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Zeair S, Mamos M, Hirchy-Żak J, Modelewski P, Stasiuk R, Post M, Uździcki A, Witkowski M, Łakomiak A, Wawrzynowicz-Syczewska M. An Inadequate Blood Supply Is a Risk Factor of Anastomotic Biliary Strictures After Liver Transplantation-A Single-Center Study. J Clin Med 2025; 14:1365. [PMID: 40004895 PMCID: PMC11856134 DOI: 10.3390/jcm14041365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2025] [Revised: 02/11/2025] [Accepted: 02/13/2025] [Indexed: 02/27/2025] Open
Abstract
Background: Anastomotic biliary strictures (BSs) are among the most common complications after liver transplantation (LT), accounting for 5-15% of adult recipients after deceased-donor transplantation. For some reason, this percentage increased in our center in recent years, and the goal of this study was to find out the reasons behind this to avoid this complication in the future. Material and Methods: We retrospectively analyzed the occurrence of anastomotic biliary strictures in 230 cadaveric-donor LTs performed in our center between January 2019 and December 2023. Many variables related to the donor, recipient, and surgical procedure were compared between patients who experienced BS and those without this complication. Statistical analysis was performed using Fisher's exact test, a one-way ANOVA test, and Pearson's correlation coefficient. Results: Altogether, 51 patients (22.17%) developed BSs. This percentage was especially high in 2023 (32%). The only significant differences found in study group compared to the control group were the requirement of additional doses of vasopressors during surgery (45 (86.53%) vs. 138 (77.09%), p = 0.0001) and more frequent instances of reperfusion syndrome (8/51 (15.68%) vs. 11/179 (6.11%), p = 0.00001). Conclusions: We conclude that ischemia during LT has an advantage over technical parameters in the development of BSs after LT. Appropriate blood volume resuscitation as opposed to inotropic treatment may reduce the risk of this complication.
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Affiliation(s)
- Samir Zeair
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Marek Mamos
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Julia Hirchy-Żak
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Patryk Modelewski
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Robert Stasiuk
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Mariola Post
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Artur Uździcki
- Department of Internal Medicine and Gastroenterology, Pomeranian Regional Hospital, 71-455 Szczecin, Poland;
| | - Michał Witkowski
- Department of General and Transplant Surgery, Pomeranian Regional Hospital, 71-455 Szczecin, Poland; (S.Z.); (R.S.); (M.P.); (M.W.)
| | - Agata Łakomiak
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
| | - Marta Wawrzynowicz-Syczewska
- Department of Infectious Diseases, Hepatology and Liver Transplantation, Pomeranian Medical University, 71-455 Szczecin, Poland; (M.M.); (J.H.-Ż.); (P.M.); (A.Ł.)
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Baraldo S, Meine GC, Santo PAE, Barbosa EC, Nau AL, Keane MG, Chavan R, Kuo YT, Ligresti D. Fully covered self-expandable metal stents versus multiple plastic stents for the treatment of post-orthotopic liver transplant anastomotic biliary strictures: An updated systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2025; 39:721-729. [PMID: 39702566 DOI: 10.1007/s00464-024-11467-6] [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: 09/15/2024] [Accepted: 12/01/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND AND AIMS The most common adverse event (AE) of orthotopic liver transplantation (OLT) is anastomotic biliary stricture (ABS). Management varies widely between centers, and it is not clear whether a combination of endoscopic dilation of the stenosis followed by multiple plastic stents (MPS) or placement of a fully covered self-expandable metal stent (fcSEMS) is better for the management of post-OLT ABS. This systematic review and meta-analysis aimed to compare the efficacy, safety, and cost of fcSEMS versus MPS in the treatment of post-OLT ABS. METHODS We searched PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) comparing fcSEMS with MPS for the treatment of patients with post-OLT ABS and reporting at least one of the outcomes of interest. The pooled estimates were calculated using the random-effects model, and I2 statistics were used to evaluate heterogeneity. RESULTS The study included 5 RCTs (245 patients). There was no statistically significant difference between fcSEMS and MPS in stricture resolution (RR 0.99; 95% CI 0.88 to 1.11; p = 0.86), stricture recurrence (RR 2.22; 95% CI 0.73 to 6.75; p = 0.16), treatment cost (MD - 5.31 thousand dollars 95% CI -12.76 to 2.13; p = 0.16), and AEs (RR 0.87; 95% CI 0.27 to 2.83; p = 0.82). However, fcSEMS reduced the number of ERCP sessions (MD - 1.7 sessions; CI 95% - 2.9 to - 0.5; p = 0.005) and treatment duration (MD-95.7 days; 95% CI -184.5 to -6.9; p = 0.03) compared with MPS. CONCLUSION fcSEMS and MPS had similar efficacy and safety in patients with ABS post-OLT. However, fcSEMS was associated with fewer ERCP sessions and shorter treatment duration.
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Affiliation(s)
- Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, R. Antenor Duarte Vilela, 1331 - Dr. Paulo Prata, Barretos, Sao Paulo, 14784 400, Brazil.
| | - Gilmara Coelho Meine
- Division of Gastroenterology, Department of Internal Medicine, Feevale University, Novo Hamburgo, Brazil
| | - Paula Arruda Espirito Santo
- Diagnostic Imaging and Specialized Diagnosis Unit, University Hospital of Federal University of Sao Carlos, Sao Carlos, Brazil
| | | | - Angélica Luciana Nau
- Department of Pediatric Gastroenterology, Jaraguá Hospital, Jaraguá do Sul, Brazil
| | - Margaret G Keane
- Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Radhika Chavan
- Department of Gastroenterology and Advanced Endoscopy, Ansh Clinic, Ahmedabad, Gujarat, India
| | - Yu-Ting Kuo
- Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
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Vingrovich O, Cooper S, Gurevich M, Cohen A, Mozer-Glassberg Y, Bar-Lev MR, Shamir R, Waisbourd-Zinman O. Biliary strictures post pediatric liver transplantation-incidence and risk factors in a single tertiary referral transplant center. Pediatr Transplant 2024; 28:e14727. [PMID: 38613151 DOI: 10.1111/petr.14727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Biliary strictures are a significant cause of morbidity and graft loss in pediatric liver transplant recipients. Risk factors for the development of biliary strictures are not fully established. We aimed to evaluate the incidence of biliary strictures and treatment modalities outcomes and to identify potential risk factors for occurrence. METHODS Pediatric patients who underwent liver transplantation in the single tertiary pediatric liver transplant center in Israel were evaluated. We compared demographics, presentation, laboratory results, imaging, treatment, and outcomes between patients with and without biliary stricture. Multivariate regression analyses were used to identify risk factors for biliary strictures. RESULTS Among 121 pediatric liver transplant patients, 65 (53.7%) were males; the median age at the time of liver transplantation was 43 (3-215) months. Fifteen patients (12.4%) had biliary strictures following transplantation. One (7%) patient with biliary stricture was treated via endoscopic retrograde cholangiopancreatography, and 12 patients (80%) underwent interventions via a percutaneous transhepatic approach. Nine of the 12 patients were treated successfully, requiring one or multiple procedures, while the remaining had surgery or laser therapy. Risk factors for the development of biliary strictures were biliary leak, acute cellular rejection, and the presence of two biliary anastomoses. CONCLUSIONS In our cohort, the presence of two biliary anastomoses and post-transplant complications including acute cellular rejection and early biliary leaks were associated with biliary strictures in pediatric liver transplantation recipients. Percutaneous transhepatic interventions result in good outcomes in most patients.
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Affiliation(s)
- Odelia Vingrovich
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Shiri Cooper
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Michael Gurevich
- Liver Transplant Unit, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Aenov Cohen
- Invasive Radiology Unit, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Yael Mozer-Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Michal Rosenfeld Bar-Lev
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orith Waisbourd-Zinman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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Han JW, Choi JY, Lee SK, Sung PS, Jang JW, Yoon SK, Choi YH, Lee IS, Oh JS, Chun HJ, Choi HJ, You YK. Long-term Clinical Outcomes and Predictive Factors for Living-donor Liver Transplant Recipients With Biliary Strictures. Transplantation 2022; 106:1990-1999. [PMID: 35771085 DOI: 10.1097/tp.0000000000004201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Biliary strictures frequently occur in living-donor liver transplant (LDLT) recipients. However, long-term clinical outcomes and their associated factors are unclear. METHODS We analyzed an historical cohort of 228 recipients who underwent LDLT with post-liver transplantation biliary strictures. Endoscopic retrograde cholangiography or percutaneous transhepatic biliary drainage were performed to treat biliary strictures. Patients that experienced persistent jaundice over 3 mo after the initial treatment were defined as a remission-failure group. RESULTS Median observation period was 8.5 y after the diagnosis of biliary stricture. The 15-y graft survival (GS) rate was 70.6%, and 15-y rate of developing portal hypertension (PH) was 26.1%. Remission failure occurred in 25.0% of study participants. In the multivariate analysis, biopsy-proven acute rejection, and portal vein/hepatic artery abnormalities were risk factors for remission failure. Development of PH, retransplantation, and death were significantly more frequent in the remission-failure group. Remission failure and PH were associated with poor GS. In multivariate analyses, hepatic artery abnormality and biloma were common significant factors that were associated with a poor GS and development of PH. CONCLUSIONS The insufficient blood supply reflected by hepatic artery abnormality and biloma might be the most important factor that can predict poor long-term survival in LDLT patients with biliary strictures. Future large-scale prospective studies are needed to validate our observations.
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Affiliation(s)
- Ji Won Han
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Young Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soon Kyu Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Pil Soo Sung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong Won Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Kew Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Hoon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Seok Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Suk Oh
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jong Chun
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyoung You
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Nahab B, Sriwastwa A, Shelton C, Ray C, Makramalla A, Seetharam C, Kord A. Stepwise Percutaneous Approach to Treat Severe Benign Hepaticojejunostomy Stenosis. Semin Intervent Radiol 2022; 39:435-440. [PMID: 36406028 PMCID: PMC9671672 DOI: 10.1055/s-0042-1757343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Bashar Nahab
- Division of Interventional Radiology, Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Aakanksha Sriwastwa
- Division of Interventional Radiology, Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Charles Shelton
- Division of Interventional Radiology, Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Charles Ray
- Division of Interventional Radiology, Department of Radiology, the University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - Abouelmagd Makramalla
- Division of Interventional Radiology, Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Chadalavada Seetharam
- Division of Interventional Radiology, Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Ali Kord
- Division of Interventional Radiology, Department of Radiology, University of Cincinnati, Cincinnati, Ohio
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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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8
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Abstract
Liver transplantation (LT) is the only curative therapy in patients with end-stage liver disease with excellent long-term survival; however, LT recipients are at risk of significant complications. Among these complications are biliary complications with an incidence ranging from 5 to 32% and associated with significant post-LT morbidity and mortality. Prompt recognition and management are critical as these complications have been associated with mortality rates up to 19% and retransplantation rates up to 13%. An important limitation of published studies is that a large proportion does not discriminate between anastomotic strictures and nonanastomotic strictures. This review aims to summarize our current understanding of risk factors and natural history, diagnostic testing, and treatment options for post-LT biliary strictures.
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Affiliation(s)
- Matthew Fasullo
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Tilak Shah
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia.,Division of Gastroenterology and Hepatology, Central Virginia Veterans Affairs Medicine Center, Richmond, Virginia
| | - Huiping Zhou
- Department of Microbiology and Immunology, VCU and McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Mohammad S Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University (VCU) Medical Center, Richmond, Virginia
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9
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Percutaneous transhepatic treatment for biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation: a 9-year single-center experience. Eur Radiol 2022; 32:2414-2425. [DOI: 10.1007/s00330-021-08373-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 02/07/2023]
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10
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Rao HB, Koshy AK, Priya K, Nair P, Sudhindran S, Venu RP. Endoscopic management of high-grade biliary strictures complicating living donor liver transplantation using soehendra stent retrievers. Scand J Gastroenterol 2021; 56:1103-1108. [PMID: 34242116 DOI: 10.1080/00365521.2021.1944300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/08/2021] [Accepted: 06/12/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Biliary strictures following living donor liver transplantation (LDLT) are usually managed by endoscopic retrograde cholangiography (ERC) with stricture dilation and stent placement. While current endoscopic techniques are successful in most cases, high-grade biliary strictures (HGBS) pose a challenge using currently employed techniques which have a low rate of technical success. AIMS In this study, we have explored the safety and efficacy of Soehendra stent retrievers (SSR) for the dilation of HGBS complicating LDLT. METHODS This was a prospective cohort study where all patients with anastomotic biliary strictures following LDLT from January 2016 till February 2018 were included. Patients with HGBS defined as the exclusive passage of 0.018-inch guidewire, were included in Group 1. In these patients, 5 Fr Soehendra stent retrievers were used to dilate HGBS over guidewire, using torsional movements. Technical success, safety and clinical response was compared with patients who required Per-cutaneous transhepatic cholangiography (PTC) with rendezvous procedure due to a failed ERC, before the commencement of the study (Group 2). RESULTS Ten patients with HGBS were included into Group 1. Technical success defined as successful placement of a biliary stent across the stricture was achieved in all the patients in group 1. Favorable response to endotherapy was higher in group 1(8/10 patients (80%)) as compared to group 2(6/14 patients (42.8%)). There were no post procedure complications in patients of group 1, while 3 patients developed cholangitis in group 2. CONCLUSIONS HGBS can be successfully treated with SSR for stricture dilation. It is safe with no significant complications and requires fewer procedures.
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Affiliation(s)
- Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Anoop K Koshy
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Krishna Priya
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Priya Nair
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - S Sudhindran
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences, Kochi, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
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11
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Jarlot-Gas C, Muscari F, Mokrane FZ, Del Bello A, Culetto A, Buscail E, Péré G, Fares N, Péron JM, Cuellar E, Barange K, Kamar N, Suc B, Maulat C. Management of anastomotic biliary stricture after liver transplantation and impact on survival. HPB (Oxford) 2021; 23:1259-1268. [PMID: 33423950 DOI: 10.1016/j.hpb.2020.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic biliary strictures (AS) is the main surgical complication after liver transplantation. The aims of this study are to investigate the risk factors of AS, its management and its impact on overall survival and survival of the graft. METHODS All patients who had received a liver transplantation with duct-to-duct anastomosis at Toulouse University Hospital between 2010 and 2016 were included. RESULTS Of 225 included patients, 56 (24.9%) presented with AS. The median time to discovery of AS was 83 days and 69.6% of the AS appeared within 6 months. Transplantation in critically ill patients, with a liver score >800 points, was an independent predictive factor of survival (P = 0.003). The first-line treatment was endoscopic (87.5%), with a success rate of 79.6% and a median of 4 procedures per patient in 12 months. In cases of failure of endoscopic therapy, percutaneous treatment had a high failure rate (50%). AS had no impact in terms of overall survival or in terms of graft survival. CONCLUSION AS do not have any repercussions on patient or graft survival, requiring long endoscopic treatment with multiple procedures. In the event of failure of this first-line endoscopic treatment, it seems preferable to turn directly towards surgical repair.
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Affiliation(s)
- Cécile Jarlot-Gas
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Fabrice Muscari
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | | | - Arnaud Del Bello
- Department of Nephrology and Transplantation, Toulouse University Hospital, Toulouse, France
| | - Adrian Culetto
- Department of Gastroenterology, Toulouse University Hospital, Toulouse, France
| | - Etienne Buscail
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Guillaume Péré
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Nadim Fares
- Department of Digestive Oncology, Toulouse University Hospital, Toulouse, France
| | - Jean-Marie Péron
- Department of Hepatology, Toulouse University Hospital, Toulouse, France
| | - Emmanuel Cuellar
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Karl Barange
- Department of Gastroenterology, Toulouse University Hospital, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Transplantation, Toulouse University Hospital, Toulouse, France
| | - Bertrand Suc
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
| | - Charlotte Maulat
- The Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France.
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12
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Karatoprak S, Kutlu R, Yılmaz S. Role of percutaneous radiological treatment in biliary complications associated with adult left lobe living donor liver transplantation: a single-center experience. ACTA ACUST UNITED AC 2021; 27:546-552. [PMID: 33599206 DOI: 10.5152/dir.2021.20523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Biliary complications develop at a higher rate in living donor liver transplantation (LDLT) compared with cadaveric liver transplantation. Almost all studies about biliary complications after LDLT were made with the right lobe. The aim of this study was to determine the frequency of biliary complications developing after adult left lobe LDLT and to evaluate the efficacy of the algorithm followed in diagnosis and treatment, particularly percutaneous radiological treatment. METHODS A total of 2185 LDLT operations performed in our center between May 2009 and December 2019 were retrospectively reviewed and patients receiving left lobe LDLT were analyzed regarding biliary complications and treatments. Biliary complications were treated via percutaneous drainage under ultrasound (US) guidance, endoscopic retrograde cholangiopancreatography (ERCP), and percutaneous transhepatic cholangiography (PTC)/ percutaneous transhepatic biliary drainage (PTBD). Patient demographics, ERCP procedures before percutaneous treatment, and percutaneous treatment indications were analyzed. RESULTS A total of 69 adult patients received left lobe LDLT. Biliary complications requiring endoscopic and/or percutaneous treatment developed in 28 patients (40%). Of these patients, 4 had bile leakage (14%), 20 had anastomosis stricture (72%), and 4 had both leakage and anastomosis stricture (14%). External drainage treatment under ultrasound guidance was sufficient for 2 of 4 patients with bile leakage, and these cases were accepted as minor bile leakage (7%). Overall, 26 patients underwent ERCP; of these, 8 were referred for PTC/PTBD because the guidewire and/or balloon-stent could not pass the anastomosis stricture (n=7) and common bile duct cannulation could not be obtained because of duodenal diverticulum (n=1). Diagnostic PTC was performed in 10 patients, 8 were referred after inadequate/failed ERCP procedure and two were referred directly without ERCP. Anastomosis stricture was found in 7 patients and anastomosis stricture and bile leakage in 3. In 7 patients determined to have stricture, balloon dilatation was applied and then biliary drainage was performed. In 3 patients who had leakage and anastomosis stricture, balloon dilatation was applied for stricture; after dilatation, an IEBD catheter was placed through the leakage region in 2 patients, while a covered metallic stent passing through the leakage region was placed in one patient. CONCLUSION Generally, ERCP is the first preferred method in biliary complications of LDLT; however, in cases where a response cannot be obtained by endoscopic treatment or require complex and/or aggressive treatment, percutaneous radiological treatment should be the treatment of choice before surgery in left lobe LDLT.
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Affiliation(s)
- Sinan Karatoprak
- Department of Radiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Ramazan Kutlu
- Department of Radiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Sezai Yılmaz
- Department of General Surgery, Inonu University Faculty of Medicine, Malatya, Turkey
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13
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Barbaro F, Tringali A, Larghi A, Baldan A, Onder G, Familiari P, Boškoski I, Perri V, Costamagna G. Endoscopic management of non-anastomotic biliary strictures following liver transplantation: Long-term results from a single-center experience. Dig Endosc 2021; 33:849-857. [PMID: 33080081 DOI: 10.1111/den.13879] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Studies on endoscopic treatment of non-anastomotic biliary strictures (NABS) following orthotopic liver transplantation (OLT) are scanty and with a short follow-up. The long-term results of endoscopic treatment with plastic stents of NABS following OLT were analyzed. METHODS Retrospective analysis of consecutive enrolled patients who underwent endoscopic treatment for NABS after OLT between 1997 and 2015. Endoscopic treatment success was defined as stricture resolution, without recurrence. RESULTS During the study period, 33 patients with NABS underwent endoscopic retrograde cholangiopancreatography (ERCP) in our center. A total of 68 ERCP were performed with a 4.4% of procedure-related adverse events. Mortality related to cholangitis secondary to endoscopic procedures was 12%. After median follow-up of 70.3 months from stents removal, NABS resolution was obtained in 12 out of 24 (50%) patients. Only one case of late NABS recurrence was observed which was successfully retreated endoscopically. According to our data analysis NABS occurring <12 months from OLT showed a worse prognosis (P < 0.04). CONCLUSIONS The follow-up of this study confirms that endoscopic treatment of NABS is unsatisfactory. However, patients who respond to endoscopic treatment maintain the response over time. Prompt treatment of acute cholangitis due to stents occlusion is advised in these patients to avoid high mortality rates.
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Affiliation(s)
- Federico Barbaro
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Baldan
- Gastroenterology and Transplant Hepatology, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Graziano Onder
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
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14
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Pamecha V, Sasturkar SV, Sinha PK, Mohapatra N, Patil N. Biliary Reconstruction in Adult Living Donor Liver Transplantation: The All-Knots-Outside Technique. Liver Transpl 2021; 27:525-535. [PMID: 37160038 DOI: 10.1002/lt.25862] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/15/2020] [Accepted: 07/29/2020] [Indexed: 12/20/2022]
Abstract
Biliary complications (BCs) following living donor liver transplantation (LDLT) can lead to significant morbidity and occasional mortality. The present study describes our experience of the all-knots-outside technique (AKOT) of biliary reconstruction (BR) and its impact on BCs. A retrospective analysis was performed using prospectively collected data of 330 consecutive adult patients undergoing LDLT from July 2011 to February 2018 with a minimal follow-up of 24 months. Only 2.8% required hepaticojejunostomy and were excluded. In an initial 122 patients, BR was performed with the standard technique (ST), and AKOT was performed in the subsequent 208 patients. In the AKOT group, a single anastomosis was attempted even for multiple ducts whenever feasible. A major BC was defined as requiring endoscopic, percutaneous, or surgical interventions. In the AKOT group, significantly more patients received a left lobe graft (5.7% versus 18.3%; P = 0.001), had shorter warm ischemia time (44.6 versus 27 minutes; P < 0.001), and had a left hepatic artery (LHA) in the right lobe that was used for arterial reconstruction (48 [39.3%] versus 122 [58.6%]; P = 0.003). The incidence of BCs in the entire cohort was 47 (14.2%). For the ST versus AKOT groups, the overall BCs (27/122 [22.1%] versus 20/208 [9.6%]; P = 0.003) and major BCs (20.5% versus 6.7%; P < 0.001) decreased significantly. In the multivariate analysis, the number of bile ducts (hazard ratio [HR], 4.18; 95% confidence interval [CI], 1.62-10.78; P = 0.003), number of anastomoses (HR, 2.03; 95% CI, 1.03-4.02; P = 0.04), and technique of anastomosis (HR, 0.36; 95% CI, 0.19-0.68; P = 0.002) predicted BCs. In conclusion, in adult LDLT, with standardization of the donor and recipient surgery, preferential use of LHA for right lobe arterial reconstruction, reduction in the number of anastomoses, and AKOT for BR significantly decreased the incidence of BCs.
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Affiliation(s)
- Viniyendra Pamecha
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shridhar Vasantrao Sasturkar
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Kumar Sinha
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nihar Mohapatra
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nilesh Patil
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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15
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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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16
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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17
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Chiang PL, Cheng YF, Huang TL, Ou HY, Yu CY, Hsu HW, Lim WX, Chen CL, Yong CC, Tsang LLC. Intensive Doppler Ultrasonography for Early Detection of Hepatic Artery Thrombosis After Adult Living Donor Liver Transplantation. Ann Transplant 2020; 25:e924336. [PMID: 32958738 PMCID: PMC7519946 DOI: 10.12659/aot.924336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Early hepatic artery thrombosis (eHAT) is a severe arterial complication leading to biliary complications and graft failure in living donor liver transplantation (LDLT). This study sought to early identify the abnormal waveforms of eHAT by using intensive Doppler ultrasonography (DUS) after LDLT and to assess the clinical outcome in these eHAT patients. Material/Methods DUS for 419 adult LDLT recipients was performed twice after vascular anastomosis during liver transplantation and once a day at the bedside for at least 2 weeks. Results Nine adult LDLT recipients with eHAT were identified by using bedside DUS with subsequent computed tomography angiography (CTA). All eHAT cases were noted in the first 2 weeks. Five patients with CTA findings of partial thrombus with the small visualized intrahepatic hepatic artery (HA) were treated with intravenous thrombolysis (IVT) (medical group). Another 4 patients with CTA findings of extrahepatic HA occlusion and nonvisualization of intrahepatic HAs were treated by arterial re-anastomosis (surgical group). The prevalence of long-term non-anastomotic biliary strictures was 33.3% in the surgical group. Intensive post-LDLT DUS is a convenient and sensitive tool for eHAT detection. Conclusions Subsequent CTA gives valid information on occluded arteries and associated findings, which impact decision-making and are correlated with patient outcome. Our protocol of DUS has high sensitivity and diagnostic accuracy for use in in eHAT patients with partial occlusion, and it can be applied for IVT treatment, avoiding the need for reoperation and preventing long-term biliary complications.
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Affiliation(s)
- Pi-Ling Chiang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Fan Cheng
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tung-Liang Huang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsin-You Ou
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Yen Yu
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsien-Wen Hsu
- Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Xiong Lim
- Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chee-Chien Yong
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Leo Leung-Chit Tsang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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18
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Noriega-Salas L, Santiago JC, Bernáldez-Gómez G, Robledo-Meléndez A, Meza-Jiménez G, Hernández C. Experience of National Medical Center of Specialties “La Raza” in the endoscopical management of bile duct complications after liver transplantation. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2020.100058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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19
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Park JK, Yang JI, Lee JK, Park JK, Lee KH, Lee KT, Joh JW, Kwon CHD, Kim JM. Long-term Outcome of Endoscopic Retrograde Biliary Drainage of Biliary Stricture Following Living Donor Liver Transplantation. Gut Liver 2020; 14:125-134. [PMID: 30970446 PMCID: PMC6974332 DOI: 10.5009/gnl18387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims: Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods: A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results: Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions: Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.
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Affiliation(s)
- Jae Keun Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Ju-Il Yang
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan,
Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
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20
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Kim YM, Chung TR, Lee DK. High-Level Biliary Strictures After Living-Donor Liver Transplantation. ADVANCED ERCP FOR COMPLICATED AND REFRACTORY BILIARY AND PANCREATIC DISEASES 2020:1-16. [DOI: 10.1007/978-981-13-0608-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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21
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Doskhanov MO, Skakbayev AS, Baimakhanov ZB, Baimakhanov BB, Kaniyev SA, Serikuly E, Seisembayev MA, Chormanov AT, Abdrashev EB, Sadykov CT, Abdiyev NM, Kausova GK. Biliary complications after liver transplantation. ANNALY KHIRURGICHESKOY GEPATOLOGII = ANNALS OF HPB SURGERY 2019; 24:80-90. [DOI: 10.16931/1995-5464.2019480-90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
Affiliation(s)
| | | | | | | | - Sh. A. Kaniyev
- Syzganov National Scientific Centre of Surgery,
Kazakstan’s Medical University “Higher School of Public Health”
| | - E. Serikuly
- Syzganov National Scientific Centre of Surgery
| | | | | | | | | | | | - G. K. Kausova
- Kazakstan’s Medical University “Higher School of Public Health”
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22
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Diogo D, Pacheco C, Oliveira R, Martins R, Oliveira P, Cipriano MA, Tralhão JG, Furtado E. Influence of Ischemia Time in Injury of Deep Peribiliary Glands of the Bile Ducts Graft: A Prospective Study. Transplant Proc 2019; 51:1545-1548. [PMID: 31155189 DOI: 10.1016/j.transproceed.2019.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The deep peribiliary glands (DPBG) are a niche of progenitor cells in the wall of the biliary duct (BD) and are the second line of multiplication when severe lesion of the epithelium occurs. Previous studies have identified DPBG injury as a cause of post-liver transplant (LT) biliary stenosis; this complication is a major cause of post-LT morbidity. The incidence of biliary stenosis in our center is high (38.1%). This study evaluates the lesion of DPBG in response to ischemia. Graft BD was collected in adult LT between August 2016-July 2017, from donation after brain death. Samples of 45 grafts were collected at 2 moments: BD1-during graft preparation and BD2-before biliary anastomosis. Histological analysis of the samples was performed and then classified according to degree of lesion (0, ≤50%, and >50%). A comparison was made between the degree of lesion and graft ischemia, graft histology, donor, and procurement variables. The DPBG lesion was more frequent in BD2 (20.9% vs 7%, P = .079). BD2 lesions with DPBG lesions had higher medians and means at all times of ischemia. The difference was greater in the warm ischemia time (0: 43.3 ± 12.53 minutes vs ≤50%: 52.4 ± 14.38 minutes, P = .068). The group of BD1 with DPBG lesion presented superior median cold ischemia time (CIT). In the analysis of the remaining variables there were also no statistically significant differences. We concluded that during the period of CIT there is already lesion of the DPBG, which increases after reperfusion of the graft, in greater association with longer warm ischemia time.
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Affiliation(s)
- D Diogo
- Adult and Paediatric Liver Transplantation Unit, Coimbra Hospital and University Centre, Coimbra, Portugal.
| | - C Pacheco
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - R Oliveira
- Department of Pathologic Anatomy, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - R Martins
- Adult and Paediatric Liver Transplantation Unit, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - P Oliveira
- Adult and Paediatric Liver Transplantation Unit, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - M A Cipriano
- Department of Pathologic Anatomy, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - J G Tralhão
- Department of Surgery, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - E Furtado
- Adult and Paediatric Liver Transplantation Unit, Coimbra Hospital and University Centre, Coimbra, Portugal
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23
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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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24
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Long-term Outcomes and Risk Factors After Adult Living Donor Liver Transplantation. Transplantation 2019; 102:e382-e391. [PMID: 29912047 DOI: 10.1097/tp.0000000000002324] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although risk factors for the long-term mortality of liver transplantation are well described, there is a lack of detailed study regarding these factors for adult living donor liver transplantation (LDLT). METHODS We retrospectively analyzed 528 adult LDLT recipients in our hospital. The risk factors were analyzed for overall deaths more than 5 years post-LDLT. RESULTS Over the 20-year follow-up, 137 patients died. Patient survival at 1, 3, 5, and 10 years post-LDLT was 87.8%, 81.8%, 79.4%, and 72.8%, respectively. The independent risk factors for more than 5 years post-LDLT overall death were hepatocellular carcinoma recurrence (hazard ratio [HR], 38.9; P < 0.001), lymphoid de novo malignancy (HR, 47.2; P = 0.001), primary sclerosing cholangitis as primary diagnosis (HR, 11.5; P < 0.001), chronic rejection (HR, 6.93; P = 0.006), acute rejection (HR, 2.96; P = 0.017), and bile duct stenosis (HR, 2.30; P = 0.045). CONCLUSIONS Not only malignancies and rejection but also bile duct stenosis and primary sclerosing cholangitis had significant impacts on late period post-LDLT mortality.
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25
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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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26
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Lee DW, Han J. Endoscopic management of anastomotic stricture after living-donor liver transplantation. Korean J Intern Med 2019; 34:261-268. [PMID: 30840808 PMCID: PMC6406087 DOI: 10.3904/kjim.2019.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 12/14/2022] Open
Abstract
The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.
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Affiliation(s)
- Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Correspondence to Jimin Han, M.D. Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Namgu, Daegu 42472, Korea Tel: +82-53-650-3442 Fax: +82-53-624-3281 E-mail:
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27
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Czubkowski P, Markiewicz-Kijewska M, Janiszewski K, Rurarz M, Kaliciński P, Jarzębicka D, Pertkiewicz J, Kamińska D, Jankowska I, Teisseyre M, Szymczak M, Pawłowska J. Percutaneous Treatment of Biliary Strictures After Pediatric Liver Transplantation. Ann Transplant 2018; 23:845-851. [PMID: 30531688 PMCID: PMC6299781 DOI: 10.12659/aot.910528] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Biliary strictures (BS) are frequent after pediatric liver transplantation (LTx) and in spite of ongoing progress, they remain a significant cause of morbidity. In children, the majority of reconstruction is hepatico-jejunal anastomosis (HJA). The aim of this study was to analyze our experience in percutaneous transhepatic treatment of BS. Material/Methods Between 1998 and 2014, 589 (269 living donor) pediatric LTx were performed in our institution. We retrospectively reviewed clinical data of patients with HJA who developed BS and who underwent percutaneous transhepatic biliary drainage (PTBD). Results Out of 400 patients with HJA, 35 patients developed BS. There were 27 cases (77%) of anastomotic BS (ABS) and 8 cases (23%) of multilevel BS (MBS). Ninety-two PTBD sessions (2.5 per patient) were performed, with successful outcomes in 20 cases (57%). Fifteen patients, after failed PTBD, underwent surgery which was successful in 11 cases. Overall good outcomes were achieved in 31 cases (88.5%). The most common complication of PTBD was cholangitis which occurred in 5.4% of the cases. We did not find any risk factors for PTBD failure, except for treatment occurring before 2007. Conclusions Percutaneous treatment is effective and safe in BS and is recommended as a first-line approach. The majority of patients in our study required multiple interventions, however, the overall risk of complications was low. Surgery is essential in selected cases and always should be considered if PTBD fails.
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Affiliation(s)
- Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | | | | | - Małgorzata Rurarz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery and Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Jarzębicka
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Jan Pertkiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Diana Kamińska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Mikołaj Teisseyre
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marek Szymczak
- Department of Pediatric Surgery and Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Joanna Pawłowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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28
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Facciorusso A, Rosca EC, Ashimi A, Ugoeze KC, Pathak U, Infante V, Muscatiello N. Management of anastomotic biliary stricture after liver transplantation: metal versus plastic stent. Ann Gastroenterol 2018; 31:728-734. [PMID: 30386124 PMCID: PMC6191877 DOI: 10.20524/aog.2018.0297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/29/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Post-transplant anastomotic biliary strictures remain refractory to endoscopic therapy in a considerable number of cases. The aim of this meta-analysis was to compare fully-covered self-expandable metal and plastic stents in the management of post-transplant biliary strictures. METHODS A meta-analysis was performed using a random effects model; results were expressed as odds ratio (OR) and mean standardized difference. The primary outcome was stricture resolution, while recurrence rate after stent placement, treatment time, and safety of the procedure were the secondary outcomes. RESULTS Through a systematic literature review until October 2017, we identified 7 studies, of which 4 were randomized controlled trials. Stricture resolution was slightly higher with metal stents, with no statistical difference between the two procedures (OR 1.38, 95% confidence interval [CI] 0.60-3.15; P=0.45) and low heterogeneity (I2=6%). Stricture recurrence showed a non-significant trend in favor of plastic stents (OR 1.82, 95%CI 0.52-6.31, P=0.35). Endoscopic retrograde cholangiopancreatography with placement of metal stents offered a significant improvement in terms of reduced treatment time (mean standardized difference: -3.58 months, 95%CI -6.23 to -0.93; P=0.008), but with more frequent complications, although not significantly so (OR 2.34, 95%CI 0.75-7.25; P=0.14). Sensitivity analysis confirmed all the findings. CONCLUSION Metal stents appear to be a promising tool that can decrease treatment time, although there is still no clear evidence of their superiority over plastic stents in terms of efficacy.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Italy (Antonio Facciorusso; Nicola Muscatiello)
| | - Elena Cecilia Rosca
- Department of Neurology, University of Medicine and Pharmacy “Victor Babes” Timisoara, Romania (Elena Cecilia Rosca)
| | - Adewale Ashimi
- Department of Obstetrics and Gynecology, Federal Medical Centre Birnin Kudu, Jigawa State, Nigeria (Adewale Ashimi)
| | - Kenneth C. Ugoeze
- Department of Pharmaceutics & Pharmaceutical Technology, University of Port Harcourt, Nigeria (Kenneth C. Ugoeze)
| | - Utkarsha Pathak
- School of Environment, Guru Gobind Singh Indraprastha University, New Delhi, India (Utkarsha Pathak)
| | - Vanessa Infante
- Department of Infectious Diseases, University of Sao Paulo, Brasil (Vanessa Infante)
| | - Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Italy (Antonio Facciorusso; Nicola Muscatiello)
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29
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Jang SI, Lee DK. Anastomotic stricture after liver transplantation: It is not Achilles' heel anymore! INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Rao HB, Prakash A, Sudhindran S, Venu RP. Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions. World J Gastroenterol 2018; 24:2061-2072. [PMID: 29785075 PMCID: PMC5960812 DOI: 10.3748/wjg.v24.i19.2061] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/28/2018] [Accepted: 05/11/2018] [Indexed: 02/06/2023] Open
Abstract
Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.
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Affiliation(s)
- Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Arjun Prakash
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Surendran Sudhindran
- Department of Transplant and Vascular Surgery, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
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31
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Forrest EA, Reiling J, Lipka G, Fawcett J. Risk factors and clinical indicators for the development of biliary strictures post liver transplant: Significance of bilirubin. World J Transplant 2017; 7:349-358. [PMID: 29312864 PMCID: PMC5743872 DOI: 10.5500/wjt.v7.i6.349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/18/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To identify risk factors associated with the formation of biliary strictures post liver transplantation over a period of 10-year in Queensland.
METHODS Data on liver donors and recipients in Queensland between 2005 and 2014 was obtained from an electronic patient data system. In addition, intra-operative and post-operative characteristics were collected and a logistical regression analysis was performed to evaluate their association with the development of biliary strictures.
RESULTS Of 296 liver transplants performed, 285 (96.3%) were from brain dead donors. Biliary strictures developed in 45 (15.2%) recipients. Anastomotic stricture formation (n = 25, 48.1%) was the commonest complication, with 14 (58.3%) of these occurred within 6-mo of transplant. A percutaneous approach or endoscopic retrograde cholangiography was used to treat 17 (37.8%) patients with biliary strictures. Biliary reconstruction was initially or ultimately required in 22 (48.9%) patients. In recipients developing biliary strictures, bilirubin was significantly increased within the first post-operative week (Day 7 total bilirubin 74 μmol/L vs 49 μmol/L, P = 0.012). In both univariate and multivariate regression analysis, Day 7 total bilirubin > 55 μmol/L was associated with the development of biliary stricture formation. In addition, hepatic artery thrombosis and primary sclerosing cholangitis were identified as independent risk factors.
CONCLUSION In addition to known risk factors, bilirubin levels in the early post-operative period could be used as a clinical indicator for biliary stricture formation.
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Affiliation(s)
- Elizabeth Ann Forrest
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Department of Surgery, Gold Coast Hospital and Health Service, Gold Coast, Queensland 4215, Australia
| | - Janske Reiling
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Queensland 4120, Australia
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, AZ Maastricht 6202, The Netherlands
- PA Research Foundation, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Geraldine Lipka
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Jonathan Fawcett
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
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32
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Mizrahi M, Cohen J, Pleskow D. Covered bridge over troubled strictures. Gastrointest Endosc 2017; 86:1046-1047. [PMID: 29146081 DOI: 10.1016/j.gie.2017.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/14/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Meir Mizrahi
- Department of Endoscopy, Harvard Medical School, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonah Cohen
- Department of Gastroenterology and Hepatology, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas Pleskow
- Department of Medicine, Harvard Medical School, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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33
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Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 2017; 31:207-217. [DOI: 10.1016/j.trre.2017.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/06/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022]
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34
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Satapathy SK, Sheikh I, Ali B, Yahya F, Kocak M, Parsa LB, Eason JD, Vanatta JM, Nair SP. Long-term outcomes of early compared to late onset choledochocholedochal anastomotic strictures after orthotopic liver transplantation. Clin Transplant 2017; 31. [PMID: 28489291 DOI: 10.1111/ctr.13003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic treatment of anastomotic biliary stricture (ABS) after liver transplantation (LT) has been proven to be effective and safe, but long-term outcomes of early compared to late onset ABS have not been studied. The aim of this study is to compare the long-term outcome of early ABS to late ABS. METHODS Of the 806 adult LT recipients (04/2006-12/2012), 93 patients met the criteria for inclusion, and were grouped into non-ABS (no stenosis on ERCP, n=41), early ABS (stenosis <90 days after LT, 18 [19.3%]), and late ABS (stenosis ≥90 days after LT, 34 [36.5%]). A propensity matched control group for the ABS group (n=42) was obtained matched for outcome variables for age, gender, and calculated MELD score at listing. RESULTS Mean number of ERCPs (2.33±1.3 vs 2.56±1.5, P=.69) were comparable between the groups; however, significantly better long-term resolution of the stricture was noted in the early ABS group (94.44% vs 67.65%, P=.04). Kaplan-Meier analysis revealed worst survival in the early ABS group compared to the non-ABS, late ABS, and control groups (P=.0001). CONCLUSION LT recipients with early ABS have inferior graft survival despite better response to endoscopic intervention.
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Affiliation(s)
- Sanjaya K Satapathy
- Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Imran Sheikh
- Department of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Bilal Ali
- Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fazal Yahya
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mehmet Kocak
- Department of Biostatistics and Epidemiology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Laxmi Babu Parsa
- Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D Eason
- Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jason M Vanatta
- Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satheesh P Nair
- Division of Transplantation, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN, USA
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Jang SI, Sung SY, Park H, Lee KH, Joo SM, Lee DK. Salvage therapy using self-expandable metal stents for recalcitrant anastomotic strictures after living-donor liver transplantation. Therap Adv Gastroenterol 2017; 10:297-309. [PMID: 28246547 PMCID: PMC5305021 DOI: 10.1177/1756283x16685059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Recently, there has been an increase in clinical success rates using nonsurgical methods to resolve anastomotic biliary strictures (ABSs) that develop after liver transplantation (LT). However, some strictures are particularly refractory and cannot be completely resolved by an endoscopic or percutaneous procedure. Consequently, the aim of this study was to examine the feasibility and efficacy of using a newly designed fully covered self-expandable metal stent (FCSEMS) to resolve refractory ABS. METHODS A total of 35 patients with an ABS that developed after LT, but could not be resolved by an endoscopic or percutaneous procedure, were included in this study. FCSEMSs were positioned endoscopically and removed after 2-3 months. After stent removal, the patients were followed to assess complications, including re-stenosis. RESULTS The mean period from LT to stricture was 13.7 months, and the mean duration of the stricture was 31.8 months. The type and mean number of procedures previously attempted were endoscopic retrograde cholangiopancreatography (ERCP) (9.1 ± 5.1) in 19 patients and percutaneous transhepatic biliary drainage (9.2 ± 4.8) in 16 patients. All patients had successful FCSEMS insertions and removals; the mean stent indwelling time was 3.2 months. The mean follow-up period was 18.7 months (range: 6.4-37.8 months). Stricture recurrence was observed in 6 of 29 patients (recurrence rate: 20.7%). The anastomotic stricture resolved with the FCSEMS insertion in 29 of 35 patients (clinical success rate: 82.9%). CONCLUSIONS The newly designed FCSEMS is a potentially feasible and effective treatment for anastomotic strictures that develop after LT but are not amenable to treatment by conventional procedures.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea Department of Medicine, The graduate school of Yonsei University, Seoul, South Korea
| | - Se Yong Sung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hun Lee
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Moon Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Jiménez-Pérez M, Melgar Simón JM, Durán Campos A, González Grande R, Rodrigo López JM, Manteca González R. Endoscopic Management of Post-Liver Transplantation Biliary Strictures With the Use of Fully Covered Metallic Stents. Transplant Proc 2016; 48:2510-2514. [PMID: 27742337 DOI: 10.1016/j.transproceed.2016.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this work was to evaluate the safety and efficacy of a fully covered self-expandable metal stent (FCSEMS) in the treatment of post-liver transplantation biliary strictures. METHODS From October 2009 to October 2014, 44 patients with post-liver transplantation biliary stenosis were treated with the use of endoscopic retrograde cholangiography and placement of FCSEMS after informed consent. The FCSEMS was scheduled to remain in situ for 3-6 months. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. Technical success, complications, and patient outcome were analyzed. RESULTS All of the strictures were anastomotic, 52% having occurred within the 1st year following the transplantation. Placement of the FCSEMS was possible on the 1st attempt in 54% of patients. Stricture resolution at the time of stent removal was seen in 100% of the cases. During an average follow-up of 27.83 ± 18.3 months after stent removal, stenosis recurred in 9 out of 41 patients (21.9%). The average time of recurrence was 11.78 ± 13.3 months. In all of these cases, the recurrence was resolved by means of placement of another FCSEMS. In 4 cases, the recurrence was associated with a migration of the prosthesis, partial in 2 cases and total in 2 cases. Stent migration occurred in a total of 17 of the 41 patients (41.4%), in 13 of the 32 (40.6%) who had no recurrence of stenosis and in 4 of the 9 (44.4%) of those who experienced recurrence. The average numbers of endoscopic retrograde cholangiography studies required per patient were 2.8 in those with no recurrence and 3.3 in those with recurrence. No death was associated with the process. CONCLUSIONS FCSEMS is a safe effective alternative to plastic stents in the treatment of post-transplantation biliary strictures, resulting in a lower risk of complications and better patient acceptance.
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Affiliation(s)
- M Jiménez-Pérez
- Unidad de Hepatología-Trasplante Hepático, Hospital Regional Universitario de Málaga, Málaga, Spain; Unidad de Gestión Clínica de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - J M Melgar Simón
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain; Unidad de Endoscopia, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - A Durán Campos
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain; Unidad de Endoscopia, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - R González Grande
- Unidad de Hepatología-Trasplante Hepático, Hospital Regional Universitario de Málaga, Málaga, Spain; Unidad de Gestión Clínica de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - J M Rodrigo López
- Unidad de Hepatología-Trasplante Hepático, Hospital Regional Universitario de Málaga, Málaga, Spain; Unidad de Gestión Clínica de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - R Manteca González
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Regional Universitario de Málaga, Málaga, Spain
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Shin M, Joh JW. Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature. World J Gastroenterol 2016; 22:6173-6191. [PMID: 27468208 PMCID: PMC4945977 DOI: 10.3748/wjg.v22.i27.6173] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/25/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation (LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.
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Sharzehi K. Biliary strictures in the liver transplant patient. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2016. [DOI: 10.1016/j.tgie.2016.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Memeo R, Piardi T, Sangiuolo F, Sommacale D, Pessaux P. Management of biliary complications after liver transplantation. World J Hepatol 2015; 7:2890-2895. [PMID: 26689137 PMCID: PMC4678375 DOI: 10.4254/wjh.v7.i29.2890] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/27/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
Biliary complications (BC) currently represent a major source of morbidity after liver transplantation. Although refinements in surgical technique and medical therapy have had a positive influence on the reduction of postoperative morbidity, BC affect 5% to 25% of transplanted patients. Bile leak and anastomotic strictures represent the most common complications. Nowadays, a multidisciplinary approach is required to manage such complications in order to prevent liver failure and retransplantation.
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Visrodia KH, Tabibian JH, Baron TH. Endoscopic management of benign biliary strictures. World J Gastrointest Endosc 2015; 7:1003-1013. [PMID: 26322153 PMCID: PMC4549657 DOI: 10.4253/wjge.v7.i11.1003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/25/2015] [Accepted: 08/03/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic management of biliary obstruction has evolved tremendously since the introduction of flexible fiberoptic endoscopes over 50 years ago. For the last several decades, endoscopic retrograde cholangiopancreatography (ERCP) has become established as the mainstay for definitively diagnosing and relieving biliary obstruction. In addition, and more recently, endoscopic ultrasonography (EUS) has gained increasing favor as an auxiliary diagnostic and therapeutic modality in facilitating decompression of the biliary tree. Here, we provide a review of the current and continually evolving role of gastrointestinal endoscopy, including both ERCP and EUS, in the management of biliary obstruction with a focus on benign biliary strictures.
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Martins FP, Kahaleh M, Ferrari AP. Management of liver transplantation biliary stricture: Results from a tertiary hospital. World J Gastrointest Endosc 2015; 7:747-757. [PMID: 26140103 PMCID: PMC4482835 DOI: 10.4253/wjge.v7.i7.747] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/30/2014] [Accepted: 05/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period.
METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure.
RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups.
CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.
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Macías-Gómez C, Dumonceau JM. Endoscopic management of biliary complications after liver transplantation: An evidence-based review. World J Gastrointest Endosc 2015; 7:606-616. [PMID: 26078829 PMCID: PMC4461935 DOI: 10.4253/wjge.v7.i6.606] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/21/2015] [Accepted: 03/18/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
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Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81:795-803. [PMID: 25665931 DOI: 10.1016/j.gie.2014.11.019] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022]
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Predictors of endoscopic treatment outcome in the management of biliary complications after orthotopic liver transplantation. Eur J Gastroenterol Hepatol 2015; 27:150-4. [PMID: 25486026 DOI: 10.1097/meg.0000000000000251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS The most common complications after liver transplantation nowadays affect the biliary tract.We carried out a retrospective study to identify predictors of endoscopic treatment outcome in the management of post-transplantation biliary complications. METHODS Data from all patients with post-transplantation biliary complications subjected to endoscopic treatment at the University of Udine between 2000 and 2012 were extracted. To identify predictors of endoscopic treatment outcome, a logistic regression analysis was carried out. Cox modeling was used to identify factors associated with mortality. RESULTS We identified 142 patients who developed biliary complications: 83 of these patients had a successful endoscopic therapy, whereas 45 had a failure. Fourteen patients, who developed nonanastomotic biliary stricture, were excluded from the analysis. Patients with biliary complications who had pretransplant Model for End-Stage Liver Disease score more than 10 [odds ratio (OR) 3.88; 95% confidence interval (CI) 1.16-12.95; P = 0.03] and stent retention time more than 12 months (OR 6.45; 95% CI 2.14-19.42; P < 0.01) were less likely to respond to endoscopic therapy. In contrast, both dilatation and stenting procedures (OR 0.10; 95% CI 0.03-0.30; P < 0.01) and 10 Fr diameter stent placement (OR 0.21; 95% CI 0.07-0.70; P = 0.01) predicted favorable endoscopic treatment outcome. Time to the occurrence of biliary complications of more than 3 months [hazard ratio (HR) 0.24; 95% CI 0.10-0.56] and placement of five or more stents (HR 0.31; 95% CI 0.12-0.79) were found to be protective against mortality, whereas hepatic artery thrombosis was a significant risk factor for mortality (HR 13.88; 95% CI 4.08-47.25). CONCLUSION We found endoscopic treatment to be less effective in patients with pretransplant Model for End-Stage Liver Disease score more than 10 and stent retention time more than 12, whereas dilatation and stenting procedure and 10 Fr diameter stent placement predicted a favorable outcome.
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Liu Y, Wang J, Yang P, Lu H, Lu L, Wang J, Li H, Duan Y, Wang J, Li Y. Delayed rearterialization unlikely leads to nonanastomotic stricture but causes temporary injury on bile duct after liver transplantation. Transpl Int 2014; 28:341-51. [PMID: 25406364 PMCID: PMC4383644 DOI: 10.1111/tri.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/17/2014] [Accepted: 11/16/2014] [Indexed: 01/16/2023]
Abstract
Nonanastomotic strictures (NAS) are common biliary complications after liver transplantation (LT). Delayed rearterialization induces biliary injury in several hours. However, whether this injury can be prolonged remains unknown. The correlation of this injury with NAS occurrence remains obscure. Different delayed rearterialization times were compared using a porcine LT model. Morphological and functional changes in bile canaliculus were evaluated by transmission electron microscopy and real-time PCR. Immunohistochemistry and TUNEL were performed to validate intrahepatic bile duct injury. Three months after LT was performed, biliary duct stricture was determined by cholangiography; the tissue of common bile duct was detected by real-time PCR. Bile canaliculi were impaired in early postoperative stage and then exacerbated as delayed rearterialization time was prolonged. Nevertheless, damaged bile canaliculi could fully recover in subsequent months. TNF-α and TGF-β expressions and apoptosis cell ratio increased in the intrahepatic bile duct only during early postoperative period in a time-dependent manner. No abnormality was observed by cholangiography and common bile duct examination after 3 months. Delayed rearterialization caused temporary injury to bile canaliculi and intrahepatic bile duct in a time-dependent manner. Injury could be fully treated in succeeding months. Solo delayed rearterialization cannot induce NAS after LT.
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Affiliation(s)
- Yang Liu
- Department of General Surgery, Second Affiliated Hospital, Xi'an Jiaotong University School of Medicine, Xi'an, China
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Nacif LS, Bernardo WM, Bernardo L, Andraus W, Torres L, Chaib E, D'Albuquerque LC, Maluf-Filho F. Endoscopic treatment of post-liver transplantation anastomotic biliary stricture: systematic review and meta-analysis. ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:240-249. [PMID: 25296086 DOI: 10.1590/s0004-28032014000300014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/14/2014] [Indexed: 12/11/2022]
Abstract
CONTEXT Biliary strictures after liver transplantation are recognized as its Achilles' heel. The strictures are classified in anastomotic and ischemic or non-anastomotic biliary strictures, and they figure among the most common complications after liver transplantation. There are some treatment options including balloon dilation, the placement of multiple plastic stents and the placement of self-expandable metal stents and all of them seem to have good results. OBJECTIVES The aim of this study was to systematically review the literature concerning the results of the endoscopic treatment of anastomotic biliary strictures after liver transplantation. METHODS A systematic review of the literature was performed on the management of anastomotic biliary strictures post- orthotopic liver transplantation. The Medline-PubMed, EMBASE, Scielo-LILACS, and Cochrane Databases were electronically searched from January 1966 to April 2013. RESULTS No well-designed randomized controlled trial was found. Most studies were retrospective or prospective comparisons in design. One study (86 patients) compared the endoscopic and the percutaneous accesses. The sustained clinical success rates were similar but the treatment duration was longer in the percutaneous group access. Two studies (56 patients) compared balloon dilation with balloon dilation and multiple plastic stents. There were no differences concerning sustained clinical success and complication rates. CONCLUSIONS Balloon dilation is as effective as balloon dilation plus multiple plastic stenting for the resolution of the anastomotic biliary strictures. Well-designed randomized trials are still needed to compare balloon dilation versus multiple plastic stenting versus metallic stenting.
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Affiliation(s)
- Lucas Souto Nacif
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | | | - Luca Bernardo
- Projeto Diretrizes, Associação Médica Brasileira, São Paulo, SP, Brasil
| | - Wellington Andraus
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Lucas Torres
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Eleazar Chaib
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Luiz Carneiro D'Albuquerque
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
| | - Fauze Maluf-Filho
- Departamento de Gastroenterologia, Divisão de Transplante Hepático e Gastrointestinal, Laboratório de Investigação Médica, LIM-37 FMUSP, São Paulo, SP, Brasil
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Mourad MM, Algarni A, Liossis C, Bramhall SR. Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation. World J Gastroenterol 2014; 20:6159-6169. [PMID: 24876737 PMCID: PMC4033454 DOI: 10.3748/wjg.v20.i20.6159] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/26/2014] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is the best treatment for end-stage hepatic failure, with an excellent survival rates over the last decade. Biliary complications after LT pose a major challenge especially with the increasing number of procured organs after circulatory death. Ischaemic cholangiopathy (IC) is a set of disorders characterized by multiple diffuse strictures affecting the graft biliary system in the absence of hepatic artery thrombosis or stenosis. It commonly presents with cholestasis and cholangitis resulting in higher readmission rates, longer length of stay, repeated therapeutic interventions, and eventually re-transplantation with consequent effects on the patient’s quality of life and increased health care costs. The pathogenesis of IC is unclear and exhibits a higher prevalence with prolonged ischaemia time, donation after circulatory death (DCD), rejection, and cytomegalovirus infection. The majority of IC occurs within 12 mo after LT. Prolonged warm ischaemic times predispose to a profound injury with a subsequently higher prevalence of IC. Biliary complications and IC rates are between 16% and 29% in DCD grafts compared to between 3% and 17% in donation after brain death (DBD) grafts. The majority of ischaemic biliary lesions occur within 30 d in DCD compared to 90 d in DBD grafts following transplantation. However, there are many other risk factors for IC that should be considered. The benefits of DCD in expanding the donor pool are hindered by the higher incidence of IC with increased rates of re-transplantation. Careful donor selection and procurement might help to optimize the utilization of DCD grafts.
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Shin M, Joh JW. Section 10. Endoscopic management of biliary complications in adult living donor liver transplantation. Transplantation 2014; 97 Suppl 8:S36-43. [PMID: 24849832 DOI: 10.1097/01.tp.0000446274.13310.b9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Living donor liver transplantation (LDLT) has become an accepted therapeutic option for patients with end-stage liver disease. However, biliary complications remain the major causes of morbidity and mortality for LDLT recipients. Although there are currently no reports of a clear therapeutic algorithm, many approaches have been developed to treat biliary complications, including surgical, endoscopic, and percutaneous transhepatic techniques. Endoscopic treatment is currently the preferred initial treatment for patients that have previously undergone duct-to-duct biliary reconstruction. This article discusses aspects of endoscopic management of biliary complications that occur in adult LDLT.
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Affiliation(s)
- Milljae Shin
- 1 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 2 Address correspondence to: Jae-Won Joh, M.D., Ph.D., Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea
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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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