• Anastomotic complications
• Biliary reconstruction methods
• Individualized surgery
• Liver transplantation

• Humans
• Anastomosis, Surgical/adverse effects
• Anastomosis, Surgical/methods
• Bile Duct Diseases/etiology
• Bile Ducts/surgery
• Biliary Tract
• Biliary Tract Diseases/etiology
• Biliary Tract Diseases/surgery
• Constriction, Pathologic/etiology
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Living Donors
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Retrospective Studies

• biliary drainage
• biliary leake
• biliary stricture
• endoscopic retrograde cholangiopancreatography
• pediatric liver transplantation
• percutaneous cholangioplasty

• Biliary
• Endoscopic
• Liver transplantation
• Stricture

• Adolescent
• Adult
• Aged
• Bile Ducts/pathology
• Bile Ducts/surgery
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Cholestasis/etiology
• Cholestasis/surgery
• Constriction, Pathologic
• Drainage/methods
• Female
• Humans
• Liver Transplantation/adverse effects
• Living Donors
• Male
• Middle Aged
• Postoperative Complications/etiology
• Postoperative Complications/surgery
• Recurrence
• Retrospective Studies
• Risk Factors
• Treatment Outcome
• Young Adult

• Bile ducts
• Cholangiopancreatography, endoscopic retrograde
• Constriction, pathologic
• Liver transplantation
• Living donors

• Anastomosis, Surgical/adverse effects
• Biliary Tract Diseases/etiology
• Biliary Tract Diseases/therapy
• Endoscopy, Digestive System/methods
• Humans
• Liver Transplantation
• Living Donors
• Postoperative Complications/etiology
• Postoperative Complications/therapy

We compared static preservation (cold storage, CS, 4 °C) with dynamic preservation (machine perfusion, MP, 20 °C) followed by reperfusion using marginal livers: a model of donation after cardiac death (DCD) livers and two models of fatty livers, the methionine-choline deficient (MCD) diet model, and obese Zucker (fa/fa) rats. CS injury in DCD livers was reversed by an oxygenated washout (OW): hepatic damage, bile flow, and the ATP/ADP ratio in the OW + CS group was comparable with the ratio obtained with MP. Using fatty livers, CS preservation induced a marked release in hepatic and biliary enzymes in obese Zucker rats when compared with the MCD group. The same trend occurred for bile flow. No difference was found when comparing MP in MCD and obese Zucker rats. Fatty acid analysis demonstrated that the total saturated (SFA)/polyunsaturated fatty acid (PUFA) ratio was, respectively, 1.5 and 0.71 in obese Zucker and MCD rats. While preservation damage in DCD livers is associated with the ATP/ADP recovered with OW, injury in fatty livers is linked to fatty acid constituents: livers from obese. Zucker rats, with greater content in saturated FA, might be more prone to CS injury. On the contrary, MCD livers with elevated PUFA content might be less susceptible to hypothermia.

• DCD livers
• dynamic machine perfusion
• fatty livers
• marginal livers
• preservation
• static cold storage

• Biliary stricture
• Endoscopic retrograde cholangiopancreatography
• Liver transplant

• Anastomosis, Surgical/methods
• Anastomotic Leak/etiology
• Biliary Tract Surgical Procedures/methods
• Case-Control Studies
• Common Bile Duct/blood supply
• Common Bile Duct/surgery
• Female
• Follow-Up Studies
• Gallbladder/surgery
• Graft Survival/physiology
• Hepatic Artery/surgery
• Humans
• Ischemia/etiology
• Liver Transplantation/methods
• Living Donors
• Male
• Middle Aged
• Mucous Membrane/surgery
• Retrospective Studies

• biliary stenosis
• complications
• hepaticojejunostomy
• infection

• Adult
• Anti-Infective Agents/therapeutic use
• Cholangiography
• Combined Modality Therapy
• Drainage/methods
• Endoscopy
• Female
• Follow-Up Studies
• Gram-Negative Bacterial Infections/diagnosis
• Gram-Negative Bacterial Infections/epidemiology
• Gram-Negative Bacterial Infections/etiology
• Gram-Negative Bacterial Infections/therapy
• Gram-Positive Bacterial Infections/diagnosis
• Gram-Positive Bacterial Infections/epidemiology
• Gram-Positive Bacterial Infections/etiology
• Gram-Positive Bacterial Infections/therapy
• Humans
• Liver Abscess/diagnosis
• Liver Abscess/epidemiology
• Liver Abscess/etiology
• Liver Abscess/therapy
• Liver Transplantation
• Male
• Middle Aged
• Mycoses/diagnosis
• Mycoses/epidemiology
• Mycoses/etiology
• Mycoses/therapy
• Postoperative Complications/diagnosis
• Postoperative Complications/epidemiology
• Postoperative Complications/therapy
• Retrospective Studies
• Treatment Outcome

• Duct to Duct
• Roux en Y
• liver transplant
• primary sclerosing cholangitis

Living donor liver transplant (LDLT) is a major surgical undertaking. Detailed pre-operative assessment of the vascular and biliary anatomy is crucial for safe and successful harvesting of the graft and transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are currently the imaging modalities of choice in pre-operative evaluation. These cross-sectional imaging techniques can reveal the vascular and biliary anatomy, assess the hepatic parenchyma and perform volumetric analysis. Knowledge of the broad indications and contraindications to qualify as a recipient for LDLT is essential for the radiologist reporting scans in a pre-transplant patient. Similarly, awareness of the various anatomical variations and pathological states in the donor is essential for the radiologist to generate a meaningful report of his/her observations. CT and MRI have largely replaced invasive techniques such as catheter angiography, percutaneous cholangiography and endoscopic retrograde cholangiopancreatography. In order to generate a meaningful report based on these pre-operative imaging scans, it is also mandatory for the radiologist to be aware of the surgeon’s perspective. We intend to provide a brief overview of the common surgical concepts of LDLT and give a detailed description of the minimum that a radiologist is expected to seek and report in CT and MR scans performed for LDLT related evaluation.

• Liver transplantation
• Pre-living donor liver transplant imaging
• Vascular anatomy and variants
• Biliary anatomy and variants
• Computed tomography
• Magnetic resonance imaging

AIM: To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a “redundant bile duct” (RBD).

METHODS: Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stones-sludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention.

RESULTS: One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twenty-one out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were plastic. Selection of stent size and length were based upon endoscopist preference. Stent size ranged from 7 to 11.5 Fr (average stent size 10 Fr); Stent length ranged from 6 to 15 cm (average length 9 cm). Concurrent biliary sphincterotomy was performed in 10/19 patients. Single ERCP session was sufficient in 6/15 (40.0%) patients, whereas 4/15 (26.7%) patients needed two ERCP sessions and 5/15 (33.3%) patients required more than two (average of 5.4 ERCP procedures). Single biliary stent was sufficient in 5 patients; the remaining patients required an average of 4.9 stents. Four out of 19 (21.1%) patients failed endotherapy (lack of resolution of RBD and recurrent cholestasis in the absence of biliary stent) and required either choledocojejunostomy (2/4) or percutaneous biliary drainage (2/4). Endoscopic complications included: 2/65 (3%) post-ERCP pancreatitis and 2/10 (20%) non-complicated post-sphincterotomy bleeding. No endoscopic related mortality was found. The medical records of the 15 successful endoscopically managed patients were reviewed for a period of one year after removal of all biliary stents. Eleven patients had continued resolution of cholestatic biomarkers (73%). One patient had recurrent hepatitis C, 2 patients suffered septic shock which was not associated with ERCP and 1 patient was transferred care to an outside provider and records were not available for our review.

CONCLUSION: Although surgical biliary reconstruction techniques have improved, RBD represents a post-OLT complication. This entity is rare however, endoscopic management of RBD represents a reasonable initial approach.

• Redundant bile duct
• Orthotopic liver transplantation
• Biliary complications
• Biliary stent
• Endoscopic retrograde cholangiopancreatography

• Adult
• Aged
• Bile Ducts, Extrahepatic/surgery
• Biliary Tract Diseases/diagnosis
• Biliary Tract Diseases/etiology
• Biliary Tract Diseases/surgery
• Chi-Square Distribution
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/instrumentation
• Female
• Humans
• Liver Transplantation/adverse effects
• Male
• Middle Aged
• Prosthesis Design
• Plastic Surgery Procedures/adverse effects
• Reoperation
• Retrospective Studies
• Risk Factors
• Sphincterotomy, Endoscopic/adverse effects
• Stents
• Texas
• Time Factors
• Treatment Outcome

Given the scarcity of donors, moderately fatty livers (FLs) are currently being considered as possible grafts for orthotopic liver transplantation (OLT), notwithstanding their poor tolerance to conventional cold preservation. The behaviour of parenchymal and sinusoidal liver cells during transplantation is being studied worldwide. Much less attention has been paid to the biliary tree, although this is considered the Achille's heel even of normal liver transplantation. To evaluate the response of the biliary compartment of FLs to the various phases of OLT reliable markers are necessary. Previously we demonstrated that Alkaline Phosphatase was scarcely active in bile canaliculi of FLs and thus ruled it out as a marker. As an alternative, dipeptidylpeptidase-IV (DPP-IV), was investigated. This ecto-peptidase plays an important role in glucose metabolism, rapidly inactivating insulin secreting hormones (incretins) that are important regulators of glucose metabolism. DPP-IV inhibitors are indeed used to treat Type II diabetes. Neuropeptides regulating bile transport and composition are further important substrates of DPP-IV in the enterohepatic axis. DPP-IV activity was investigated with an azo-coupling method in the liver of fatty Zucker rats (fa/fa), using as controls lean Zucker (fa/+) and normal Wistar rats. Protein expression was studied by immunofluorescence with the monoclonal antibody (clone 5E8). In Wistar rat liver, DPP-IV activity and expression were high in the whole biliary tree, and moderate in sinusoid endothelial cells, in agreement with the literature. Main substrates of DPP-IV in hepatocytes and cholangiocytes could be incretins GLP-1 and GIP, and neuropeptides such as vasoactive intestinal peptide (VIP) and substance P, suggesting that these substances are inactivated or modified through the biliary route. In lean Zucker rat liver the enzyme reaction and protein expression patterns were similar to those of Wistar rat. In obese rat liver the patterns of DPP-IV activity and expression in hepatocytes reflected the morphological alterations induced by steatosis as lipid-rich hepatocytes had scarce activity, located either in deformed bile canaliculi or in the sinusoidal and lateral domains of the plasma membrane. These findings suggest that bile canaliculi in steatotic cells have an impaired capacity to inactivate incretins and neuropeptides. Incretin and/or neuropeptide deregulation is indeed thought to play important roles in obesity and insulin-resistance. No alteration in enzyme activity and expression was found in the upper segments of the biliary tree of obese respect to lean Zucker and Wistar rats. In conclusion, this research demonstrates that DPP-IV is a promising in situ marker of biliary functionality not only of normal but also of fatty rats. The approach, initially devised to investigate the behaviour of the liver during the various phases of transplantation, appears to have a much higher potentiality as it could be further exploited to investigate any pathological or stressful conditions involving the biliary tract (i.e., metabolic syndrome and cholestasis) and the response of the biliary tract to therapy and/or to surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of biliary complications in liver transplant patients; however, its safety and efficacy have not been established in this setting. This study was performed to evaluate the safety and long-term efficacy of ERCP in transplant patients.

The case reports of 1,500 liver transplant patients were reviewed. Orthotopic liver transplantation (OLT) patients were matched 1:2 with non-OLT patients and followed-up for long-term outcome (median, 7.4 years).

Of the 1,500 liver transplant patients, 94 (6.3%) underwent 150 ERCPs after OLT. Anastomotic strictures were present in 45 patients, biliary stones in 24, biliary leaks in 7, papillary stenosis in 2, and primary sclerosing cholangitis in 1. An ERCP success rate of 90.7% was achieved; biliary stenting led to resolution of the bile leak in 7/7 (100%) patients, and biliary stones were removed in 21/24 (87.5%) patients. In addition, 34 of 45 patients with anastomotic stricture underwent endoscopic dilation. We obtained complete resolution in 22/34 (64.7%) patients. OLT patients did not show a higher probability of complications (odds ratio [OR], 1.04), of pancreatitis (OR, 0.80) or of bleeding (OR, 1.34).

ERCP is safe and effective for the treatment of post-OLT biliary complications, has a low rate of pancreatitis and results in a durable effect.

• Biliary complications
• Endoscopic retrograde cholangiopancreatography
• Liver transplant
• Pancreatitis

Biliary strictures are one of the most common complications following liver transplantation, representing an important cause of morbidity and mortality in transplant recipients. The reported incidence of biliary stricture is 5% to 15% following deceased donor liver transplantations and 28% to 32% following living donor liver transplantations. Bile duct strictures following liver transplantation are easily and conveniently classified as anastomotic strictures (AS) or non-anastomotic strictures (NAS). NAS are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and the need for retransplantation. Current endoscopic strategies to correct biliary strictures following liver transplantation include repeated balloon dilatations and the placement of multiple side-by-side plastic stents. Endoscopic balloon dilatation with stent placement is successful in the majority of AS patients. In patients for whom gaining biliary access is technically difficult, a combined endoscopic and percutaneous/surgical approach proves quite useful. Future directions, including novel endoscopic retrograde cholangiopancreatography techniques, advanced endoscopy, and improved stents could allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. The aim of this review is to detail the present status of endoscopy in the diagnosis, treatment, outcome, and future directions of biliary strictures related to orthotopic liver transplantation from the viewpoint of a clinical gastroenterologists.

• Anastomotic strictures
• Bile duct diseases
• Endoscopic retrograde cholangiopancreatography
• Liver transplantation

• Anastomotic strictures
• Bile duct diseases
• Endoscopic retrograde cholangiopancreatography
• Liver transplantation

• Adult
• Anastomosis, Surgical/adverse effects
• Anastomotic Leak/therapy
• Bile Ducts/surgery
• Biliary Tract Diseases/etiology
• Cadaver
• Constriction, Pathologic/etiology
• Constriction, Pathologic/surgery
• Drainage/methods
• Humans
• Incidence
• Liver Transplantation/adverse effects
• Living Donors
• Postoperative Complications/etiology
• Postoperative Complications/surgery
• Plastic Surgery Procedures
• Risk Factors
• Tissue Donors
• Treatment Outcome

Biliary complications often lead to acute and chronic liver injury after orthotopic liver transplantation (OLT). Bile composition and secretion depend on the integrated action of all the components of the biliary tree, starting from hepatocytes. Fatty livers are often discarded as grafts for OLT, since they are extremely vulnerable to conventional cold storage (CS). However, the insufficiency of donors has stimulated research to improve the usage of such marginal organs as well as grafts. Our group has recently developed a machine perfusion system at subnormothermic temperature (20°C; MP20) that allows a marked improvement in preservation of fatty and even of normal rat livers as compared with CS. We sought to evaluate the response of the biliary tree of fatty liver to MP20, and a suitable marker was essential to this purpose. Alkaline phosphatase (AlkP, EC 3.1.3.1), frequently used as marker of membrane transport in hepatocytes and bile ducts, was our first choice. Since no histochemical data were available on AlkP distribution and activity in fatty liver, we have first settled to investigate AlkP activity in the steatotic liver of fatty Zucker rats (fa/fa), using as controls lean Zucker (fa/+) and normal Wistar rats. The AlkP reaction in Wistar rats was in accordance with the existing data and, in particular, was present in bile canaliculi of hepatocytes in the periportal region and midzone, in the canals of Hering and in small bile ducts but not in large bile ducts. In lean ZR liver the AlkP reaction in Hering canals and small bile ducts was similar to Wistar rat liver but hepatocytes had lower canalicular activity and besides presented moderate basolateral reaction. The difference between lean Zucker and Wistar rats, both phenotypically normal animals, could be related to the fact that lean Zucker rats are genotypically heterozygous for a recessive mutated allele. In fatty liver, the activity in ductules and small bile ducts was unchanged, but most hepatocytes were devoid of AlkP activity with the exception of clusters of macrosteatotic hepatocytes in the mid-zone, where the reaction was intense in basolateral domains and in distorted canaliculi, a typical pattern of cholestasis. The interpretation of these data was hindered by the fact that the physiological role of AlkP is still under debate. In the present study, the various functions proposed for the role of the enzyme in bile canaliculi and in cholangiocytes are reviewed. Independently of the AlkP role, our data suggest that AlkP does not seem to be a reliable marker to study the initial step of bile production during OLT of fatty livers, but may still be used to investigate the behaviour of bile ductules and small bile ducts.

• Adult
• Aged
• Anastomotic Leak/mortality
• Anastomotic Leak/therapy
• Biliary Fistula/mortality
• Biliary Fistula/therapy
• Catheterization/methods
• Cause of Death
• Cohort Studies
• Drainage/methods
• Female
• Humans
• Male
• Middle Aged
• Postoperative Complications/mortality
• Postoperative Complications/therapy
• Retrospective Studies
• Survival Rate
• Tomography, Spiral Computed
• Upper Gastrointestinal Tract/surgery

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Biliary strictures are classified as anastomotic or non-anastomotic strictures according to location and are defined by distinct clinical behaviors. Anastomotic strictures are localized and short. The outcome of endoscopic treatment for anastomotic strictures is excellent. Non-anastomotic strictures often result from ischemic and immunological events, occur earlier and are usually multiple and longer. They are characterized by a far less favorable response to endoscopic management, higher recurrence rates, graft loss and need for retransplantation. Living donor OLT patients present a unique set of challenges arising from technical factors, and stricture risk for both recipients and donors. Endoscopic treatment of living donor OLT patients is less promising. Current endoscopic strategies for biliary strictures after OLT include repeated balloon dilations and placement of multiple side-by-side plastic stents. Lifelong surveillance is required in all types of strictures. Despite improvements in incidence and long term outcomes with endoscopic management, and a reduced need for surgical treatment, the impact of strictures on patients after OLT is significant. Future considerations include new endoscopic technologies and improved stents, which could potentially allow for a decreased number of interventions, increased intervals before retreatment, and decreased reliance on percutaneous and surgical modalities. This review focuses on the role of endoscopy in biliary strictures, one of the most common biliary complications after OLT.

• Anastomotic strictures
• Bile duct diseases
• Endoscopic retrograde cholangiopancreatography
• Orthotopic liver transplantation
• Surgical anastomosis

Interventional radiology has acquired a key role in every liver transplantation (LT) program by treating the majority of vascular and non-vascular post-transplant complications, improving graft and patient survival and avoiding, in the majority of cases, surgical revision and/or re-transplantation. The aim of this paper is to review indications, technical consideration, results achievable and potential complications of interventional radiology procedures after deceased donor LT and living related adult LT.

• Liver transplantation
• Interventional radiology
• Complication
• Review
• Liver

• Anastomosis, Surgical/adverse effects
• Biliary Tract Diseases/diagnosis
• Biliary Tract Diseases/etiology
• Biliary Tract Diseases/surgery
• Constriction, Pathologic
• Endoscopy, Digestive System/methods
• Humans
• Liver Transplantation/adverse effects
• Liver Transplantation/methods
• Treatment Outcome

• Adolescent
• Adult
• Child
• Child, Preschool
• Female
• Hepatectomy/methods
• Humans
• Infant
• Liver/anatomy & histology
• Liver Transplantation/physiology
• Living Donors/statistics & numerical data
• Male
• Middle Aged
• Organ Size
• Retrospective Studies
• Tissue and Organ Harvesting/methods

• Anastomosis, Surgical
• Bile Duct Diseases/chemically induced
• Bile Duct Diseases/surgery
• Bile Duct Diseases/therapy
• Cholangiopancreatography, Endoscopic Retrograde
• Gallbladder/surgery
• Gallstones/surgery
• Humans
• Liver Transplantation/adverse effects
• Plastic Surgery Procedures
• Retrospective Studies