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1
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Pinheiro LW, Martins FP, De Paulo GA, Contini MLC, Ferrari AP, Della Libera E. Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture. World J Gastrointest Endosc 2022; 14:547-554. [PMID: 36186946 PMCID: PMC9516474 DOI: 10.4253/wjge.v14.i9.547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/19/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS.
AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.
METHODS This study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (HanarostentTM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent.
RESULTS Three patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy.
CONCLUSION In this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.
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Affiliation(s)
- Larissa Wermelinger Pinheiro
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
| | - Fernanda Prata Martins
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| | | | | | - Angelo Paulo Ferrari
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| | - Ermelindo Della Libera
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
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2
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Forde JJ, Bhamidimarri KR. Management of Biliary Complications in Liver Transplant Recipients. Clin Liver Dis 2022; 26:81-99. [PMID: 34802665 DOI: 10.1016/j.cld.2021.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.
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Affiliation(s)
- Justin J Forde
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA.
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3
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Fernandez-Simon A, Sendino O, Chavez-Rivera K, Córdova H, Colmenero J, Crespo G, Fundora Y, Samaniego F, Ruiz P, Fondevila C, Navasa M, Cárdenas A. The presence and outcome of biliary sphincter disorders in liver-transplant recipients according to the Rome IV classification. Gastroenterol Rep (Oxf) 2021; 9:299-305. [PMID: 34567561 PMCID: PMC8460114 DOI: 10.1093/gastro/goab025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/13/2021] [Accepted: 05/11/2021] [Indexed: 11/27/2022] Open
Abstract
Background Biliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria. Methods We reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP. Results Among the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up. Conclusions PS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.
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Affiliation(s)
- Alejandro Fernandez-Simon
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Oriol Sendino
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Karina Chavez-Rivera
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Henry Córdova
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jordi Colmenero
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Gonzalo Crespo
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Yilliam Fundora
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Franco Samaniego
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Pablo Ruiz
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Constantino Fondevila
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Andrés Cárdenas
- GI Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain.,Liver Transplant Unit, Institut Clínic de Malalties Digestives i Metabòliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
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4
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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5
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Lim C, Shih K, Wu S, Fan C, Yen H, Su W, Tsai H. Safety of endoscopic retrograde cholangiopancreatography in liver transplanted patients: A single‐center retrospective study. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Cherng‐Harng Lim
- Division of Gastroenterology and Hepatology, Department of Internal MedicineChanghua Christian Hospital Changhua Taiwan
| | - Kai‐Lun Shih
- Division of Gastroenterology and Hepatology, Department of Internal MedicineChanghua Christian Hospital Changhua Taiwan
| | - Shun‐Sheng Wu
- Division of Gastroenterology and Hepatology, Department of Internal MedicineChanghua Christian Hospital Changhua Taiwan
| | - Chuan‐San Fan
- Division of Gastroenterology and Hepatology, Department of Internal MedicineChanghua Christian Hospital Changhua Taiwan
| | - Hsu‐Heng Yen
- Division of Gastroenterology and Hepatology, Department of Internal MedicineChanghua Christian Hospital Changhua Taiwan
| | - Wei‐Wen Su
- Division of Gastroenterology and Hepatology, Department of Internal MedicineChanghua Christian Hospital Changhua Taiwan
| | - Hao‐Chien Tsai
- Nursing DepartmentChanghua Christian Hospital Changhua Taiwan
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6
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Moy BT, Birk JW. A Review on the Management of Biliary Complications after Orthotopic Liver Transplantation. J Clin Transl Hepatol 2019; 7:61-71. [PMID: 30944822 PMCID: PMC6441650 DOI: 10.14218/jcth.2018.00028] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/23/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Orthotopic liver transplantation is the definitive treatment for end-stage liver disease and hepatocellular carcinomas. Biliary complications are the most common complications seen after transplantation, with an incidence of 10-25%. These complications are seen both in deceased donor liver transplant and living donor liver transplant. Endoscopic treatment of biliary complications with endoscopic retrograde cholangiopancreatography (commonly known as ERCP) has become a mainstay in the management post-transplantation. The success rate has reached 80% in an experienced endoscopist's hands. If unsuccessful with ERCP, percutaneous transhepatic cholangiography can be an alternative therapy. Early recognition and treatment has been shown to improve morbidity and mortality in post-liver transplant patients. The focus of this review will be a learned discussion on the types, diagnosis, and treatment of biliary complications post-orthotopic liver transplantation.
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Affiliation(s)
- Brian T. Moy
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- *Correspondence to: John W. Birk, Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT 06030, USA. E-mail:
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7
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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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8
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Landi F, de'Angelis N, Sepulveda A, Martínez-Pérez A, Sobhani I, Laurent A, Soubrane O. Endoscopic treatment of anastomotic biliary stricture after adult deceased donor liver transplantation with multiple plastic stents versus self-expandable metal stents: a systematic review and meta-analysis. Transpl Int 2018; 31:131-151. [PMID: 29090502 DOI: 10.1111/tri.13089] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/05/2017] [Accepted: 10/24/2017] [Indexed: 02/06/2023]
Abstract
Anastomotic biliary strictures (ABSs) occur in up to 15% of patients after liver transplantation (LT). The aim of this study was to compare the efficacy and safety of self-expandable metal stents (SEMS) versus multiple plastic stents (MPS). Databases were searched through April 2017. The outcome measures were technical success, stricture resolution, recurrence and complications. We synthesized the findings descriptively and performed a meta-analysis. Three randomized controlled trials and one retrospective cohort study were identified, including 179 MPS and 119 SEMS patients. Outcome data were pooled in a meta-analysis that showed an advantage of SEMS in terms of the number of ERCP procedures (mean difference: 1.69 ERCP; 95% CI, 1-2.39; P < 0.00001) and treatment days (mean difference: 40.2 days; 95% CI, 3.9-76.4; P = 0.03), with no differences in terms of ABS resolution or recurrence. Fourteen case series reported MPS outcomes and fifteen reported SEMS outcomes, including 647 and 419 patients, respectively. Based on low-quality evidence, we cannot draw any reliable conclusions on the superiority of MPS or SEMS strategies. Even though shorter treatment times and fewer ERCP procedures support the use of SEMS, whether one technique has well-defined advantages over the other remains unclear.
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Affiliation(s)
- Filippo Landi
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, APHP, University Paris Est, UPEC, Creteil, France
| | - Nicola de'Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, APHP, University Paris Est, UPEC, Creteil, France
| | - Ailton Sepulveda
- Department of Hepatobiliary Surgery and Liver Transplantation, Beaujon Hospital, University Hospitals Paris Nord Val de Seine, Clichy, France
| | - Aleix Martínez-Pérez
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, APHP, University Paris Est, UPEC, Creteil, France
| | - Iradj Sobhani
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor University Hospital, APHP, University Paris Est, UPEC, Creteil, France
| | - Alexis Laurent
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, APHP, University Paris Est, UPEC, Creteil, France
| | - Olivier Soubrane
- Department of Hepatobiliary Surgery and Liver Transplantation, Beaujon Hospital, University Hospitals Paris Nord Val de Seine, Clichy, France
- University Paris Diderot, Sorbonne Paris Cité, Paris, France
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9
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Barakat MT, Huang RJ, Thosani NC, Choudhary A, Girotra M, Banerjee S. Liver transplant-related anastomotic biliary strictures: a novel, rapid, safe, radiation-sparing, and cost-effective management approach. Gastrointest Endosc 2018; 87:501-508. [PMID: 28757315 PMCID: PMC5787034 DOI: 10.1016/j.gie.2017.07.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/10/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Biliary strictures after orthotopic liver transplantation (OLT) are typically managed by sequential ERCP procedures, with incremental dilation of the stricture and stent exchange (IDSE) and placement of new stents. This approach resolves >80% of strictures after 12 months but requires costly, lengthy ERCPs with significant patient radiation exposure. Increasing awareness of the harmful effects of radiation, escalating healthcare costs, and decreasing reimbursement for procedures mandate maximal efficiency in performing ERCP. We compared the traditional IDSE protocol with a sequential stent addition (SSA) protocol, in which additional stents are placed across the stricture during sequential ERCPs, without stent removal/exchange or stricture dilation. METHODS Patients undergoing ERCP for OLT-related anastomotic strictures from 2010 to 2016 were identified from a prospectively maintained endoscopy database. Procedure duration, fluoroscopy time, stricture resolution rates, adverse events, materials fees, and facility fees were analyzed for IDSE and SSA procedures. RESULTS Seventy-seven patients underwent 277 IDSE and 132 SSA procedures. Mean fluoroscopy time was 64.5% shorter (P < .0001) and mean procedure duration 41.5% lower (P < .0001) with SSA compared with IDSE. SSA procedures required fewer accessory devices, resulting in significantly lower material (63.8%, P < .0001) and facility costs (42.8%, P < .0001) compared with IDSE. Stricture resolution was >95%, and low adverse event rates did not significantly differ. CONCLUSIONS SSA results in shorter, cost-effective procedures requiring fewer accessory devices and exposing patients to less radiation. Stricture resolution rates are equivalent to IDSE, and adverse events do not differ significantly, even in this immunocompromised population.
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Affiliation(s)
- Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Robert J Huang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nirav C Thosani
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Abhishek Choudhary
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Mohit Girotra
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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10
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Forrest EA, Reiling J, Lipka G, Fawcett J. Risk factors and clinical indicators for the development of biliary strictures post liver transplant: Significance of bilirubin. World J Transplant 2017; 7:349-358. [PMID: 29312864 PMCID: PMC5743872 DOI: 10.5500/wjt.v7.i6.349] [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: 08/13/2017] [Revised: 09/18/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To identify risk factors associated with the formation of biliary strictures post liver transplantation over a period of 10-year in Queensland.
METHODS Data on liver donors and recipients in Queensland between 2005 and 2014 was obtained from an electronic patient data system. In addition, intra-operative and post-operative characteristics were collected and a logistical regression analysis was performed to evaluate their association with the development of biliary strictures.
RESULTS Of 296 liver transplants performed, 285 (96.3%) were from brain dead donors. Biliary strictures developed in 45 (15.2%) recipients. Anastomotic stricture formation (n = 25, 48.1%) was the commonest complication, with 14 (58.3%) of these occurred within 6-mo of transplant. A percutaneous approach or endoscopic retrograde cholangiography was used to treat 17 (37.8%) patients with biliary strictures. Biliary reconstruction was initially or ultimately required in 22 (48.9%) patients. In recipients developing biliary strictures, bilirubin was significantly increased within the first post-operative week (Day 7 total bilirubin 74 μmol/L vs 49 μmol/L, P = 0.012). In both univariate and multivariate regression analysis, Day 7 total bilirubin > 55 μmol/L was associated with the development of biliary stricture formation. In addition, hepatic artery thrombosis and primary sclerosing cholangitis were identified as independent risk factors.
CONCLUSION In addition to known risk factors, bilirubin levels in the early post-operative period could be used as a clinical indicator for biliary stricture formation.
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Affiliation(s)
- Elizabeth Ann Forrest
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Department of Surgery, Gold Coast Hospital and Health Service, Gold Coast, Queensland 4215, Australia
| | - Janske Reiling
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Queensland 4120, Australia
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, AZ Maastricht 6202, The Netherlands
- PA Research Foundation, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Geraldine Lipka
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Jonathan Fawcett
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
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Karthik SV, Quak SH, Aw MM. Endoscopic retrograde cholangio-pancreatography in the management of biliary complications after paediatric liver transplantation - a retrospective study. Transpl Int 2017; 31:313-317. [PMID: 29130583 DOI: 10.1111/tri.13091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/30/2017] [Accepted: 10/31/2017] [Indexed: 01/03/2023]
Abstract
The published paediatric experience with endoscopic retrograde cholangio-pancreatography (ERCP) in the diagnosis and management of biliary complications following liver transplantation (LT) is limited. We describe our experience with ERCP in the management of children following LT who presented with biliary complications, over a 20-year period (1995-2014). The retrospectively reviewed data are summarized descriptively. Of 94 children (47 boys) who received 102 liver transplants at our centre, seven children (five boys, two girls) underwent ERCP after liver transplantation. In total, 25 ERCP procedures were carried out in these patients. The median age at liver transplantation was 10.7 (3.9-16.2) years. The median interval between LT and the first ERCP was 28 days (12 days-6.8 years). All patients were on standard calcineurin-inhibitor-based immunosuppression regimens. Six of the seven patients underwent ERCP on more than one occasion [median number of ERCP sessions per patient- 4, (1-6)]. Seventeen procedures were carried out under conscious sedation, remaining eight under general anaesthesia. Sedation was achieved employing a standard regimen (Midazolam 5 mg with Pethidine 50 mg) and occasionally Fentanyl. ERCP is an effective and safe intervention from both diagnostic and therapeutic point of view, in the management of post-LT biliary complications in children.
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Affiliation(s)
| | - Seng-Hock Quak
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Marion M Aw
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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12
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Daniel K, Said A. Early Biliary complications after liver transplantation. Clin Liver Dis (Hoboken) 2017; 10:63-67. [PMID: 30992762 PMCID: PMC6467113 DOI: 10.1002/cld.654] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/30/2017] [Accepted: 07/11/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Kim Daniel
- Department of GastroenterologyMedical College of WisconsinMilwaukee
| | - Adnan Said
- University of Wisconsin School of Medicine and Public Health,Madison VA Medical CenterMadisonWI
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Shamsaeefar A, Nikeghbalian S, Kazemi K, Motazedian N, Geramizadeh B, Malekhosseini SA. Thirteen-Year Evaluation of the Management of Biliary Tract Complication After Deceased Donor Liver Transplantation. Prog Transplant 2017; 27:192-195. [PMID: 28617155 DOI: 10.1177/1526924817699964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Although patient and graft survival rate has increased in recent years, biliary complications after liver transplantation are associated with significant morbidity and mortality. METHODS AND MATERIALS We reviewed the database of 1930 patients who underwent deceased donor liver transplantation between 2000 and 2013. The patients had abnormal results in liver tests, as well as fever and jaundice. Abdominal sonography was performed, and if complication was identified, the patient underwent an interventional procedure by endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. If the complication was not resolved by the mentioned procedures, exploration of common bile duct and Roux-en-Y choledochojejunostomy or revision of Roux-en-Y choledochojejunostomy was done. RESULTS Our study group comprised 105 patients including 66 (63%) men and 39 (37.1%) women with a mean age of 36.7 ± 12.5 years (range: 15-66 years). Among 1930 patients, 105 (5.4%) cases presented with biliary complication after liver transplantation, of which 97 (5%) and 8 (0.4%) cases presented with biliary stricture and bile leak/biloma, respectively. CONCLUSION In our study, most patients with biliary complications after liver transplantation responded to interventional procedures, with 37.1% requiring surgical exploration.
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Affiliation(s)
- Alireza Shamsaeefar
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saman Nikeghbalian
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kourosh Kazemi
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Motazedian
- 2 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bita Geramizadeh
- 2 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Malekhosseini
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
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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: 9] [Impact Index Per Article: 1.1] [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: 04/18/2017] [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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15
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Lee HW, Shah NH, Lee SK. An Update on Endoscopic Management of Post-Liver Transplant Biliary Complications. Clin Endosc 2017; 50:451-463. [PMID: 28415168 PMCID: PMC5642064 DOI: 10.5946/ce.2016.139] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/16/2017] [Accepted: 02/22/2017] [Indexed: 02/07/2023] Open
Abstract
Biliary complications are the most common post-liver transplant (LT) complications with an incidence of 15%-45%. Furthermore, such complications are reported more frequently in patients who undergo a living-donor LT compared to a deceased-donor LT. Most post-LT biliary complications involve biliary strictures, bile leakage, and biliary stones, although many rarer events, such as hemobilia and foreign bodies, contribute to a long list of related conditions. Endoscopic treatment of post-LT biliary complications has evolved rapidly, with new and effective tools improving both outcomes and success rates; in fact, the latter now consistently reach up to 80%. In this regard, conventional endoscopic retrograde cholangiopancreatography remains the preferred initial treatment. However, percutaneous transhepatic cholangioscopy is now central to the management of endoscopy-resistant cases involving complex hilar or multiple strictures with associated stones. Many additional endoscopic tools and techniques-such as the rendezvous method, magnetic compression anastomosis , and peroral cholangioscopy-combined with modified biliary stents have significantly improved the success rate of endoscopic management. Here, we review the current status of endoscopic treatment of post-LT biliary complications and discuss conventional as well as the aforementioned new tools and techniques.
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Affiliation(s)
- Hyun Woo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Najmul Hassan Shah
- Division of Gastroenterology and Hepatology, Liver Transplant Program, Shifa International Hospital Ltd., Shifa College of Medicine, Islamabad, Pakistan
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med 2016; 34:2200-2208. [DOI: 10.1016/j.ajem.2016.08.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023] Open
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17
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Endoscopic treatment of biliary stones in patients with liver transplantation. Surg Endosc 2016; 31:1327-1335. [DOI: 10.1007/s00464-016-5116-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 07/12/2016] [Indexed: 01/26/2023]
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18
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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: 35] [Impact Index Per Article: 3.9] [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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19
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Carrion AF. Risk factors and outcomes of carbapenem-resistant Klebsiella pneumoniae infections in liver transplant recipients. Liver Transpl 2016; 22:698-699. [PMID: 26849961 DOI: 10.1002/lt.24413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 01/18/2016] [Accepted: 01/28/2016] [Indexed: 01/13/2023]
Affiliation(s)
- Andres F Carrion
- Division of Gastroenterology and Hepatology Paul L, Foster School of Medicine Texas Tech University Health Sciences Center, El Paso, TX
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20
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Chang JH, Lee I, Choi MG, Han SW. Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 2016; 22:1593-1606. [PMID: 26819525 PMCID: PMC4721991 DOI: 10.3748/wjg.v22.i4.1593] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/02/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach.
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21
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Martins FP, Kahaleh M, Ferrari AP. Management of liver transplantation biliary stricture: Results from a tertiary hospital. World J Gastrointest Endosc 2015; 7:747-757. [PMID: 26140103 PMCID: PMC4482835 DOI: 10.4253/wjge.v7.i7.747] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/30/2014] [Accepted: 05/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period.
METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure.
RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups.
CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.
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Girotra M, Soota K, Klair JS, Dang SM, Aduli F. Endoscopic management of post-liver transplant biliary complications. World J Gastrointest Endosc 2015; 7:446-459. [PMID: 25992185 PMCID: PMC4436914 DOI: 10.4253/wjge.v7.i5.446] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/15/2014] [Accepted: 02/04/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary complications are being increasingly encountered in post liver transplant patients because of increased volume of transplants and longer survival of these recipients. Overall management of these complications may be challenging, but with advances in endoscopic techniques, majority of such patients are being dealt with by endoscopists rather than the surgeons. Our review article discusses the recent advances in endoscopic tools and techniques that have proved endoscopic retrograde cholangiography with various interventions, like sphincterotomy, bile duct dilatation, and stent placement, to be the mainstay for management of most of these complications. We also discuss the management dilemmas in patients with surgically altered anatomy, where accessing the bile duct is challenging, and the recent strides towards making this prospect a reality.
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23
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Shin M, Joh JW. Section 10. Endoscopic management of biliary complications in adult living donor liver transplantation. Transplantation 2014; 97 Suppl 8:S36-43. [PMID: 24849832 DOI: 10.1097/01.tp.0000446274.13310.b9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Living donor liver transplantation (LDLT) has become an accepted therapeutic option for patients with end-stage liver disease. However, biliary complications remain the major causes of morbidity and mortality for LDLT recipients. Although there are currently no reports of a clear therapeutic algorithm, many approaches have been developed to treat biliary complications, including surgical, endoscopic, and percutaneous transhepatic techniques. Endoscopic treatment is currently the preferred initial treatment for patients that have previously undergone duct-to-duct biliary reconstruction. This article discusses aspects of endoscopic management of biliary complications that occur in adult LDLT.
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Affiliation(s)
- Milljae Shin
- 1 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 2 Address correspondence to: Jae-Won Joh, M.D., Ph.D., Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea
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Internal hernia in a liver transplant recipien: a case report. Case Rep Surg 2013; 2013:923647. [PMID: 24159411 PMCID: PMC3789415 DOI: 10.1155/2013/923647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 08/14/2013] [Indexed: 02/08/2023] Open
Abstract
Biliary complications have great importance for liver transplant recipients because of affecting long-term prognosis. In rare situations, an internal hernia of the Roux-en-Y loop cause graft injury. A 42-year-old woman with a history of living donor liver transplantation 6 years ago presented with prolonged graft injury during the past 6 months. She suddenly developed ileus of the small bowel with internal hernia through the defect of the mesentery around the Roux-en-Y limb of the hepaticojejunostomy. Emergent surgery was performed to reduce the hernia and volvulus; also the mesenteric rent was closed with interrupted suture of silk. Internal hernia of the small bowel after liver transplantation is rare but causes graft injury due to associated biliary complications and rapid deterioration of patient's condition.
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25
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DeBenedet AT, Scheiman JM, Elta GH, Elmunzer BJ. Peritoneal fluid bilirubin to serum bilirubin ratio for the diagnosis of bile leaks in orthotopic liver transplant recipients. Dig Dis Sci 2013; 58:3044-8. [PMID: 23812826 DOI: 10.1007/s10620-013-2730-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 05/29/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND A peritoneal fluid-to-serum bilirubin ratio (FSBR) of >5 has been shown to be accurate for the detection of bile leaks in post-cholecystectomy and trauma patients; however, there are no studies evaluating the accuracy of this threshold ratio in orthotopic liver transplant (OLT) recipients. METHODS We performed a nested case-control analysis to determine the optimal FSBR threshold for diagnosing bile leaks in OLT recipients and the relationship between FSBR and likelihood of bile leak. Adult OLT patients undergoing ERCP for suspected bile leak were divided into 2 groups: those with cholangiographic evidence of a bile leak and those without evidence of leak. Of 57 included patients, 37 were found to have a bile leak on cholangiogram (64.9 %). RESULTS We found a relationship between higher FSBR and the presence of a bile leak (OR 2.84, 95 % CI 1.37-5.88, p = 0.005). A FSBR of >3.25 produced the optimal sensitivity and specificity for identifying bile leaks in OLT recipients (area under ROC curve 0.8865, sensitivity 72.97 %, specificity 95.00 %). CONCLUSIONS We conclude FSBR is an easily accessible, moderately accurate test to diagnose bile leaks in liver transplant recipients. This test can inform clinical decision-making with regard to the utilization of ERCP in lower suspicion transplant recipients with a suspected bile leak.
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Affiliation(s)
- Anthony T DeBenedet
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical Center, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109-5362, USA,
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26
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Arain MA, Attam R, Freeman ML. Advances in endoscopic management of biliary tract complications after liver transplantation. Liver Transpl 2013; 19:482-98. [PMID: 23417867 DOI: 10.1002/lt.23624] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 02/04/2013] [Indexed: 12/11/2022]
Abstract
Biliary tract complications after liver transplantation (LT) most commonly include biliary leaks, strictures, and stone disease. Living donor recipients and donation after cardiac death recipients are at an increased risk of developing biliary complications. Biliary leaks usually occur early after transplantation, whereas strictures and stone disease occur later. The diagnosis of biliary complications relies on a combination of clinical presentation, laboratory abnormalities, and imaging modalities. Biliary leaks are usually diagnosed on the basis of bilious output from a surgical drain, fluid collections on imaging, or a cholescintigraphy scan demonstrating a leak. Magnetic resonance cholangiopancreatography (MRCP) is noninvasive, does not require the administration of an intravenous contrast agent, and provides detailed imaging of the entire biliary system both above and below the anastomosis. The latter not only helps in the diagnosis of biliary strictures and stones before patients undergo invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) but also allows treating physicians to plan the optimal treatment approach. MRCP has, therefore, replaced invasive therapeutic modalities such as ERCP as the modality of choice for the diagnosis of biliary strictures and stones. There have been significant advances in endoscopic accessories, including biliary catheters, wires, and stents, as well as endoscopic technologies such as overtube-assisted endoscopy over the last decade. These developments have resulted in almost all patients, including those with difficult strictures or altered surgical anatomies (eg, Roux-en-Y hepaticojejunostomy), being treated via an endoscopic approach with percutaneous transhepatic cholangiography, which is more invasive and associated with significant morbidity, with surgery being reserved for a small minority of patients. Advances in the diagnosis and endoscopic management of patients with biliary complications after LT are discussed in this review.
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Affiliation(s)
- Mustafa A Arain
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
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Nasr JY, Slivka A. Endoscopic approach to the post liver transplant patient. Gastrointest Endosc Clin N Am 2013; 23:473-81. [PMID: 23540971 DOI: 10.1016/j.giec.2012.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Biliary complications occur after liver transplantation. These complications can be effectively and safely managed using endoscopic approaches and can prevent unnecessary and potentially morbid surgery.
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Affiliation(s)
- John Y Nasr
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Balderramo D, Sendino O, Miquel R, de Miguel CR, Bordas JM, Martinez-Palli G, Leoz ML, Rimola A, Navasa M, Llach J, Cardenas A. Prospective evaluation of single-operator peroral cholangioscopy in liver transplant recipients requiring an evaluation of the biliary tract. Liver Transpl 2013; 19:199-206. [PMID: 23404861 DOI: 10.1002/lt.23585] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/23/2012] [Indexed: 12/13/2022]
Abstract
In this descriptive study, we examined the role of single-operator cholangioscopy (SOC) in the evaluation of biliary complications after liver transplantation (LT). We prospectively included adult recipients of deceased donor LT who were referred for endoscopic retrograde cholangiopancreatography between June 2009 and July 2011. All patients underwent SOC with biopsy of the biliary anastomosis. Sixteen patients were included: 12 with biliary anastomotic strictures (ASs), 2 with common bile duct stones, 1 with a bile leak, and 1 with sphincter of Oddi dysfunction. Patients with ASs displayed 1 of 2 patterns: (A) mild erythema (n = 9) or (B) edema, ulceration, and sloughing (n = 3). Those without ASs displayed a pale mucosa with mild edema at the anastomosis. Patients with ASs and pattern B required a longer period of stenting than patients with pattern A (457 versus 167 days, P = 0.02). In addition, patients with pattern A had a better response and better resolution of their strictures with endoscopic therapy than those with pattern B (66% versus 33%, P = 0.13). Histological examinations of ASs showed nonspecific intraepithelial inflammation in patients with patterns A and B. Biopsy samples from patients without ASs showed normal columnar epithelial bile duct cells. The total cholangioscopy time for all procedures was 26.8 ± 10.1 minutes. In conclusion, SOC in LT recipients is feasible and allows adequate visualization and tissue sampling of ASs and bile ducts. Two distinct visual patterns that are easily identified with SOC may help to predict the outcomes of endoscopic therapy in patients with biliary complications after LT.
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Affiliation(s)
- Domingo Balderramo
- Gastrointestinal/Endoscopy Unit, Institute of Digestive and Metabolic Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Hsieh TH, Mekeel KL, Crowell MD, Nguyen CC, Das A, Aqel BA, Carey EJ, Byrne TJ, Vargas HE, Douglas DD, Mulligan DC, Harrison ME. Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy. Gastrointest Endosc 2013; 77:47-54. [PMID: 23062758 DOI: 10.1016/j.gie.2012.08.034] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 08/30/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Living-donor liver transplantation (LDLT) has emerged as a viable strategy in an era of organ shortage. However, biliary strictures are a common complication of LDLT, and these strictures frequently require surgical revision after unsuccessful endoscopic therapy. The optimal endoscopic treatment for anastomotic biliary strictures (ABSs) after LDLT is undefined. OBJECTIVE To determine the outcome of an aggressive endoscopic approach to ABSs after LDLT that uses endoscopic dilation followed by maximal stent placement. DESIGN A retrospective study. SETTING A tertiary-care academic medical center. PATIENTS Forty-one patients with a diagnosis of ABS. INTERVENTIONS Endoscopic retrograde cholangiography with balloon dilation and maximal stenting. MAIN OUTCOME MEASUREMENTS Stricture resolution, stricture recurrence, and complication rates. RESULTS Of 110 LDLTs completed, a biliary stricture developed after transplantation in 41 (37.3%), which included 38 patients with duct-to-duct anastomosis. The median (interquartile range [IQR]) follow-up time is 74.2 (2.5-120.8) months. Among them, 23 (60.5%) were male, and 20 (52.6%) had bile leakage associated with ABSs. The median time (IQR) to the development of an ABS after LDLT was 2.1 (1.2-4.1) months. Endoscopic retrograde cholangiography was attempted as initial therapy in all patients: 32 were managed entirely by endoscopic therapy, and 6 required initial percutaneous transhepatic cholangiography (PTC) to cross the biliary stricture, with endoscopic therapy performed thereafter. A median (IQR) of 4.0 (3.0-5.3) endoscopic interventions and 7.0 (4.0-10.3) stents were required to resolve the stricture. The time from the first intervention to stricture resolution was 5.3 (range 3.8-8.9) months. Biochemical markers including aspartate transaminase (76 vs 39 U/L, P = .001), alanine transaminase (127.5 vs 45.5 U/L, P < .001), alkaline phosphatase (590 vs 260 IU/L, P < .001), and total bilirubin (2.57 vs 1.73 mg/dL, P = .017) significantly improved after intervention. Recurrent stricture was observed after initial treatment in 8 (21%) patients. All recurrences were successfully re-treated endoscopically. All patients have been managed without surgical revision or retransplantation, resulting in 100% success by an intention-to-treat analysis. LIMITATIONS Retrospective study, small sample size. CONCLUSIONS In this series, aggressive endoscopy-based treatment with maximal stent placement strategy allows 100% resolution of all duct-to-duct ABSs after LDLT without the need for surgical intervention or retransplantation.
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Affiliation(s)
- Ting-Hui Hsieh
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA
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Chennat J. Indications for endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2012.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Balderramo D, Sendino O, Burrel M, Real MI, Blasi A, Martinez-Palli G, Bordas JM, Carlos Garcia-Valdecasas J, Rimola A, Navasa M, Llach J, Cardenas A. Risk factors and outcomes of failed endoscopic retrograde cholangiopancreatography in liver transplant recipients with anastomotic biliary strictures: a case-control study. Liver Transpl 2012; 18:482-489. [PMID: 22467549 DOI: 10.1002/lt.23371] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anastomotic strictures (ASs) of the biliary duct after liver transplantation (LT) are primarily managed with endoscopic retrograde cholangiopancreatography (ERCP), but in some cases, this fails because of difficulties in passing the strictures. The aim of this case-control study was to examine specific risk factors for initial ERCP failure and the outcomes of percutaneous transhepatic cholangiography (PTC) as a second-line approach in LT recipients with ASs. Between January 2002 and December 2010, we identified LT recipients with ASs who experienced initial ERCP failure (which was defined as the inability to traverse the AS with guidewires in 2 or more consecutive procedures). A period-matched control group (ratio = 1:2) with ASs and initial ERCP success was analyzed. Preoperative, intraoperative, postoperative, and endoscopic variables were evaluated as risk factors. The outcomes of PTC and the need for hepaticojejunostomy (HJ) or retransplantation were evaluated. Seventeen cases who experienced initial ERCP failure were compared with 34 controls. The median times from LT to ERCP were similar (8.7 months for cases and 8.6 months for controls, P = not significant). A multivariate analysis revealed that previous bile leaks [odds ratio (OR) = 6.07, 95% confidence interval (CI) = 1.0-36.5] and more than 4 U of intraoperatively transfused red blood cells (OR = 11.51, 95% CI = 1.9-71.2) were independent risk factors for failure. PTC was an effective second-line treatment in only 3 of 12 cases (25%). The need for HJ was more frequent for the cases (13/17 or 76.5%) versus the controls (7/34 or 20.6%, P < 0.001). One patient in each group underwent retransplantation (P = not significant). In conclusion, previous bile leaks and high packed red blood cell transfusion requirements during surgery are risk factors for initial ERCP failure in LT recipients with ASs. A high proportion of these patients will need surgery as their final therapy.
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Affiliation(s)
- Domingo Balderramo
- Gastrointestinal/Endoscopy Unit, Institute of Digestive and Metabolic Diseases, University of Barcelona, Barcelona, Spain
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Balderramo D, Bordas JM, Sendino O, Abraldes JG, Navasa M, Llach J, Cardenas A. Complications after ERCP in liver transplant recipients. Gastrointest Endosc 2011; 74:285-294. [PMID: 21704993 DOI: 10.1016/j.gie.2011.04.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 04/19/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Complications of the biliary tract after liver transplantation are successfully managed with ERCP; however, the incidence and risk factors for post-ERCP complications remain unknown. OBJECTIVE To examine the incidence, risk factors, and short-term outcome of post-ERCP complications in liver transplant (LT) recipients. DESIGN Retrospective evaluation of all ERCPs performed in LT recipients at our institution during a 7-year, 4-month period. SETTING Tertiary referral center. PATIENTS A total of 243 ERCPs performed in 121 LT recipients with duct-to-duct anastomosis. MAIN OUTCOME MEASUREMENTS Incidence of post-ERCP complications. Predictive factors were determined by univariate and multivariate analyses. RESULTS Overall complications occurred in 22 procedures (9%) (13 mild, 9 moderate): pancreatitis in 9 patients (3.7%), cholangitis in 8 patients (3.3%), postsphincterotomy bleeding in 4 patients (1.6%), and subcapsular hematoma in 1 patient (0.4%). The mean hospitalization for post-ERCP complications was 4.8 days (range 2-11 days). Logistic regression identified mammalian target of rapamycin inhibitors (odds ratio [OR], 4.65; 95% CI, 1.01-21.81; P = .049), serum creatinine level greater than 2 mg/dL (OR, 4.17; 95% CI, 1.07-16.26; P = .04), biliary sphincterotomy (OR, 3.03; 95% CI, 1.07-8.53; P = .037), and more than 2 pancreatic duct contrast injections (OR, 2.95; 95% CI, 1.10-7.91; P = .032) as independent risk factors for post-ERCP complications, whereas steroid therapy (OR, 0.23; 95% CI, 0.08-0.63; P = .004) was an independent protective factor. LIMITATIONS Single-center retrospective study. CONCLUSIONS The rate of complications after ERCP in LT recipients seems to be similar to that of non-LT recipients. Complications in this analysis were more common in LT recipients receiving mammalian target of rapamycin inhibitors and those with renal failure, biliary sphincterotomy, and more than 2 pancreatic duct injections, whereas they were less common in those patients on steroid therapy.
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Affiliation(s)
- Domingo Balderramo
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Sibulesky L, Heckman MG, Perry DK, Taner CB, Willingham DL, Nguyen JH. A single-center experience with biliary reconstruction in retransplantation: duct-to-duct or Roux-en-Y choledochojejunostomy. Liver Transpl 2011; 17:710-6. [PMID: 21618692 DOI: 10.1002/lt.22263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Retransplantation is the only therapy for patients who have a failing liver graft, and it can be technically challenging. Although duct-to-duct (DD) biliary reconstruction is considered standard in deceased donor orthotopic whole organ liver transplantation, Roux-en-Y (RY) choledochojejunostomy is preferred by most for biliary reconstruction in retransplantation. We performed a retrospective review of 128 patients who underwent retransplantation after a first transplant with DD biliary construction. Of these 128 patients, 83 had DD biliary reconstructions, and 45 had RY biliary reconstructions. Log-rank tests were used to compare the complication rates between the DD and RY groups, whereas multivariate Cox proportional hazards models were used to compare patient and graft survival between the groups. The median Model for End-Stage Liver Disease score at retransplantation was significantly higher in the DD group (27 versus 21, P = 0.005). The median length of follow-up was 3.3 years. The biliary complication rates were 7% and 11% in the DD group and 10% and 10% in the RY group 30 days and 1 year after retransplantation, respectively (P = 0.73). The rates of primary graft nonfunction complications, hepatic artery thrombosis complications, and reoperation did not differ significantly between groups (all P ≥ 0.37). In comparison with RY reconstruction, there was no evidence of a difference in patient survival (relative risk = 0.79, P = 0.47) or graft survival (relative risk = 0.94, P = 0.85) for patients with DD reconstruction in multivariate analysis. In conclusion, our results provide evidence that DD biliary reconstruction is feasible in liver retransplantation without increased rates of biliary complications or compromised patient and graft survival. Further studies with larger sample sizes are needed.
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Affiliation(s)
- Lena Sibulesky
- Division of Transplant Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL 32224, USA
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Live donor liver transplantation for primary sclerosing cholangitis: is disease recurrence increased? Curr Opin Gastroenterol 2011; 27:301-5. [PMID: 21248637 DOI: 10.1097/mog.0b013e3283437a8c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW There is convincing evidence that primary sclerosing cholangitis (PSC) recurs after deceased donor liver transplantation with an incidence of about 20% after 5 years. This review summarizes data regarding recurrent disease in the setting of live donor liver transplantation. RECENT FINDINGS End-stage liver disease secondary to PSC accounts for less than 3% of all live donor liver transplantations worldwide. Therefore, there are only few data regarding recurrent disease in this setting available, mainly from Japanese transplant centers. Based on these studies, however, only including a small number of patients, recurrent disease was diagnosed in 25-67% of transplant recipients after a mean follow-up of 34 months following transplantation. Cytomegalovirus infection in the early postoperative phase and biologically related donors were found to be statistically significant risk factors for disease recurrence. More than one third of patients with recurrent disease either died or developed graft failure. SUMMARY These data suggest that patients with PSC undergoing live donor liver transplantation, especially with biologically related donors, may have a higher risk to develop recurrent disease compared with the deceased donor setting. However, this fact has to be interpreted with great caution, primarily due to the rather small number of patients. Further studies analyzing pooled data of all transplant centers performing live donor liver transplantations are needed to confirm these findings.
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