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1
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Chiche L, Marichez A, Rayar M, Simon A, Mohkam K, Muscari F, Boudjema K, Mabrut JY, Adam JP, Laurent C. Liver transplantation: Do not abandon T-tube drainage-a multicentric retrospective study of the ARCHET research group. Updates Surg 2025; 77:65-75. [PMID: 39541088 DOI: 10.1007/s13304-024-02008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/25/2024] [Indexed: 11/16/2024]
Abstract
Biliary complications remain a real issue in liver transplantation (LT). Despite meta-analyses, the anastomosis technique, especially the use of biliary drain as T-Tube drain (TT) or transcystic drain, remains controversial. This study conducted by the ARCHET research group examine the incidence and types of biliary complications (BC) after LT according to the presence or absence of a biliary drain. 1485 patients with LT surgery between 2009 to 2015 in 4 LT centers were included, divided into 3 groups: no drain (ND n = 442), transcystic drain (TCD, n = 169) and TT(n = 874).The T-Tube group includes 3 techniques: transanastomotic, subanastomotic and tunneled retroperitoneal. Fistula and biliary stricture (AS) rates were studied. The risk factors of BC were investigated by multivariate analysis. The BC rate was lower in the TT group (17% TT, 25% TCD, 31% ND, p < 0.05), the complication rate Dindo-Clavien grade ≥ III is higher in the ND group (24% vs. 10% TT p < 0.05). Arterial complication has been found as a risk factor of BC with the multivariate analysis (p < 0.01, OR 1.86 [1.20-2.84]). In addition, the TT decreased by 5 the risk of AS (p < 0.05, OR 0.19 [0.12-0.28]). The fistula rate does not differ regardless of the reconstruction mode. In this study, biliary drain decreases the rate of BC. The findings confirmed the role of T-tube insertion in prevention of AS regardless of the way it is set up.
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Affiliation(s)
- Laurence Chiche
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France.
- Inserm, UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion", Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France.
| | - Arthur Marichez
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
- Inserm, UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion", Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France
| | - Michel Rayar
- Department of Hepatobiliary and Digestive Surgery, CHU Rennes, Rennes, France
- Department of Research INSERM CIC 1414, University Rennes, Rennes, France
| | - Agathe Simon
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Kayvan Mohkam
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse CHU Lyon, Lyon, France
- Department of Research, INSERM Unit U1052, Cancer Research Center of Lyon, Lyon, France
| | - Fabrice Muscari
- Department of Digestive Surgery, Toulouse University Hospital, 31059, Toulouse, France
- Department of Research, INSERM, CRCT, University Toulouse, Toulouse, France
| | - Karim Boudjema
- Department of Digestive Surgery, Toulouse University Hospital, 31059, Toulouse, France
- Department of Research, INSERM, CRCT, University Toulouse, Toulouse, France
| | - Jean-Yves Mabrut
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse CHU Lyon, Lyon, France
- Department of Research, INSERM Unit U1052, Cancer Research Center of Lyon, Lyon, France
| | - Jean-Philippe Adam
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Christophe Laurent
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
- Inserm UMR 1312, Team 8 "Biotherapy Genetics and Oncology", Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France
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2
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Vernuccio F, Mercante I, Tong XX, Crimì F, Cillo U, Quaia E. Biliary complications after liver transplantation: A computed tomography and magnetic resonance imaging pictorial review. World J Gastroenterol 2023; 29:3257-3268. [PMID: 37377585 PMCID: PMC10292145 DOI: 10.3748/wjg.v29.i21.3257] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/23/2023] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
Biliary complications are the most common complications after liver transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are cornerstones for timely diagnosis of biliary complications after liver transplantation. The diagnosis of these complications by CT and MRI requires expertise, mainly with respect to identifying subtle early signs to avoid missed or incorrect diagnoses. For example, biliary strictures may be misdiagnosed on MRI due to size mismatch of the common ducts of the donor and recipient, postoperative edema, pneumobilia, or susceptibility artifacts caused by surgical clips. Proper and prompt diagnosis of biliary complications after transplantation allows the timely initiation of appropriate management. The aim of this pictorial review is to illustrate various CT and MRI findings related to biliary complications after liver transplantation, based on time of presentation after surgery and frequency of occurrence.
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Affiliation(s)
- Federica Vernuccio
- Department of Radiology, University Hospital of Padova, Padova 35128, Italy
| | - Irene Mercante
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Xiao-Xiao Tong
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Filippo Crimì
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Umberto Cillo
- Department of Surgery, Hepatobiliary Surgery and Liver Transplant Center, Oncology and Gastroenterology (DISCOG), University of Padova, Padova 35128, Italy
| | - Emilio Quaia
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
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Anılır E, Oral A, Atasoy A, Civan HA, Topçu FS, Bayramoğlu M, Şahin E, Dirican A, Ünal B. A Single-Center's Early Surgical Outcomes of Living Donor Liver Transplantation. Transplant Proc 2023:S0041-1345(23)00156-2. [PMID: 37121859 DOI: 10.1016/j.transproceed.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/06/2023] [Accepted: 03/14/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has become an increasingly common surgical option because the number of cadaveric donors is insufficient to fulfill the organ needs of patients facing end-stage cirrhosis. Many centers are investigating different surgical techniques to achieve lower complication rates. We aimed to examine our complication rates in light of demographic data, graft data, and perioperative findings as a single-center experience. METHODS The study included one hundred and three patients who underwent LDLT for end-stage liver cirrhosis. Demographic data; sex; age; blood group; Model for End-Stage Liver Disease score; Child score; etiology; liver side; graft-to-recipient weight ratio; hepatic artery, portal vein, and bile anastomosis type rates; anhepatic phase; cold ischemia time; operation time; and blood product transfusion rates were analyzed. Biliary complications in patients with single or multiple biliary anastomoses, right or left liver transplants, and with or without hepatic artery thrombosis were analyzed statistically. RESULTS There was no significant difference in biliary complications between patients who underwent single or multiple bile anastomosis (P = .231) or patients receiving right lobe and left lobe transplants (P = .315). Although there was no statistically significant difference in the rate of portal vein thrombosis between the regular and reconstructed portal vein anastomosis groups (P = .693), the postoperative portal vein thrombosis rate was statistically higher in patients with left lobe transplants (P = .044). CONCLUSIONS Vascular and biliary complication rates can be reduced with increasing experience.
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Affiliation(s)
- Ender Anılır
- Organ Transplantation Center, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey.
| | - Alihan Oral
- Internal Medicine Department, Fenerbahce University Medicana Hospital, Istanbul, Turkey
| | - Alp Atasoy
- Gastroenterology Department, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
| | - Hasret Ayyıldız Civan
- Pediatric Gastroenterology Department, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
| | - Feyza Sönmez Topçu
- Radiology Department, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
| | - Mert Bayramoğlu
- Radiology Department, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
| | - Emrah Şahin
- Organ Transplantation Center, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
| | - Abuzer Dirican
- Organ Transplantation Center, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
| | - Bülent Ünal
- Organ Transplantation Center, İstanbul Aydın University Medikalpark Florya Hospital, Istanbul, Turkey
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4
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Elkomos BE, Abdelaal A. Do We Need to Use a Stent in Biliary Reconstruction to Decrease the Incidence of Biliary Complications in Liver Transplantation? A Systematic Review and Meta-Analysis. J Gastrointest Surg 2023; 27:180-196. [PMID: 36376727 PMCID: PMC9877101 DOI: 10.1007/s11605-022-05479-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/20/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIM Biliary complications are a significant cause of morbidity post-transplantation, and the routine use of biliary stents in liver transplantation to reduce these complications remains controversial. This study aimed to compare the incidence of biliary complications with and without the use of trans anastomotic biliary stent in liver transplantation. METHOD PubMed, Scopes, Web of Science, and Cochrane library were searched for eligible studies from inception to February 2022, and a systematic review and meta-analysis were done to compare the incidence of biliary complications in the two groups. RESULTS Seventeen studies with a total of 2623 patients were included. The pooled results from the included studies showed an equal rate of biliary complications (i.e., strictures, leaks and cholangitis) in stented and non-stented patients after liver transplantation. However, the cost and biliary intervention rates are higher in stented patients. In addition to that, our sub-group analysis showed no significant decrease in the incidence of biliary complications after using trans anastomotic biliary stent in living donor liver transplant (LDLT), deceased donor liver transplant (DDLT), Roux-en-Y hepaticojejunostomy (RYHJ), and duct-to-duct anastomosis, pediatric, and adult liver transplantation. CONCLUSION No added benefit on the routine use of endobiliary stent in liver transplantation. However, stented patients are at higher risk of needing multiple ERCPs.
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Affiliation(s)
| | - Amr Abdelaal
- General Surgery Department, Ain Shams University Hospital, Cairo, Egypt
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5
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Khubutiya MS, Kurenkov AV, Teterin YS, Yartsev PA, Novruzbekov MS. [Endoscopic intraluminal treatment of early biliary complications after orthotopic liver transplantation]. Khirurgiia (Mosk) 2023:13-19. [PMID: 37530766 DOI: 10.17116/hirurgia202308113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
OBJECTIVE To improve the outcomes after orthotopic liver transplantation (OLT) followed by early biliary complications via endoscopic bilioduodenal stenting. MATERIAL AND METHODS The study enrolled 41 patients with early biliary complications within 90 days after OLT. All patients underwent endoscopic treatment between 2001 and 2021. There were 34 (82.9%) men and 7 (17.1%) women aged 48.5±12.5 years. Strictures and failure of biliary anastomosis occurred in 33 (80.5%) and 8 (19.5%) patients, respectively. RESULTS After endoscopic treatment, serum bilirubin normalized in 3.3±0.86 days in patients with strictures (23.7 (16.4; 34.5) mmol/l, p<0.001). Diameter of lobar ducts as a criterion of biliary hypertension was normalized after 4 (2.5; 5.5) days (p<0.001). Bile leakage after stenting with a covered self-expanding stent regressed in all 7 patients after 3 (2; 5) days. In 1 patient, bile output through the drainage stopped in 8 days after bilioduodenal stenting with a plastic stent. CONCLUSION Endoscopic bilioduodenal stenting is always effective and minimally invasive treatment after liver transplantation followed by early biliary complications (failure or stricture of anastomosis). This approach minimizes postoperative complications (9.8%) that do not require surgical intervention (Clavien-Dindo grade I).
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Affiliation(s)
- M Sh Khubutiya
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - A V Kurenkov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - Yu S Teterin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - P A Yartsev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - M S Novruzbekov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
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6
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Martinino A, Pereira JPS, Spoletini G, Treglia G, Agnes S, Giovinazzo F. The use of the T-tube in biliary tract reconstruction during orthotopic liver transplantation: An umbrella review. Transplant Rev (Orlando) 2022; 36:100711. [PMID: 35843181 DOI: 10.1016/j.trre.2022.100711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 11/23/2022]
Abstract
Biliary complications are one of the main concerns after liver transplantation, and to avoid these, the use of a T-tube has been advocated in biliary reconstruction. Most liver transplantation centres perform a biliary anastomosis without a T-tube to avoid the risk of complications and T-tube-related costs. Several meta-analyses have reached discordant conclusions regarding the benefits of using the T-tube. An umbrella review was performed to summarise quantitative measures about overall biliary complications, biliary leaks, biliary strictures and cholangitis associated with the T-tube use after liver transplantation. Published systematic reviews and meta-analyses related to the use of T-Tube in liver transplantation were searched and analysed. From the comprehensive literature search from PubMed, EMBASE and Cochrane Library databases on the 25th of October 2021, 104 records were retrieved. Seven meta-analyses and two systematic reviews were included in the final analysis. All the meta-analyses of RCT stated no differences in overall biliary complications and biliary leaks when using T-tube for a liver transplant (I2 ≥ 90% and I2 range 0-76%, respectively). The meta-analysis of the RCTs evaluating the risks of biliary strictures after liver transplantation showed that T-tube protects from the complication (I2 range 0-80%). Biliary anastomosis without a T-tube has equivalent overall biliary complications and bile leaks compared to the T-tube reconstruction. The incidence of biliary strictures is attenuated in patients with T-tubes, and most meta-analyses of RCTs have very low heterogeneity. Therefore, the present umbrella review suggests a selective T-tube use, particularly in small biliary ducts or transplants with marginal grafts at high risk of post-LT strictures.
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Affiliation(s)
| | | | - Gabriele Spoletini
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giorgio Treglia
- Academic Education, Research and Innovation Area, General Directorate, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland; Faculty of Biology and Medicine, University of Lausanne, 1011 Lausanne, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, 6900 Lugano, Switzerland
| | - Salvatore Agnes
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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7
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Kalisvaart M, de Jonge J, Abt P, Orloff S, Muiesan P, Florman S, Spiro M, Raptis DA, Eghtesad B. The role of T-tubes and abdominal drains on short-term outcomes in liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14719. [PMID: 35596705 PMCID: PMC10078006 DOI: 10.1111/ctr.14719] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This systematic review and expert panel recommendation aims to answer the question regarding the routine use of T-tubes or abdominal drains to better manage complications and thereby improve outcomes after liver transplantation. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel to assess the potential risks and benefits of T-tubes and intra-abdominal drainage in liver transplantation (CRD42021243036). RESULTS Of the 2996 screened records, 33 studies were included in the systematic review, of which 29 (six RCTs) assessed the use of T-tubes and four regarding surgical drains. Although some studies reported less strictures when using a T-tube, there was a trend toward more biliary complications with T-tubes, mainly related to biliary leakage. Due to the small number of studies, there was a paucity of evidence on the effect of abdominal drains with no clear benefit for or against the use of drainage. However, one study investigating the open vs. closed circuit drains found a significantly higher incidence of intra-abdominal infections when open-circuit drains were used. CONCLUSIONS Due to the potential risk of biliary leakage and infections, the routine intraoperative insertion of T-tubes is not recommended (Level of Evidence moderate - very low; grade of recommendation strong). However, a T-tube can be considered in cases at risk for biliary stenosis. Due to the scant evidence on abdominal drainage, no change in clinical practice in individual centers is recommended. (Level of Evidence very low; weak recommendation).
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Affiliation(s)
- Marit Kalisvaart
- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jeroen de Jonge
- Erasmus MC Transplant Institute, Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter Abt
- Department of Surgery, Division of Transplantation, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/ Hepatobiliary Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Paolo Muiesan
- Policlinico di Milano Ospedale Maggiore
- Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Sander Florman
- The Recanati Miller Transplantation Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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8
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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: 27] [Impact Index Per Article: 9.0] [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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9
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Pravisani R, Isola M, Lorenzin D, Cherchi V, Boscolo E, Mocchegiani F, Terrosu G, Baccarani U. Re-thinking of T-tube use in whole liver transplantation: an analysis on the risk of delayed graft function. Updates Surg 2022; 74:571-577. [PMID: 35325442 PMCID: PMC8995289 DOI: 10.1007/s13304-022-01267-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/28/2022] [Indexed: 02/07/2023]
Abstract
The liver-gut axis has been identified as crucial mediator of liver regeneration. Thus, the use of a T-tube in liver transplantation (LT), which interrupts the enterohepatic bile circulation, may potentially have a detrimental effect on the early allograft functional recovery. We retrospectively analyzed a cohort of 261 patients transplanted with a whole liver graft, with a duct-to-duct biliary anastomosis, who did not develop any surgical complication within postoperative day 14. Early allograft dysfunction (EAD) was defined according to the criteria of Olthoff et al. (EAD-O), and graded according to the Model for Early Allograft Function (MEAF) score. EAD-O developed in 24.7% of recipients and the median MEAF score was 4.0 [interquartile range 2.9-5.5]. Both MEAF and EAD predicted 90-day post-LT mortality. A T-tube was used in 49.4% of cases (n = 129). After a propensity score matching for donor age, cold and warm ischemia time, donor risk index, balance of risk score, Child-Pugh class C, and MELD score, the T-tube group showed a significantly higher prevalence of EAD-O and value of MEAF than the no-T-tube group (EAD-O: 29 [34.1%] vs 16 [19.0%], p = 0.027; MEAF 4.5 [3.5-5.7] vs 3.7 [2.9-5.0], p = 0.014). In conclusion, T-tube use in LT may be a risk factor for EAD and higher MEAF, irrespective of graft quality and severity of pre-LT liver disease.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Miriam Isola
- Division of Medical Statistic, Department of Medicine, University of Udine, Udine, Italy
| | - Dario Lorenzin
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Vittorio Cherchi
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Erica Boscolo
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Mocchegiani
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Giovanni Terrosu
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
- Dipartimento Di Area Medica, University of Udine, P.Le Kolbe, Via Colugna 50, 33100 Udine, Italy
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10
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Spoletini G, Bianco G, Franco A, Frongillo F, Nure E, Giovinazzo F, Galiandro F, Tringali A, Perri V, Costamagna G, Avolio AW, Agnes S. Pediatric T-tube in adult liver transplantation: Technical refinements of insertion and removal. World J Gastrointest Surg 2021; 13:1628-1637. [PMID: 35070068 PMCID: PMC8727192 DOI: 10.4240/wjgs.v13.i12.1628] [Citation(s) in RCA: 1] [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: 03/17/2021] [Revised: 05/17/2021] [Accepted: 11/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With the increasing use of extended-criteria donor organs, the interest around T-tubes in liver transplantation (LT) was restored whilst concerns regarding T-tube-related complications persist. AIM To describe insertion and removal protocols implemented at our institution to safely use pediatric rubber 5-French T-tubes and subsequent outcomes in a consecutive series of adult patients. METHODS Data of consecutive adult LT patients from brain-dead donors, treated from March 2017 to December 2019, were collected (i.e., biliary complications, adverse events, treatment after T-Tube removal). Patients with upfront hepatico-jejunostomy, endoscopically removed T-tubes, those who died or received retransplantation before T-tube removal were excluded. RESULTS Seventy-two patients were included in this study; T-tubes were removed 158 d (median; IQR 128-206 d) after LT. In four (5.6%) patients accidental T-tube removal occurred requiring monitoring only; in 68 (94.4%) patients Nelaton drain insertion was performed according to our protocol, resulting in 18 (25%) patients with a biliary output, subsequently removed after 2 d (median; IQR 1-4 d). Three (4%) patients required endoscopic retrograde cholangiopancreatography (ERCP) due to persistent Nelaton drain output. Three (4%) patients developed suspected biliary peritonitis, requiring ERCP with sphincterotomy and nasobiliary drain insertion (only one revealing contrast extravasation); no patient required percutaneous drainage or emergency surgery. CONCLUSION The use of pediatric rubber 5-French T-tubes in LT proved safe in our series after insertion and removal procedure refinements.
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Affiliation(s)
- Gabriele Spoletini
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Bianco
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Antonio Franco
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Francesco Frongillo
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Erida Nure
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Federica Galiandro
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Alfonso Wolfango Avolio
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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11
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Song S, Lu T, Yang W, Gong S, Lei C, Yang J, Feng L, Tian H, Yang K, Guo T. T-tube or no T-tube for biliary tract reconstruction in orthotopic liver transplantation: an updated systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2021; 15:1201-1213. [PMID: 33720798 DOI: 10.1080/17474124.2021.1903874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives: Biliary tract reconstruction with or without T-tube is commonly used in orthotopic liver transplantation (OLT). However, the efficacy and safety of T-tube usage remain controversial. This meta-analysis was conducted to assess the latest evidence of clinical outcomes.Methods: Embase, Cochrane Library, PubMed, and Web of Science were systematically searched from inception to 20 January 2021 for eligible studies. The analyses were performed using Review Manager and Stata.Results: A total of 24 trials involving 3320 participants were included in the meta-analysis. Compared with the no T-tube group, there was a higher incidence of overall biliary complications (OR:1.54; 95%CI, 1.06-2.24; P = 0.02), bile leaks (OR:2.34; 95%CI,1.57-3.48; P < 0.0001), cholangitis (OR:2.78; 95%CI,1.19-6.51; P = 0.002), and longer cold ischemia time (MD:22.27; 95%CI,0.80-43.74; P = 0.04) in the T-tube group. Furthermore, the no T-tube group had significantly higher odds of biliary strictures than the T-tube group (OR:0.60; 95%CI, 0.47-0.78; P = 0.0001).Conclusion: T-tube is still not routinely recommended, but is a good choice for OLT patients at high risk of biliary strictures. Notably, the higher rate of biliary complications in the T-tube group did not translate into an increase in endoscopic or re-operative interventions.
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Affiliation(s)
- Shaoming Song
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tingting Lu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Institution of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou, China
| | - Wenwen Yang
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Shiyi Gong
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Caining Lei
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Jia Yang
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Lufang Feng
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hongwei Tian
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
| | - Tiankang Guo
- Department of Clinical Medicine, The First Clinical Medical College of Lanzhou University, Lanzhou, China.,Department of General Surgery, Gansu Provincial Hospital, Lanzhou, China
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12
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Matar AJ, Ross-Driscoll K, Kenney L, Wichmann HK, Magliocca JF, Kitchens WH. Biliary Complications Following Adult Deceased Donor Liver Transplantation: Risk Factors and Implications at a High-volume US Center. Transplant Direct 2021; 7:e754. [PMID: 34514109 PMCID: PMC8425824 DOI: 10.1097/txd.0000000000001207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/11/2021] [Accepted: 07/02/2021] [Indexed: 01/20/2023] Open
Abstract
Biliary leaks and anastomotic strictures comprise the majority of biliary complications (BCs) following liver transplantation (LT). Currently, there are few large contemporary case series of BCs in adult deceased donor liver transplant (DDLT) recipients in the literature. The purpose of this study was to examine the pretransplant and intraoperative risk factors associated with BCs at a high-volume tertiary care center and determine the impact of these BCs on their posttransplant course and long-term transplant outcomes. METHODS We retrospectively reviewed all adult patients undergoing a DDLT from a donor after brain death (DBD) at Emory University between January 2015 and December 2019. RESULTS A total of 647 adult patients underwent DDLT from a DBD during the study period and were included in analyses. The median length of follow-up posttransplant was 2.5 y. There were a total of 27 bile leaks (4.2%) and 69 biliary strictures (10.7%). Recipient age and cold ischemic time were identified as risk factors for biliary leak, whereas alcoholic cirrhosis as transplant indication was a risk factor for biliary stricture. Placement of a biliary stent was associated with the development of both biliary leaks and anastomotic strictures. Posttransplant, biliary leaks were a significant risk factor for future episodes of acute rejection but did not impact overall survival. In contrast, biliary strictures were associated with a significantly reduced overall survival at 1- and 4-y post DDLT. CONCLUSIONS BCs are a major source of morbidity and mortality following DDLT, with strictures and leaks associated with distinct posttransplant complications.
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Affiliation(s)
- Abraham J. Matar
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Katie Ross-Driscoll
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Lisa Kenney
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Hannah K. Wichmann
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - Joseph F. Magliocca
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
| | - William H. Kitchens
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, GA
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13
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Pravisani R, De Simone P, Patrono D, Lauterio A, Cescon M, Gringeri E, Colledan M, Di Benedetto F, di Francesco F, Antonelli B, Manzia TM, Carraro A, Vivarelli M, Regalia E, Vennarecci G, Guglielmo N, Cesaretti M, Avolio AW, Valentini MF, Lai Q, Baccarani U. An Italian survey on the use of T-tube in liver transplantation: old habits die hard! Updates Surg 2021; 73:1381-1389. [PMID: 33792888 PMCID: PMC8397659 DOI: 10.1007/s13304-021-01019-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/02/2021] [Indexed: 12/13/2022]
Abstract
There is enough clinical evidence that a T-tube use in biliary reconstruction at adult liver transplantation (LT) does not significantly modify the risk of biliary stricture/leak, and it may even sustain infective and metabolic complications. Thus, the policy on T-tube use has been globally changing, with progressive application of more restrictive selection criteria. However, there are no currently standardized indications in such change, and many LT Centers rely only on own experience and routine. A nation-wide survey was conducted among all the 20 Italian adult LT Centers to investigate the current policy on T-tube use. It was found that 20% of Centers completely discontinued the T-tube use, while 25% Centers used it routinely in all LT cases. The remaining 55% of Centers applied a selective policy, based on criteria of technical complexity of biliary reconstruction (72.7%), followed by low-quality graft (63.6%) and high-risk recipient (36.4%). A T-tube use > 50% of annual caseload was not associated with high-volume Center status (> 70 LT per year), an active pediatric or living-donor transplant program, or use of DCD grafts. Only 10/20 (50%) Centers identified T-tube as a potential risk factor for complications other than biliary stricture/leak. In these cases, the suspected pathogenic mechanism comprised bacterial colonization (70%), malabsorption (70%), interruption of the entero-hepatic bile-acid cycle (50%), biliary inflammation due to an indwelling catheter (40%) and gut microbiota changes (40%). In conclusion, the prevalence of T-tube use among the Italian LT Centers is still relatively high, compared to the European trend (33%), and the potential detrimental effect of T-tube, beyond biliary stricture/leak, seems to be somehow underestimated.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University Hospital Pisa, Pisa, Italy
| | - Damiano Patrono
- General Surgery 2U, Liver Transplant Center, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Andrea Lauterio
- General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria-Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital, Padua, Italy
| | - Michele Colledan
- Chirurgia Generale 3, Trapianti Addominali, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT-UPMC, Palermo, Italy
| | - Barbara Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Maria Manzia
- HPB and Transplant Unit, Department of Surgery Science, University of Rome Tor Vergata, Rome, Italy
| | - Amedeo Carraro
- General Surgery and Liver Transplant Unit, University Hospital of Verona, Verona, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Enrico Regalia
- HPB Surgery and Transplantation Unit, Istituto Nazionale Tumori, IRCCS, Milano, Italy
| | - Giovanni Vennarecci
- Laproscopic, Hepatic, and Liver Transplant Unit, AORN A. Cardarelli, Naples, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | - Manuela Cesaretti
- Liver Transplant Unit, Department of General Surgery, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfonso Wolfango Avolio
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Filippa Valentini
- General Surgery and Liver Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy.
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14
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Zhao JZ, Qiao LL, Du ZQ, Zhang J, Wang MZ, Wang T, Liu WM, Zhang L, Dong J, Wu Z, Wu RQ. T-tube vsno T-tube for biliary tract reconstruction in adult orthotopic liver transplantation: An updated systematic review and meta-analysis. World J Gastroenterol 2021; 27:1507-1523. [DOI: https:/dx.doi.org/10.3748/wjg.v27.i14.1507] [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: 04/21/2025] Open
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15
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Zhao JZ, Qiao LL, Du ZQ, Zhang J, Wang MZ, Wang T, Liu WM, Zhang L, Dong J, Wu Z, Wu RQ. T-tube vs no T-tube for biliary tract reconstruction in adult orthotopic liver transplantation: An updated systematic review and meta-analysis. World J Gastroenterol 2021; 27:1507-1523. [PMID: 33911471 PMCID: PMC8047534 DOI: 10.3748/wjg.v27.i14.1507] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/29/2020] [Accepted: 03/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Whether to use a T-tube for biliary anastomosis during orthotopic liver transplantation (OLT) remains a debatable question. Some surgeons chose to use a T-tube because they believed that it reduces the incidence of biliary strictures. Advances in surgical techniques during the last decades have significantly decreased the overall incidence of postoperative biliary complications. Whether using a T-tube during OLT is still associated with the reduced incidence of biliary strictures needs to be re-evaluated. AIM To provide an updated systematic review and meta-analysis on using a T-tube during adult OLT. METHODS In the electronic databases MEDLINE, PubMed, Scopus, ClinicalTrials.gov, the Cochrane Library, the Cochrane Hepato-Biliary Group Controlled Trails Register, and the Cochrane Central Register of Controlled Trials, we identified 17 studies (eight randomized controlled trials and nine comparative studies) from January 1995 to October 2020. The data of the studies before and after 2010 were separately extracted. We chose the overall biliary complications, bile leaks or fistulas, biliary strictures (anastomotic or non-anastomotic), and cholangitis as outcomes. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to describe the results of the outcomes. Furthermore, the test for overall effect (Z) was used to test the difference between OR and 1, where P ≤ 0.05 indicated a significant difference between OR value and 1. RESULTS A total of 1053 subjects before 2010 and 1346 subjects after 2010 were included in this meta-analysis. The pooled results showed that using a T-tube reduced the incidence of postoperative biliary strictures in studies before 2010 (P = 0.012, OR = 0.62, 95%CI: 0.42-0.90), while the same benefit was not seen in studies after 2010 (P = 0.60, OR = 0.76, 95%CI: 0.27-2.12). No significant difference in the incidence of overall biliary complications (P = 0.37, OR = 1.41, 95%CI: 0.66-2.98), bile leaks (P = 0.89, OR = 1.04, 95%CI: 0.63-1.70), and cholangitis (P = 0.27, OR = 2.00, 95%CI: 0.59-6.84) was observed between using and not using a T-tube before 2010. However, using a T-tube appeared to increase the incidence of overall biliary complications (P = 0.049, OR = 1.49, 95%CI: 1.00-2.22), bile leaks (P = 0.048, OR = 1.91, 95%CI: 1.01-3.64), and cholangitis (P = 0.02, OR = 7.21, 95%CI: 1.37-38.00) after 2010. A random-effects model was used in biliary strictures (after 2010), overall biliary complications (before 2010), and cholangitis (before 2010) due to their heterogeneity (I 2 = 62.3%, 85.4%, and 53.6%, respectively). In the sensitivity analysis (only RCTs included), bile leak (P = 0.66) lost the significance after 2010 and a random-effects model was used in overall biliary complications (before 2010), cholangitis (before 2010), bile leaks (after 2010), and biliary strictures (after 2010) because of their heterogeneity (I 2 = 92.2%, 65.6%, 50.9%, and 80.3%, respectively). CONCLUSION In conclusion, the evidence gathered in our updated meta-analysis showed that the studies published in the last decade did not provide enough evidence to support the routine use of T-tube in adults during OLT.
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Affiliation(s)
- Jun-Zhou Zhao
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Lin-Lan Qiao
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Zhao-Qing Du
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Jia Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Meng-Zhou Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Tao Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Wu-Ming Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Lin Zhang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Jian Dong
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Rong-Qian Wu
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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16
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Magro B, Tacelli M, Mazzola A, Conti F, Celsa C. Biliary complications after liver transplantation: current perspectives and future strategies. Hepatobiliary Surg Nutr 2021; 10:76-92. [PMID: 33575291 DOI: 10.21037/hbsn.2019.09.01] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
Importance Liver transplantation (LT) is a life-saving therapy for patients with end-stage liver disease and with acute liver failure, and it is associated with excellent outcomes and survival rates at 1 and 5 years. The incidence of biliary complications (BCs) after LT is reported to range from 5% to 20%, most of them occurring in the first three months, although they can occur also several years after transplantation. Objective The aim of this review is to summarize the available evidences on pathophysiology, risk factors, diagnosis and therapeutic management of BCs after LT. Evidence Review a literature review was performed of papers on this topic focusing on risk factors, classifications, diagnosis and treatment. Findings Principal risk factors include surgical techniques and donor's characteristics for biliary leakage and anastomotic biliary strictures and vascular alterations for non- anastomotic biliary strictures. MRCP is the gold standard both for intra- and extrahepatic BCs, while invasive cholangiography should be restricted for therapeutic uses or when MRCP is equivocal. About treatment, endoscopic techniques are the first line of treatment with success rates of 70-100%. The combined success rate of ERCP and PTBD overcome 90% of cases. Biliary leaks often resolve spontaneously, or with the positioning of a stent in ERCP for major bile leaks. Conclusions and Relevance BCs influence morbidity and mortality after LT, therefore further evidences are needed to identify novel possible risk factors, to understand if an immunological status that could lead to their development exists and to compare the effectiveness of innovative surgical and machine perfusion techniques.
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Affiliation(s)
- Bianca Magro
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Matteo Tacelli
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Filomena Conti
- Service d'Hépatologie et Transplantation Hépatique, Hôpital de la Pitié Salpétrière, AP-HP, Paris, France
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy
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17
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Zheng BW, Yi SH, Wu T, Liao M, Zhang YC, Yuan LX, Zheng RQ, Yang Y, Ren J. CEUS detection of biliary ischaemia during the first 4 weeks after liver transplantation predicts non-anastomotic biliary stricture. Clin Hemorheol Microcirc 2021; 79:519-530. [PMID: 34366329 DOI: 10.3233/ch-211097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Biliary ischaemia is an important factor in the pathogenesis of non-anastomotic biliary stricture (NAS) after liver transplantation (LT). Contrast-enhanced ultrasound (CEUS) can be used to detect biliary ischaemia, but no study has examined the utility of CEUS in predicting NAS. OBJECTIVE To evaluate whether repeated CEUS as a non-invasive method of biliary ischaemia can identify NAS. METHODS Consecutive LT patients who underwent CEUS examinations at 1-4 weeks after LT from September 2012 to December 2015 at our institution were included. The CEUS images and clinical data were analysed. RESULTS Among 116 eligible LT patients, 39 (33.6%) were diagnosed with NAS within 1 year after LT. The patients with NAS had a significantly higher CEUS score at weeks 2-4 (all P < 0.05) and a higher slope of CEUS score progression (0.480 vs -0.044, P < 0.001). The accuracy of CEUS in identifying NAS improved over time after LT, reaching its maximum at week 4, with a sensitivity of 66.7%, a specificity of 87.9%, a positive predictive value (PPV) of 75.9%, a negative predictive value (NPV) of 82.3%, and an accuracy of 80.2%in the full cohort when a CEUS score≥3 was used as the cut-off. Multivariate analysis identified gamma-glutamyl transpeptidase (GGT), alanine transaminase (ALT) and the CEUS score at week 4 as independent predictors of NAS. In the task of identifying NAS, an NAS score combining the above 3 variables at week 4 showed areas under the receiver operating characteristic curve of 0.88 (95%CI, 0.78-0.99) in the estimation group (n = 60) and 0.82 (95%CI, 0.69-0.96) in the validation group (n = 56). An NAS score cut-off of 0.396 identified 87.2%of NAS cases in the estimation group, with a PPV of 93.3%; and 75.0%of NAS cases in the validation group, with a PPV of 58.8%. CONCLUSIONS CEUS examination during the first 4 weeks is useful in assessing the risk of NAS within 1 year after LT. In particular, an NAS score combining the CEUS score, GGT level, and ALT level at week 4 can be used to accurately predict the risk of NAS in LT patients.
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Affiliation(s)
- Bo-Wen Zheng
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Shu-Hong Yi
- Department of Liver Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Tao Wu
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Mei Liao
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Ying-Cai Zhang
- Department of Liver Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Lian-Xiong Yuan
- Department of Scientific Research, The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Rong-Qin Zheng
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Yang Yang
- Department of Liver Transplantation, The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
| | - Jie Ren
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Key Laboratory of Hepatology Research, Guangzhou, Guangdong, People's Republic of China
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18
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Girard E, Chagnon G, Moreau‐Gaudry A, Letoublon C, Favier D, Dejean S, Trilling B, Nottelet B. Evaluation of a biodegradable
PLA–PEG–PLA
internal biliary stent for liver transplantation: in vitro degradation and mechanical properties. J Biomed Mater Res B Appl Biomater 2020; 109:410-419. [DOI: 10.1002/jbm.b.34709] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/16/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Edouard Girard
- Univ. Grenoble Alpes, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC‐IMAG Grenoble France
- Département de chirurgie digestive et de l'urgence Centre Hospitalier Grenoble‐Alpes Grenoble France
| | - Grégory Chagnon
- Univ. Grenoble Alpes, CNRS, Grenoble INP, TIMC‐IMAG Grenoble France
| | - Alexandre Moreau‐Gaudry
- Univ. Grenoble Alpes, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC‐IMAG Grenoble France
- Univ. Grenoble Alpes, CNRS, Grenoble INP, TIMC‐IMAG Grenoble France
| | - Christian Letoublon
- Département de chirurgie digestive et de l'urgence Centre Hospitalier Grenoble‐Alpes Grenoble France
| | - Denis Favier
- Univ. Grenoble Alpes, CNRS, Grenoble INP, TIMC‐IMAG Grenoble France
| | - Stéphane Dejean
- IBMM Université de Montpellier, CNRS, ENSCM Montpellier France
| | - Bertrand Trilling
- Univ. Grenoble Alpes, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC‐IMAG Grenoble France
- Département de chirurgie digestive et de l'urgence Centre Hospitalier Grenoble‐Alpes Grenoble France
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Brüggenwirth IMA, Porte RJ, Martins PN. Bile Composition as a Diagnostic and Prognostic Tool in Liver Transplantation. Liver Transpl 2020; 26:1177-1187. [PMID: 32246581 DOI: 10.1002/lt.25771] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/06/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
Bile secretion and composition reflects the functional status of hepatocytes and cholangiocytes. Bile composition can have a role in the assessment of donor grafts before implantation in the recipient. In addition, changes in bile composition after liver transplantation can serve as a diagnostic and prognostic tool to predict posttransplant complications, such as primary nonfunction, acute cellular rejection, or nonanastomotic biliary strictures. With the popularization of liver machine perfusion preservation in the clinical setting, there is a revisited interest in biliary biomarkers to assess graft viability before implantation. This review discusses current literature on biliary biomarkers that could predict or assess liver graft and bile duct viability. Bile composition offers an exciting and novel perspective in the search for reliable hepatocyte and cholangiocyte viability biomarkers.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, the Netherlands
| | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
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20
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Girard E, Chagnon G, Broisat A, Dejean S, Soubies A, Gil H, Sharkawi T, Boucher F, Roth GS, Trilling B, Nottelet B. From in vitro evaluation to human postmortem pre-validation of a radiopaque and resorbable internal biliary stent for liver transplantation applications. Acta Biomater 2020; 106:70-81. [PMID: 32014582 DOI: 10.1016/j.actbio.2020.01.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 12/17/2022]
Abstract
The implantation of an internal biliary stent (IBS) during liver transplantation has recently been shown to reduce biliary complications. To avoid a potentially morbid ablation procedure, we developed a resorbable and radiopaque internal biliary stent (RIBS). We studied the mechanical and radiological properties of RIBS upon in vivo implantation in rats and we evaluated RIBS implantability in human anatomical specimens. For this purpose, a blend of PLA50-PEG-PLA50 triblock copolymer, used as a polymer matrix, and of X-ray-visible triiodobenzoate-poly(ε-caprolactone) copolymer (PCL-TIB), as a radiopaque additive, was used to design X-ray-visible RIBS. Samples were implanted in the peritoneal cavity of rats. The radiological, chemical, and biomechanical properties were evaluated during degradation. Further histological studies were carried out to evaluate the degradation and compatibility of the RIBS. A human cadaver implantability study was also performed. The in vivo results revealed a decline in the RIBS mechanical properties within 3 months, whereas clear and stable X-ray visualization of the RIBS was possible for up to 6 months. Histological analyses confirmed compatibility and resorption of the RIBS, with a limited inflammatory response. The RIBS could be successfully implanted in human anatomic specimens. The results reported in this study will allow the development of trackable and degradable IBS to reduce biliary complications after liver transplantation. STATEMENT OF SIGNIFICANCE: Biliary reconstruction during liver transplantation is an important source of postoperative morbidity and mortality although it is generally considered as an easy step of a difficult surgery. In this frame, internal biliary stent (IBS) implantation is beneficial to reduce biliary anastomosis complications (leakage, stricture). However, current IBS are made of non-degradable silicone elastomeric materials, which leads to an additional ablation procedure involving potential complications and additional costs. The present study provides in vitro and human postmortem implantation data related to the development and evaluation of a resorbable and radiopaque internal biliary stent (RIBS) that could tackle these drawbacks.
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Affiliation(s)
- Edouard Girard
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France; Département de chirurgie digestive et de l'urgence, Centre Hospitalier Grenoble-Alpes, 38000 Grenoble, France; Laboratoire d'anatomie des Alpes françaises (LADAF), UFR de médecine de Grenoble, Université de Grenoble-Alpes, F-38700 Grenoble, France.
| | - Grégory Chagnon
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France
| | - Alexis Broisat
- INSERM, Unité 1039, F-38000 Grenoble, France; Radiopharmaceutiques Biocliniques, Université Grenoble-Alpes, F-38000 Grenoble, France
| | - Stéphane Dejean
- IBMM, Université de Montpellier, CNRS, ENSCM, Montpellier, France
| | - Audrey Soubies
- INSERM, Unité 1039, F-38000 Grenoble, France; Radiopharmaceutiques Biocliniques, Université Grenoble-Alpes, F-38000 Grenoble, France
| | - Hugo Gil
- Département d'anatomopathologie et cytologie, Centre Hospitalier Grenoble-Alpes, 38000 Grenoble, France
| | - Tahmer Sharkawi
- ICGM, Université de Montpellier, CNRS, ENSCM, Montpellier, France
| | - François Boucher
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France; Radiopharmaceutiques Biocliniques, Université Grenoble-Alpes, F-38000 Grenoble, France
| | - Gaël S Roth
- Institute for Advanced Biosciences, INSERM U1209/CNRS UMR 5309, Université Grenoble-Alpes, F-38700 Grenoble, France; Clinique universitaire d'Hépato-gastroentérologie et Oncologie digestive, CHU Grenoble-Alpes, Grenoble 38043, France
| | - Bertrand Trilling
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, F-38000 Grenoble, France; Département de chirurgie digestive et de l'urgence, Centre Hospitalier Grenoble-Alpes, 38000 Grenoble, France; Laboratoire d'anatomie des Alpes françaises (LADAF), UFR de médecine de Grenoble, Université de Grenoble-Alpes, F-38700 Grenoble, France
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21
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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: 1] [Impact Index Per Article: 0.2] [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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22
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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: 65] [Impact Index Per Article: 10.8] [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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23
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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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24
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Selective Indication of T-Tube in Liver Transplantation: Prospective Validation of the Results of a Randomized Controlled Trial. Transplant Proc 2019; 51:44-49. [DOI: 10.1016/j.transproceed.2018.03.133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/15/2018] [Indexed: 01/03/2023]
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25
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Fontanilla Echeveste T, Villacastín Ruiz E, Álvarez Guisasola V, Duca AM. Updates on liver transplantation: vascular and biliary complications. RADIOLOGIA 2018; 60:521-533. [PMID: 30001830 DOI: 10.1016/j.rx.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/29/2018] [Accepted: 05/29/2018] [Indexed: 12/29/2022]
Abstract
This article uses a practical approach to explain the imaging findings for vascular and biliary complications after total liver transplantation in adults, comparing them to the normal imaging findings after transplantation. It emphasizes the radiologic management of patients who have undergone transplantations and explains the treatment of the different complications by interventional radiology. The information provided comes from the authors' experience and a thorough, up-to-date review of the indexed literature.
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Affiliation(s)
- T Fontanilla Echeveste
- Servicio de Radiología, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España.
| | - E Villacastín Ruiz
- Servicio de Radiología, Hospital Universitario Río Hortega, Valladolid, España
| | - V Álvarez Guisasola
- Servicio de Radiología, Hospital Universitario Río Hortega, Valladolid, España
| | - A M Duca
- Servicio de Medicina Interna, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
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26
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Internal biliary stenting in liver transplantation. Langenbecks Arch Surg 2018; 403:487-494. [DOI: 10.1007/s00423-018-1669-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
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27
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Renz BW, Bösch F, Angele MK. Bile Duct Injury after Cholecystectomy: Surgical Therapy. Visc Med 2017; 33:184-190. [PMID: 28785565 PMCID: PMC5527188 DOI: 10.1159/000471818] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries. METHODS This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view. RESULTS AND CONCLUSION In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.
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Affiliation(s)
| | | | - Martin K. Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
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28
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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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29
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Biliary Duct-to-Duct Reconstruction with a Tunneled Retroperitoneal T-Tube During Liver Transplantation: a Novel Approach to Decrease Biliary Leaks After T-Tube Removal. J Gastrointest Surg 2017; 21:723-730. [PMID: 27815760 DOI: 10.1007/s11605-016-3313-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/19/2016] [Indexed: 01/31/2023]
Abstract
The benefit of placing a T-tube for duct-to-duct biliary reconstruction during orthotopic liver transplantation (OLT) remains controversial because it could be associated with specific complications, especially at the time of T-tube removal. While the utility of T-tube during OLT represents an eternal debate, only a few technical refinements of T-tube placement have been described since the report of the original technique by Starzl and colleagues. Herein, we present a novel technique of T-tube placement for duct-to-duct biliary reconstruction during OLT, using a tunneled retroperitoneal route. On the basis of our experience of 305 patients who benefitted from the reported technique, the placement of a tunneled retroperitoneal biliary T-tube appears to be safe and results in a low rate of biliary complications, especially at the time of T-tube removal.
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30
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Olthof PB, Coelen RJ, Wiggers JK, Besselink MG, Busch OR, van Gulik TM. External biliary drainage following major liver resection for perihilar cholangiocarcinoma: impact on development of liver failure and biliary leakage. HPB (Oxford) 2016; 18:348-53. [PMID: 27037204 PMCID: PMC4814608 DOI: 10.1016/j.hpb.2015.11.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative biliary drainage is considered essential in perihilar cholangiocarcinoma (PHC) requiring major hepatectomy with biliary-enteric reconstruction. However, evidence for postoperative biliary drainage as to protect the anastomosis is currently lacking. This study investigated the impact of postoperative external biliary drainage on the development of post-hepatectomy biliary leakage and liver failure (PHLF). METHODS All patients who underwent major liver resection for suspected PHC between 2000 and 2015 were retrospectively analyzed. Biliary leakage and PHLF was defined as grade B or higher according to the International Study Group of Liver Surgery (ISGLS) criteria. RESULTS Eighty-nine out of 125 (71%) patients had postoperative external biliary drainage. PHLF was more prevalent in the drain group (29% versus 6%; P = 0.004). There was no difference in the incidence of biliary leakage (32% versus 36%). On multivariable analysis, postoperative external biliary drainage was identified as an independent risk factor for PHLF (Odds-ratio 10.3, 95% confidence interval 2.1-50.4; P = 0.004). CONCLUSIONS External biliary drainage following major hepatectomy for PHC was associated with an increased incidence of PHLF. It is therefore not recommended to routinely use postoperative external biliary drainage, especially as there is no evidence that this decreases the risk of biliary anastomotic leakage.
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Affiliation(s)
- Pim B. Olthof
- Correspondence Pim B. Olthof, Department of Experimental Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Tel: +31 20 56 68837. Fax: +31 20 697 6621.
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31
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Lee SK, Choi JY, Yeo DM, Lee YJ, Yoon SK, Bae SH, Jang JW, Kim HY, Kim DG, You YK. Risk factors of biliary intervention by imaging after living donor liver transplantation. World J Gastroenterol 2016; 22:2342-2348. [PMID: 26900296 PMCID: PMC4735008 DOI: 10.3748/wjg.v22.i7.2342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 11/14/2015] [Accepted: 12/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the risk factors of biliary intervention using magnetic resonance cholangiopancreatography (MRCP) after living donor liver transplantation (LDLT). METHODS We retrospectively enrolled 196 patients who underwent right lobe LDLT between 2006 and 2010 at a single liver transplantation center. Direct duct-to-duct biliary anastomosis was performed in all 196 patients. MRCP images routinely taken 1 mo after LDLT were analyzed to identify risk factors for biliary intervention during follow-up, such as retrograde cholangiopancreatography or percutaneous transhepatic biliary drainage. Two experienced radiologists evaluated the MRCP findings, including the anastomosis site angle on three-dimensional images, the length of the filling defect on maximum intensity projection, bile duct dilatation, biliary stricture, and leakage. RESULTS Eighty-nine patients underwent biliary intervention during follow-up. The anastomosis site angle [hazard ratio (HR) = 0.48; 95% confidence interval (CI), 0.30-0.75, P < 0.001], a filling defect in the anastomosis site (HR = 2.18, 95%CI: 1.41-3.38, P = 0.001), and biliary leakage (HR = 2.52, 95%CI: 1.02-6.20, P = 0.048) on MRCP were identified in the multivariate analysis as significant risk factors for biliary intervention during follow-up. Moreover, a narrower anastomosis site angle (i.e., below the median angle of 113.3°) was associated with earlier biliary intervention (38.5 ± 4.2 mo vs 62. 1 ± 4.1 mo, P < 0.001). Kaplan-Meier analysis comparing biliary intervention-free survival according to the anastomosis site angle revealed that lower survival was associated with a narrower anastomosis site angle (36.3% vs 62.0%, P < 0.001). CONCLUSION The biliary anastomosis site angle in MRCP after LDLT may be associated with the need for biliary intervention.
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32
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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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33
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Weiss S, Messner F, Huth M, Weissenbacher A, Denecke C, Aigner F, Brandl A, Dziodzio T, Sucher R, Boesmueller C, Oellinger R, Schneeberger S, Oefner D, Pratschke J, Biebl M. Impact of abdominal drainage systems on postoperative complication rates following liver transplantation. Eur J Med Res 2015; 20:66. [PMID: 26293656 PMCID: PMC4546128 DOI: 10.1186/s40001-015-0163-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/11/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Depending on the extent of surgery, coagulation status and the number of anastomoses, drains are routinely used during liver transplantation. The aim of this study was to compare different drain types with regard to abdominal complication rates. METHODS All consecutive full-size orthotopic liver transplantations (LTX) performed over a 7-year period were included in this retrospective analysis. Abdominal drain groups were divided into open-circuit drains and closed-circuit drains. Data are reported as total number (%) or median (range); for all comparisons a p value <0.05 was considered statistically significant. RESULTS A total of 256 LTX [age 56.89 (0.30-75.21) years; MELD 14.5 (7-40)] was included; 56 (21.8 %) patients received an open-circuit Easy Flow Drain (Group 1) and 200 (78.2 %) a closed-circuit Robinson Drainage System (Group 2). For Groups 1 and 2, overall infection rates were 78.6 and 56 % (p = 0.001), abdominal infection rates 50.82 and 21.92 % (p = 0.001), yeast infection rates 37 and 23 % (p = 0.02), abdominal bleeding rates 26.78 and 17 % (p = 0.07), biliary complication rates 14.28 and 13.5 % (p = 0.51), respectively. CONCLUSIONS In this retrospective series, open-circuit drains were associated with more abdominal complications, mainly due to intraabdominal infections, than were closed-circuit drains.
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Affiliation(s)
- Sascha Weiss
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Marcus Huth
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Christian Denecke
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Felix Aigner
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Andreas Brandl
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Tomasz Dziodzio
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Robert Sucher
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Claudia Boesmueller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Robert Oellinger
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Dietmar Oefner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Johann Pratschke
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Matthias Biebl
- Department of General, Visceral and Transplantation Surgery, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Moris D, Sotiropoulos GC, Vernadakis S. A Question Seeking for an Answer: Use of T-tube in the Era of Liver Transplantation With Grafts From Extended Criteria Donors and Donors After Cardiac Death. Ann Surg 2015; 261:e173-e174. [PMID: 24836143 DOI: 10.1097/sla.0000000000000692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Demetrios Moris
- Transplantation Unit, Laikon General Hospital, University of Athens, Athens, Greece Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany
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Sun N, Zhang J, Li X, Zhang C, Zhou X, Zhang C. Biliary tract reconstruction with or without T-tube in orthotopic liver transplantation: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2015; 9:529-38. [PMID: 25583036 DOI: 10.1586/17474124.2015.1002084] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION At present whether to use T-tube or not during orthotopic liver transplantation (OLT) in biliary tract reconstruction still remains controversial. Most transplant centers choose not to use T-tube because the T-tube can increase the incidence of cholangitis, but some centers still use T-tube because the T-tube can decrease the incidence of anastomotic strictures. AIM The purpose of this study is to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT. METHODS systematic review and meta-analysis of a collection of 15 studies (six randomized control trails (RCTs) and nine comparative studies) to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT. RESULTS The data showed that the biliary tract reconstruction with T-tube and without T-tube had equivalent outcomes for overall biliary complications (six RCTs p = 0.76; odd ratio [OR] = 1.19; 95% CI: 0.40, 3.58; all studies p = 0.14; OR = 1.50; 95% CI: 0.88, 2.57), bile leaks (six RCTs p = 0.61; OR = 0.86; 95% CI: 0.49, 1.52; all studies p = 0.09; OR = 1.39; 95% CI: 0.95, 2.02), cholangitis (six RCTs p = 0.13; OR = 5.54; 95% CI: 0.62, 49.79; all studies p = 0.08; OR = 4.27; 95% CI: 0.86, 21.16), hepatic artery thrombosis (two RCTs p = 1.00; OR = 1.00; 95% CI: 0.22, 4.49; all studies p = 0.75; OR = 1.19; 95% CI: 0.41, 3.44). However, in the group with T-tube there were better outcomes for biliary strictures (six RCTs p = 0.0003; OR = 0.34; 95% CI: 0.19, 0.61; all studies p < 0.0001; OR = 0.49; 95% CI: 0.34, 0.69). DISCUSSION Although most organizations choose not to use T-tube in OLT, we suggest that use of T-tube in biliary tract reconstruction during OLT for the recipients who possibly have high risks of biliary stricture is useful and necessary.
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Affiliation(s)
- Ning Sun
- Department of Hepatobiliary and Transplantation Surgery, the First Affiliated Hospital of China Medical University, Shenyang, P.R. China
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National assessment of early biliary complications after liver transplantation: economic implications. Transplantation 2015; 98:1226-35. [PMID: 25119126 DOI: 10.1097/tp.0000000000000197] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvement in surgical technique and medical management of liver transplant recipients, biliary complications remain a frequent cause of posttransplant morbidity and graft loss. Biliary complications require potentially expensive interventions including radiologic procedures and surgical revisions. METHODS A national data set linking transplant registry and Medicare claims data for 12,803 liver transplant recipients was developed to capture information on complications, treatments, and associated direct medical costs up to 3 years after transplantation. RESULTS Biliary complications were more common in recipients of donation after cardiac death compared to donation after brain death allografts (23% vs. 19% P<0.001). Among donation after brain death recipients, biliary complications were associated with $54,699 (95% confidence interval [CI], $49,102 to $60,295) of incremental spending in the first year after transplantation and $7,327 in years 2 and 3 (95% CI, $4,419-$10,236). Biliary complications in donation after cardiac death recipients independently increased spending by $94,093 (95% CI, $64,643-$124,542) in the first year and $12,012 (95% CI, $-1,991 to $26,016) in years 2 and 3. CONCLUSION This national study of biliary complications demonstrates the significant economic impact of this common perioperative complication and suggests a potential target for quality of care improvements.
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Fernández-Simon A, Díaz-Gonzalez A, Thuluvath PJ, Cárdenas A. Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation. Clin Liver Dis 2014; 18:913-26. [PMID: 25438291 DOI: 10.1016/j.cld.2014.07.009] [Citation(s) in RCA: 14] [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 after liver transplantation (LT) are an important cause of morbidity and mortality. In most cases, an anastomosis of the bile duct is performed as a duct-to-duct reconstruction, which makes endoscopic therapy with endoscopic retrograde cholangiography (ERC) feasible. Biliary anastomotic strictures (AS) are the most common cause of biliary complications. The early detection of an AS, which can sometimes be challenging given that its clinical presentation is often subtle, is of key importance to obtain high treatment success. In this review, we focus on the management of AS after LT with a special emphasis on ERC.
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Affiliation(s)
- Alejandro Fernández-Simon
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Alvaro Díaz-Gonzalez
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Paul J Thuluvath
- Medical Director, Institute for Digestive Health & Liver Disease, Mercy Medical Center, 301 Street, Paul Place, Baltimore, MD 21202, USA
| | - Andrés Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain.
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Surgical revision of hepaticojejunostomy strictures after pancreatectomy. Langenbecks Arch Surg 2014; 400:67-75. [PMID: 25277247 DOI: 10.1007/s00423-014-1246-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 08/21/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND After pancreatic surgery hepaticojejunostomy (HJ) stricture is a rare condition. Usually, management is conservative, while operative revision ("redo") is only rarely performed. METHODS This was an observational cohort design that analyzed the outcome of patients who had a surgical revision of HJ strictures after pancreatic surgery at a specialized pancreatic center. RESULTS During a period of 7 years from January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy (PD) or HJ. Among this patient population, 3 % (23/887) underwent a redo of the HJ secondary to stricture formation. Major symptoms of HJ strictures were recurrent cholangitis in 91 % (21/23) and jaundice in 39 % (9/23). The median time from the index operation until redo of the HJ was 16 ± 27 months. The median survival of patients with malignancy after redo of the HJ was 45 ± 67 months. Major surgical morbidity was 9 % (2/23), and mortality was 0 % (0/23). In 78 % (18/23), there were no further episodes of cholangitis after a median follow of 49 ± 73 months, while none of the patients with redo of the HJ developed a restenosis of the HJ. CONCLUSION Surgical revision (redo) of HJ strictures can be safely performed by an experienced pancreatic surgeon with a low morbidity without mortality with good long-term results.
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Jablonska B. End-to-end ductal anastomosis in biliary reconstruction: indications and limitations. Can J Surg 2014; 57:271-277. [PMID: 25078933 PMCID: PMC4119121 DOI: 10.1503/cjs.016613] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2013] [Indexed: 01/08/2023] Open
Abstract
End-to-end ductal anastomosis is a physiologic biliary reconstruction that is commonly used in liver transplantation and less frequently in the surgical treatment of iatrogenic bile duct injuries. Currently, end-to-end ductal anastomosis is the biliary reconstruction of choice for liver transplantation in most adult patients. In recent years, it has also been performed for liver transplantation in children and in select patients with primary sclerosing cholangitis. The procedure is also performed in some patients with iatrogenic bile duct injuries, as it establishes physiologic bile flow. Proper digestion and absorption as well as postoperative endoscopic access are possible in patients who undergo end-to-end ductal anastomosis. It allows endoscopic diagnostic and therapeutic procedures in patients following surgery. This anastomosis is technically simple and associated with fewer early postoperative complications than the Roux-en-Y hepaticojejunostomy; however, end-to-end ductal anastomosis is not possible to perform in all patients. This review discusses the indications for and limitations of this biliary reconstruction, the technique used in liver transplantation and surgical repair of injured bile ducts, suture types and use of a T-tube.
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Affiliation(s)
- Beata Jablonska
- From the Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
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40
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Intraoperative placement of external biliary drains for prevention and treatment of bile leaks after extended liver resection without bilioenteric anastomosis. World J Surg 2014; 37:2629-34. [PMID: 23892726 DOI: 10.1007/s00268-013-2161-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Improved surgical techniques, substantial preoperative diagnostics, and advanced perioperative management permit extensive and complex liver resection. Thus, hepatic malignancies that would have been considered inoperable some years ago may be curatively resected today. Despite all this progress, biliary leakage remains a clinically relevant issue, especially after extended liver resection. Intraoperative decompression of bile ducts by means of distinct biliary drains is controversial. Although drainage is rarely used as a routine procedure, it might be useful in selected patients at high risk for biliary leakage. METHODS We describe surgical management of long-segment exposed or injured bile ducts after extended parenchymal resection with concomitant lymphadenectomy. Because blood supply to the bile duct may be impaired, the risk of biliary necrosis and/or leakage is significant. Internal splinting of the bile duct to ensure optimum decompression plus guidance might be helpful. Thus, in selected cases after trisectionectomy we inserted an external-internal or internal-external drain into long-segment exposed bile ducts. For internal-external drains the tube was diverted via the major duodenal papilla into the duodenum and then transfixed after the duodenojejunal flexure through the jejunal wall by means of a Witzel's channel. RESULTS Because the entire bile duct is splinted, this technique is superior to bile duct decompression with a T-tube. This is supported by the course of a patient suffering biliary leakage after extended right-sided hepatectomy for colorectal metastasis. Initially, a T-tube was inserted for decompression, but biliary leakage persisted. After inserting transhepatic external-internal drainage, bile leakage stopped immediately. The patient's course was then uneventful. Five other patients (mostly with locally advanced hepatocellular or cholangiocellular carcinoma) treated similarly were discharged without complications. Drain removal 6 weeks postoperatively was uncomplicated in five of the 6 patients. In the sixth patient, external-internal drainage was replaced by a Yamakawa-type prosthesis for a biliary stricture. None of the patients suffered severe complications during long-term follow-up. CONCLUSIONS The bile duct drainage technique presented in this study was useful for preventing and treating bile leakage after long-segment exposure of extrahepatic bile ducts during major hepatectomy. Transhepatic or internal-external drains are often used for bilioenteric anastomoses, but similar drainage techniques have not been reported for the native bile duct. T-tubes are generally used in this situation. In particular cases, however, inner splinting of the bile duct and appropriate movement of the bile via a tube can be helpful.
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Reply to Letter: "A Question Seeking for an Answer: Use of T-tube in the Era of Liver Transplantation With Grafts From Extended Criteria Donors and Donors After Cardiac Death". Ann Surg 2014; 261:e174-5. [PMID: 24836150 DOI: 10.1097/sla.0000000000000722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.25liver.o9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Miller C, Diago Uso T. The liver transplant operation. Clin Liver Dis (Hoboken) 2013; 2:192-196. [PMID: 30992860 PMCID: PMC6448650 DOI: 10.1002/cld.232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 06/15/2013] [Indexed: 02/04/2023] Open
Affiliation(s)
- Charles Miller
- Cleveland Clinic, Liver Transplant Program, Department of General Surgery Cleveland, OH
| | - Teresa Diago Uso
- Cleveland Clinic, Liver Transplant Program, Department of General Surgery Cleveland, OH
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44
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Kochhar G, Parungao JM, Hanouneh IA, Parsi MA. Biliary complications following liver transplantation. World J Gastroenterol 2013; 19:2841-2846. [PMID: 23704818 PMCID: PMC3660810 DOI: 10.3748/wjg.v19.i19.2841] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 03/23/2013] [Accepted: 04/10/2013] [Indexed: 02/06/2023] Open
Abstract
Biliary tract complications are the most common complications after liver transplantation. These complications are encountered more commonly as a result of increased number of liver transplantations and the prolonged survival of transplant patients. Biliary complications remain a major source of morbidity in liver transplant patients, with an incidence of 5%-32%. Post liver transplantation biliary complications include strictures (anastomotic and non-anastomotic), leaks, stones, sphincter of Oddi dysfunction, and recurrence of primary biliary disease such as primary sclerosing cholangitis and primary biliary cirrhosis. The risk of occurrence of a specific biliary complication is related to the type of biliary reconstruction performed at the time of liver transplantation. In this article we seek to review the major biliary complications and their relation to the type of biliary reconstruction performed at the time of liver tranplantation.
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Intraoperative cryoprecipitate transfusion and its association with the incidence of biliary complications after liver transplantation--a retrospective cohort study. PLoS One 2013; 8:e60727. [PMID: 23675406 PMCID: PMC3651089 DOI: 10.1371/journal.pone.0060727] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 03/01/2013] [Indexed: 12/27/2022] Open
Abstract
Background Cryoprecipitate is largely used for acquired hypofibrinogenemia in the setting of massive hemorrhage in liver transplantation (LT). However, the influence of intraoperative cryoprecipitate transfusion on biliary complications (BC) after LT has not been studied in detail. Study Design and Methods In a series of 356 adult patients who received their first LT, the causes of BC were retrospectively studied by multivariate logistic regression analysis. The clinical relationship between intraoperative cryoprecipitate transfusion and BC occurrence was studied through a retrospective cohort study in patients. All patients received follow-ups for one year, and, during the follow-up period, the time of BC occurrence and liver biopsies were recorded. Results Intraoperative cryoprecipitate transfusion (RR = 3.46, 95% CI [1.72–6.97], P<0.001), cold ischemia time >8 h (RR = 4.24, 95% CI [2.28–7.92], P<0.01), and high-level Child-Pugh ( RR = 1.71, 95% CI [1.11–2.63], P = 0.014) are independent risk factors to predict BC after LT according to time-to-event analysis. One year BC-free survival probability of patients received intraoperative cryoprecipitate transfusions was significantly lower when compared to the group that received no cryoprecipitate(P<0.001). Moreover, BC patients in the cryoprecipitate transfusion group owned different liver pathological feature, pathological micro-thrombus formation and cholestasis were seen more often (41.4% vs 0%, 62.1% vs 12.5%, respectively) than no cryoprecipitate transfusion group. Conclusion These findings suggested that intraoperative cryoprecipitate transfusion was associated with BC after LT. The mechanism of BC occurrence might involve micro-thrombus formation and immune rejection.
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Seehofer D, Eurich D, Veltzke-Schlieker W, Neuhaus P. Biliary complications after liver transplantation: old problems and new challenges. Am J Transplant 2013; 13:253-65. [PMID: 23331505 DOI: 10.1111/ajt.12034] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/01/2012] [Accepted: 10/23/2012] [Indexed: 01/25/2023]
Abstract
Due to a vulnerable blood supply of the bile ducts, biliary complications are a major source of morbidity after liver transplantation (LT). Manifestation is either seen at the anastomotic region or at multiple locations of the donor biliary system, termed as nonanastomotic biliary strictures. Major risk factors include old donor age, marginal grafts and prolonged ischemia time. Moreover, partial LT or living donor liver transplantation (LDLT) and donation after cardiac death (DCD) bear a markedly higher risk of biliary complications. Especially accumulation of several risk factors is critical and should be avoided. Prophylaxis is still a major issue; however no gold standard is established so far, since many risk factors cannot be influenced directly. The diagnostic workup is mostly started with noninvasive imaging studies namely MRI and MRCP, but direct cholangiography still remains the gold standard. Especially nonanastomotic strictures require a multidisciplinary treatment approach. The primary management of anastomotic strictures is mainly interventional. However, surgical revision is finally indicated in a significant number of cases. Using adequate treatment algorithms, a very high success rate can be achieved in anastomotic complications, but in nonanastomotic strictures a relevant number of graft failures are still inevitable.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral and Transplantation Surgery, Charité Campus Virchow, Berlin, Germany.
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48
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Gastaca M. Biliary complications after orthotopic liver transplantation: a review of incidence and risk factors. Transplant Proc 2013; 44:1545-9. [PMID: 22841209 DOI: 10.1016/j.transproceed.2012.05.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Biliary complications (BCs) are a common source of morbidity after liver transplantation, leading to long-term and repeated therapies. The incidence of BCs currently ranges from 5% and 25%. Biliary strictures and leaks are the most common complications after deceased donor liver transplantation (DDLT), occurring in 9%-12% and 5%-10% of cases, respectively. Hepatic artery complications are recognized as the major risk factor for BCs; however, other circumstances such as advanced donor age, prolonged cold and warm ischemia times, grafts from donors after cardiac death, occurrence of a previous bile leak, T-tube use, cytomegalovirus infection, or graft steatosis have also been reported to be potential risk factors. Use of various preservation solutions has not significantly improved the biliary complication rate after DDLT. Technical modifications in biliary reconstruction have been proposed to improve outcomes after DDLT; the use of a T-tube for biliary reconstruction continues to be controversial. Non anastomotic strictures (NAS) are recognized to be different from anastomotic strictures. Although they have been associated with ischemic or immunological mechanisms, bile salt toxicity has recently been recognized as a potential factor for NAS. Donation after cardiac death is a significant source of organs that has been associated with decreased graft survival due to the increased BCs.
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Affiliation(s)
- M Gastaca
- Hepato-Biliary Surgery and Liver Transplantation Unit, Hospital Universitario de Cruces, Bilbao, Spain.
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49
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Gastaca M, Matarranz A, Muñoz F, Valdivieso A, Aguinaga A, Testillano M, Bustamante J, Terreros I, Suarez MJ, Montejo M, Ortiz de Urbina J. Biliary complications in orthotopic liver transplantation using choledochocholedochostomy with a T-tube. Transplant Proc 2013; 44:1554-6. [PMID: 22841211 DOI: 10.1016/j.transproceed.2012.05.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite significant advances in orthotopic liver transplantation (OLT), biliary tract reconstruction is still a major source of complications. Choledochocholedochostomy with a T-tube used to be the standard procedure for biliary reconstruction after OLT. However, many centers currently avoid use of the T-tube because of the high incidence of complications. Our aim was to study the biliary complications occurring at our center when end-to-end choledochocholedochostomy (EE-CC) over a T-tube was used as the standard procedure for biliary reconstruction. A retrospective review was conducted of all patients who underwent liver transplantation from February 1, 1996, to April 30, 2010. Only patients requiring any therapy to treat biliary complications were considered, whereas those with concomitant hepatic artery complications were excluded. The study cohort consisted of 743 patients who had EE-CC with a T-tube. Of these, 73 patients (9.8%) experienced any biliary complication. Anastomotic strictures occurred in 17 patients (2.3%), and non-anastomotic strictures in 2 (0.3%). Fifteen patients with anastomotic strictures were successfully treated by dilatation and stenting. Bile leakage was diagnosed in 39 patients (5.2%). Leakage occurred at the anastomosis in 15 patients (2%), and at the exit site of the T-tube in 24 patients (3.2%). Tube opening was the only treatment used in 30 patients with bile leakage (76.9%). Seven patients experienced leaks after elective T-tube removal (1%). Overall, repeat surgery to manage biliary complications was needed in 9 patients (1.2%). The mortality rate from biliary complications was 0.13%. In conclusion, EE-CC with a T-tube was followed by a low incidence of biliary complications. The complication rate after elective T-tube removal and the repeat surgery rate were extremely low. These results might challenge the current trend to avoid T-tube stenting in OLT.
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Affiliation(s)
- M Gastaca
- Hepato-biliary Surgery and Liver Transplantation Unit, Hospital Universitario de Cruces, Bilbao, Spain.
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Cascales Campos P, Ramírez Romero P, González R, Pons JA, Miras M, Sanchez Bueno F, Robles R, Parrilla P. Laparoscopic treatment of biliary peritonitis after removal of T-tube in liver transplant patients. Transplant Proc 2012; 44:1550-1553. [PMID: 22841210 DOI: 10.1016/j.transproceed.2012.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION T-tube removal in liver transplant patients can occasionally cause a massive biliary leak and may require surgical treatment for its resolution. We present our experience with a laparoscopic approach to biliary peritonitis in liver transplant patients after the removal of a T-tube. PATIENTS AND METHODS From January 2003 until February 2010, we performed 351 liver transplantations in 313 recipients, including 135 with a T-tube. After its removal 31 biliary leaks developed (23%); 12 were massive and required surgery, which utilized a laparoscopic approach. RESULTS The mean length of the intervention was 72.9 ± 12.87 minutes (range = 55-95), without any complications during the procedure, and no need to convert to a laparotomy. Mean hospital stay after the intervention was 6.75 ± 3.88 days (range 4-18). There was no mortality from the procedure. CONCLUSION The laparoscopic approach for biliary leakage after T-tube removal is indicated when large diffuse acute peritonitis is established a few hours postremoval of the T-tube. This safe procedure treats the complication without the need for another laparotomy.
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Affiliation(s)
- P Cascales Campos
- Department of Surgery, Liver Transplant Unit, Virgen de la Arrixaca University Hospital, Murcia, Spain.
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