Y, Isayama H. Usefulness of stent placement above the papilla, so-called, 'inside stent'. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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37
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Rao HB, Prakash A, Sudhindran S, Venu RP. Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions. World J Gastroenterol 2018; 24:2061-2072. [PMID: 29785075 PMCID: PMC5960812 DOI: 10.3748/wjg.v24.i19.2061] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/28/2018] [Accepted: 05/11/2018] [Indexed: 02/06/2023] Open
Abstract
Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.
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Affiliation(s)
- Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Arjun Prakash
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Surendran Sudhindran
- Department of Transplant and Vascular Surgery, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
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Fang C, Yan S, Zheng S. Bile Leakage after Liver Transplantation. Open Med (Wars) 2017; 12:424-429. [PMID: 29318188 PMCID: PMC5757350 DOI: 10.1515/med-2017-0062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 10/18/2017] [Indexed: 12/12/2022] Open
Abstract
Objective To evaluate the risk factors and outcome of bile leak after liver transplantation. Methods We undertook a retrospective study of patients who underwent liver transplantation in our institution between January 2010 and January 2014. The characteristics and survival rate of patients with or without bile leak were compared. Results Bile leak was observed in sixteen patients after liver transplantation (2.7% of the total number of patients transplanted). Total operating time and bile duct reconstruction technique (duct-to-duct anastomosis or Rouxen-Y cholangiojejunostomy) were found to differ significantly between patients with and without bile leak in univariate (p = 0.001 and 0.024, respectively) and multivariate analyses (p = 0.012 and 0.026, respectively). There was no difference in the one-year patient survival rate between the two groups. However, two-year patient survival rate was significantly lower in the bile leak group (p = 0.003). Both one-year and two-year graft survival rates were significantly lower in the bile leak group (p = 0.049 and <0.001, respectively). Conclusions Cholangiojejunostomy and prolonged total operating time are risk factors for bile leak after deceased donor liver transplantation. Bile leak reduces graft and patient survival rates after deceased donor liver transplantation.
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Affiliation(s)
- Cheng Fang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine. No.79 Qingchun Road, Hangzhou, Zhejiang Province, China, Tel: 86-571-87236570
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Thornburg B, Katariya N, Riaz A, Desai K, Hickey R, Lewandowski R, Salem R. Interventional radiology in the management of the liver transplant patient. Liver Transpl 2017; 23:1328-1341. [PMID: 28741309 DOI: 10.1002/lt.24828] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) is commonly used to treat patients with end-stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328-1341 2017 AASLD.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Nitin Katariya
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Robert Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL.,Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
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Woo YS, Lee KH, Lee KT, Lee JK, Kim JM, Kwon CHD, Joh JW, Kang D, Cho J. Postoperative changes of liver enzymes can distinguish between biliary stricture and graft rejection after living donor liver transplantation: A longitudinal study. Medicine (Baltimore) 2017; 96:e6892. [PMID: 28984750 PMCID: PMC5737986 DOI: 10.1097/md.0000000000006892] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is no known useful clinical parameter that can specifically predict a biliary stricture and differentiate it from other related complications after living donor liver transplantations (LDLT). The aims of this study were to determine whether the changes of liver enzymes can predict postoperative biliary stricture apart from other complications. We reviewed the medical records of 203 patients who underwent LDLT with duct to duct anastomosis from 2008 to 2010. The longitudinal changes of liver enzyme over time and the occurrence of complication were evaluated. A total of 124 patients had no complication up to 2 years after LDLT, and 74 patients had complications including biliary stricture and graft rejection. Complications developed more frequently in patients who's alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) did not return to the baseline plateau at 30 days after LDLT (ALP; P = .045, GGT; P = .047). Aspartate transaminase (AST) and alanine transaminase (ALT) increased continuously until the diagnosis of complication in both stricture and rejection groups with more rapid increase in enzymes in the rejection versus stricture group (P < .05). In addition, AST and ALT were 2-fold higher in the rejection than the stricture group at the diagnosis of each complication (AST; P < .05, ALT; P < .05). The increasing slope and final levels of AST and ALT are potentially helpful parameters to differentiate rejection and stricture, the 2 most common posttransplantation complications.
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Affiliation(s)
- Young Sik Woo
- Department of Interanl Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine
| | - Kwang Hyuck Lee
- Department of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | | | | | | | | | | | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Departments of Epidemiology and Social, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, USA
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Azzam AZ, Tanaka K. Biliary complications after living donor liver transplantation: A retrospective analysis of the Kyoto experience 1999-2004. Indian J Gastroenterol 2017; 36:296-304. [PMID: 28744748 DOI: 10.1007/s12664-017-0771-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 07/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM In living donor liver transplantation (LDLT), biliary complications continue to be the most frequent cause of morbidity and may contribute to mortality of recipients although there are advances in surgical techniques. This study will evaluate retrospectively the short-term and long-term management of biliary complications. METHODS During the period from May 1999, to May 2004, 505 patients underwent 518 LDLT in the Department of Liver Transplantation and Immunology, Kyoto University Hospital, Japan. The data was collected and analyzed retrospectively. RESULTS The recipients were 261 males (50.4%) and 257 females (49.6%). Biliary complications were reported in 202/518 patients (39.0%), included; biliary leakage in 79/518 (15.4%) patients, leakage followed by biloma in 13/518 (2.5%) patients, leakage followed by stricture in 9/518 (1.8%) patients, and biliary strictures in 101/518 (19.3%) patients. Proper management of the biliary complications resulted in a significant (p value 0.002) success rate of 96.5% compared to the failure rate which was 3.5%. CONCLUSION Careful preoperative evaluation and the proper intraoperative techniques in biliary reconstruction decrease biliary complications. Early diagnosis and proper management of biliary complications can decrease their effect on both the patient and the graft survival over the long period of follow up.
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Affiliation(s)
- Ayman Zaki Azzam
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Koichi Tanaka
- Kobe International Frontier, Medical Center Medical Corporation, Kobe, Japan
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Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017; 10:297-311. [PMID: 28600688 DOI: 10.1007/s12328-017-0754-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.
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Affiliation(s)
- Takeshi Tsujino
- Miyuki Clinic, 1-8-3 Renko-ji, Tama, Tokyo, 2060021, Japan.
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Rao HB, Ahamed H, Panicker S, Sudhindran S, Venu RP. Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome. World J Gastrointest Pathophysiol 2017; 8:77-86. [PMID: 28573070 PMCID: PMC5437505 DOI: 10.4291/wjgp.v8.i2.77] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/23/2017] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To identify factors predicting outcome of endoscopic therapy in bile duct strictures (BDS) post living donor liver transplantation (LDLT).
METHODS Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms (Pruritus, Jaundice, cholangitis), intra-op variables (cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis (HAT), bile leak, infections], stricture morphology (length, donor and recipient duct diameters) and relevant laboratory data both pre- and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0.
RESULTS Forty-one patients were included (age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients (48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy (multiple endoscopic retrograde cholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome (P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak (> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis (P < 0.05).
CONCLUSION Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.
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Kırnap M, Ayvazoğlu Soy EH, Akdur A, Yıldırım S, Harman A, Moray G, Haberal M. Incidence and Treatment of Bile Stones After Liver Transplant. EXP CLIN TRANSPLANT 2017. [PMID: 28411359 DOI: 10.6002/ect.2017.0023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although the incidence of bile stones after liver transplant is rare (2%-6%), various complications can occur, including recurrent cholangitis, biliary strictures, graft loss, and patient mortality. MATERIALS AND METHODS We retrospectively evaluated bile stone incidence, pathogenesis, and treatment in 352 liver transplant recipients, comparing demographics, transplant indication, blood lipid profile, bile reconstruction technique, postoperative complications, time of diagnosis, and treatment regimens. RESULTS Of 352 recipients, 18 had bile stones, with 13 of these patients (72.2%) receiving duct-to-duct bile reconstruction, 17 having biliary complications before bile stone development, 7 (38.9%) having biliary stricture, 6 (33.3%) having biliary leakage, 4 (22.2%) having biliary strictures secondary to biliary leakage, and 7 (38.9%) having hepatic artery complications early posttransplant. Previous biliary complications and recurrent cholangitis significantly increased bile stones. Incidence in patients with triglyceride levels > 250 mg/dL was significantly different from those with levels at < 250 mg/dL. Cold ischemia time was significant in those with and without bile stones (P = .001). Three patients (16%) were treated by endoscopic tools, with others (15/18, 84%) treated via percutaneous procedures. CONCLUSIONS Bile stone risk can be greater in those with previous biliary complications, hepatic artery problems, long cold ischemia time, and high cholesterol levels. It can be successfully treated by endoscopic and percutaneous techniques.
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Affiliation(s)
- Mahir Kırnap
- Department of General Surgery, Başkent University, Faculty of Medicine, Ankara, Turkey
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Roos FJM, Poley JW, Polak WG, Metselaar HJ. Biliary complications after liver transplantation; recent developments in etiology, diagnosis and endoscopic treatment. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624111 DOI: 10.1016/j.bpg.2017.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary complications are considered to be the Achilles' heel of liver transplantation. The most common complications are leaks and bile duct strictures. Strictures can arise at the level of the anastomosis (anastomotic strictures; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). Endoscopic treatment via endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the preferred therapy for these complications. This review will focus on the diagnostic modalities, new insights in etiology of biliary complications and outcomes after different endoscopic therapies, in both deceased donor transplantation and living-donor liver transplantations. Advances in recent therapies, such as the use of self-expendable metal stents (SEMS) and endoscopic therapy for patients with a bilio-digestive anastomosis will be discussed.
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Kul M, Erden A, Düşünceli Atman E. Diagnostic value of Gd-EOB-DTPA-enhanced MR cholangiography in non-invasive detection of postoperative bile leakage. Br J Radiol 2017; 90:20160847. [PMID: 28181823 DOI: 10.1259/bjr.20160847] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To assess the diagnostic value of dynamic T1 weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced MR cholangiography (MRC) for the detection of active bile leaks. METHODS A total of 28 patients with suspected biliary leakage who underwent routine T2 weighted (T2w) MRC and T1w GD-EOB-DTPA-enhanced MRC at our institution from February 2013 to June 2016 were included in this study. The image sets were retrospectively analyzed in consensus by three radiologists. T1w Gd-EOB-DTPA-enhanced MRC findings were correlated with clinical data, follow-up examinations and findings of invasive/surgical procedures. Patients with positive bile leak findings in Gd-EOB-DTPA-enhanced MRC were divided into hepatobiliary phase (HBP) (20-30 min) and delayed phase (DP) (60-390 min) group according to elapsed time between Gd-EOB-DTPA injection and initial bile leak findings in MRC images. These groups were compared in terms of laboratory test results (total bilirubin, liver enzymes) and the presence of bile duct dilatation in T2w MRC images. RESULTS In each patient, visualization of bile ducts was sufficient in the HBP. The accuracy, sensitivity and specificity of dynamic Gd-EOB-DTPA-enhanced T1w MRC in the detection of biliary leaks were 92.9%, 90.5% and 100%, respectively (p < 0.001). 19 of 28 patients had bile leak findings in T1w Gd-EOB-DTPA-enhanced MRC [HBP group: N = 7 (36.8%), DP group: N = 12 (63.2%)]. There was no statistically significant difference in terms of laboratory test results and the presence of bile duct dilatation between HBP and DP group (p > 0.05). Three patients, each of them in DP group, showed normal laboratory test results and bile duct diameters. CONCLUSION Dynamic T1w Gd-EOB-DTPA-enhanced MRC is a useful non-invasive diagnostic tool to detect bile leak. Advances in knowledge: Prolonged DP imaging may be required for bile leak detection even if visualization of biliary tree is sufficient in HBP and liver function tests, total bilirubin levels and bile duct diameters are normal.
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Affiliation(s)
- Melahat Kul
- Department of Radiology, Ibni Sina Hospital, Ankara University Medical Faculty, Ankara, Turkey
| | - Ayşe Erden
- Department of Radiology, Ibni Sina Hospital, Ankara University Medical Faculty, Ankara, Turkey
| | - Ebru Düşünceli Atman
- Department of Radiology, Ibni Sina Hospital, Ankara University Medical Faculty, Ankara, Turkey
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Garg B, Rastogi R, Gupta S, Rastogi H, Garg H, Chowdhury V. Evaluation of biliary complications on magnetic resonance cholangiopancreatography and comparison with direct cholangiography after living-donor liver transplantation. Clin Radiol 2017; 72:518.e9-518.e15. [PMID: 28118992 DOI: 10.1016/j.crad.2016.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/13/2016] [Accepted: 12/23/2016] [Indexed: 02/08/2023]
Abstract
AIM To evaluate the imaging characteristics of biliary complications following liver transplantation on magnetic resonance cholangiopancreatography (MRCP) and its diagnostic accuracy in comparison with direct cholangiography. MATERIAL AND METHODS In this prospective study, 34 patients being evaluated for possible biliary complications after living-donor liver transplantation (LDLT) with abnormal MRCP findings were followed up for information regarding direct cholangiography either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC) within 7 days of MRCP. Twenty-nine patients underwent ERCP and five patients underwent PTC. RESULTS Compared to findings at direct cholangiography, MRCP presented 96.9% sensitivity, 96.9% positive predictive value, and 94.1% accuracy for the detection of biliary complications. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for detection of anastomotic strictures, biliary leak, and biliary stone or sludge on MRCP was found to be 100%, 84.6%, 91.3%, 100% and 94.1%; 72.7%, 95.7%, 88.9%, 88% and 88.2%; 80%, 100%, 100%, 96.7% and 97.1%, respectively. CONCLUSION MRCP is a reliable non-invasive technique to evaluate the biliary complications following LDLT. MRCP should be the imaging method of choice for diagnosis in this setting and direct cholangiography should be reserved for cases that need therapeutic interventions.
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Affiliation(s)
- B Garg
- Department of Radiology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110027, India
| | - R Rastogi
- Department of Radiology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110027, India.
| | - S Gupta
- Department of Liver Transplant Surgery, Centre for Liver and Biliary Sciences, Indraprastha Apollo Hospital, New Delhi, India
| | - H Rastogi
- Department of Radiology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110027, India
| | - H Garg
- Department of Hepatology and Gastroenterology, Centre for Liver & Biliary Sciences, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110027, India
| | - V Chowdhury
- Department of Radiology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110027, India
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Shao XD, Qi XS, Guo XZ. Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis. Saudi J Gastroenterol 2017; 23:150-160. [PMID: 28611338 PMCID: PMC5470374 DOI: 10.4103/1319-3767.207713] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to evaluate the effectiveness and safety of endoscopic retrograde cholangiopancreatography with double balloon enteroscope (DBE-ERCP) in patients with altered gastrointestinal anatomy in a meta-analysis. MATERIALS AND METHODS A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane library covering the period from January 2001 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using the I2 test. RESULTS Ten studies involving a total of 301 patients were included in the analysis. The pooled enteroscopy, diagnostic, and therapeutic success rates were 89.75% [95% confidence interval (CI): 79.65-94.30%], 79.92% (95% CI: 68.06-89.59%), and 63.55% (95% CI: 53.70-72.86%), respectively. DBE-ERCP-related complications occurred in 18 patients including perforation (5), pancreatitis (3), cholangitis (9), and bleeding (1). The incidence of DBE-ERCP-related complication was 6.27% (95% CI: 2.61-11.38%). CONCLUSION Diagnostic and therapeutic DBE-ERCPs are feasible in patients with altered gastrointestinal anatomy. DBE-ERCP may be considered when pancreaticobiliary diseases occur in patients undergoing Roux-en-Y reconstruction or pancreaticoduodenectomy.
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Affiliation(s)
- Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China,Address for correspondence: Dr. Xiao-Dong Shao, Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang - 110016, China. E-mail:
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang, China
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Shin M, Joh JW. Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature. World J Gastroenterol 2016; 22:6173-6191. [PMID: 27468208 PMCID: PMC4945977 DOI: 10.3748/wjg.v22.i27.6173] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/25/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation (LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.
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Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016; 8:461-470. [PMID: 27057304 PMCID: PMC4820638 DOI: 10.4254/wjh.v8.i10.461] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.
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