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Jadaun SS, Nekarakanti PK, Bhatia S, Kumar M, Singh P, Singla V, Singh SA, Agarwal S, Saigal S, Gupta S. Post-living donor liver transplant biliary strictures: prevalence, predictors, and long-term outcomes in a retrospective study. CLINICAL TRANSPLANTATION AND RESEARCH 2025; 39:55-65. [PMID: 40150918 PMCID: PMC11959435 DOI: 10.4285/ctr.24.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 12/16/2024] [Accepted: 01/20/2025] [Indexed: 03/29/2025]
Abstract
Background Post-liver transplant biliary strictures are a common cause of morbidity among patients who have undergone living donor liver transplantation (LDLT). Limited data are available concerning the response rates to various treatment modalities and the long-term outcomes for these individuals. Methods This study was a retrospective analysis of a prospectively collected database, including adult patients aged 18 years or older who underwent LDLT between 2006 and 2022. Results Between 2006 and 2022, a total of 3,550 patients underwent liver transplantation. After applying exclusion criteria, 2,956 patients were included in the analysis. During the study period, 344 patients (11.6%) developed biliary strictures. Of these, 77.0% underwent endoscopic retrograde cholangiopancreatography as the primary treatment for biliary strictures, while the remainder received percutaneous transhepatic biliary drainage. Identified risk factors for post-liver transplant biliary strictures included the presence of multiple biliary anastomoses, bile leak, and older donor and recipient ages. The overall graft and patient survival rates were comparable between patients with and without biliary strictures, at both 1 year (93.0% vs. 96.3%) and 5 years (82.3% vs. 79.2%). Conclusions Biliary strictures are observed in approximately 11% of recipients following LDLT. While the presence of biliary strictures is associated with increased morbidity, it does not significantly impact patient survival.
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Affiliation(s)
- Shekhar Singh Jadaun
- Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Phani Kumar Nekarakanti
- Department of Liver Transplant and GI Surgery, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Sushant Bhatia
- Department of Liver Transplant and GI Surgery, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Mukesh Kumar
- Department of Liver Transplant and GI Surgery, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Pankaj Singh
- Department of Gastroenterology, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Vikas Singla
- Department of Gastroenterology, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Shweta A. Singh
- Department of Anesthesia and Critical Care, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Department of Liver Transplant and GI Surgery, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Department of Liver Transplant and GI Surgery, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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Bhangui P. Management of biliary complications after LDLT. Updates Surg 2024:10.1007/s13304-024-01988-z. [PMID: 39276196 DOI: 10.1007/s13304-024-01988-z] [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: 07/16/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024]
Abstract
Biliary complications (BC) in the recipient continue to be an as yet, unresolved issue following living donor liver transplantation (LDLT). Bile leaks (BL) and biliary anastomotic strictures (BAS) are the most common BCs, with the latter contributing to close to 80%. With increasing expertise, endoscopic treatment with endoscopic retrograde cholangiography (ERC) [the first-line treatment] and percutaneous transhepatic cholangiography (PTC) with percutaneous transhepatic biliary drainage (PTBD) alone or in combination with ERC lead to successful management in a majority of these cases. However, prediction of difficulty of endoscopic success in biliary strictures, optimal duration of indwelling stents and their planned removal, management options in high-grade strictures (HGS) and the long-term outcome of patients requiring intervention for BC's are still unanswered questions in this setting. This review will try to summarise pertinent issues, novel insights and finally propose basic principles to be adhered to when dealing with the gamut of possible biliary complications after LDLT.
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Affiliation(s)
- Prashant Bhangui
- Master in HPB Surgery (Henri Bismuth Hepatobiliary Institute, France), European Inter-University Diploma in HPB Oncology, Fellowship in Hepatobiliary Surgery and Liver Transplantation (Hopital Paul Brousse, France), Director, Liver Transplantation and Hepatobiliary Surgery, Medanta Institute Of Liver Transplantation and Regenerative Medicine, Medanta - The Medicity, Gurgaon, Delhi NCR, 122001, India.
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Yamada R, Kuriyama N, Tanaka T, Nose K, Nakamura Y, Miwata T, Tsuboi J, Mizuno S, Nakagawa H. Inside stent placement is suitable for preoperative biliary drainage in patients with perihilar cholangiocarcinoma. BMC Gastroenterol 2024; 24:174. [PMID: 38769494 PMCID: PMC11106890 DOI: 10.1186/s12876-024-03266-z] [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: 10/25/2023] [Accepted: 05/15/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND/PURPOSE Endoscopic biliary stenting (EBS) is commonly used for preoperative drainage of localized perihilar cholangiocarcinoma (LPHC). This study retrospectively compared the utility of inside stent (IS) and conventional stent (CS) for preoperative EBS in patients with LPHC. METHODS EBS was performed in 56 patients with LPHC. EBS involved the placement of a CS (n = 32) or IS (n = 24). Treatment outcomes were compared between these two groups. RESULTS Preoperative recurrent biliary obstruction (RBO) occurred in 23 patients (71.9%) in the CS group and 7 (29.2%) in the IS group, with a significant difference (p = 0.002). The time to RBO (TRBO) was significantly longer in IS than in CS (log-rank: p < 0.001). The number of stent replacements was significantly lower in IS than CS [0.38 (0-3) vs. 1.88 (0-8), respectively; p < 0.001]. Gemcitabine-based neoadjuvant chemotherapy (NAC) was administered to 26 patients (46.4%). Among patients who received NAC, TRBO was longer in IS than in CS group (log-rank: p < 0.001). The IS group had a significantly shorter preoperative and postoperative hospital stay than the CS group (20.0 vs. 37.0 days; p = 0.024, and 33.5 vs. 41.5 days; p = 0.016). Both the preoperative and the postoperative costs were significantly lower in the IS group than in the CS group (p = 0.049 and p = 0.0034, respectively). CONCLUSION Compared with CS, IS for preoperative EBS in LPHC patients resulted in fewer complications and lower re-intervention rates. The fact that the IS group had shorter preoperative and postoperative hospital stays and lower costs both preoperatively and postoperatively compared to the CS group may suggest that the use of IS has the potential to benefit not only the patient but also the healthcare system.
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Affiliation(s)
- Reiko Yamada
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan.
| | - Naohisa Kuriyama
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takamitsu Tanaka
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan
| | - Kenji Nose
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan
| | - Yoshifumi Nakamura
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan
| | - Tetsuro Miwata
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan
| | - Junya Tsuboi
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan
| | - Shugo Mizuno
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hayato Nakagawa
- Gastroenterology and Hepatology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie-prefecture, 514-8507, Japan
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4
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Harputluoglu M, Calgin MZ, Ataman E, Tikici D, Kutluturk K, Kutlu R, Efe CS, Yilmaz S. Outcomes of patients with primary sclerosing cholangitis after liver transplantation in a predominantly living donor liver transplant center. JOURNAL OF LIVER TRANSPLANTATION 2023; 12:100186. [DOI: 10.1016/j.liver.2023.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2025] Open
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Seifert L, von Renesse J, Seifert AM, Sturm D, Meisterfeld R, Rahbari NN, Kahlert C, Distler M, Weitz J, Reissfelder C. Interrupted versus continuous suture technique for biliary-enteric anastomosis: randomized clinical trial. BJS Open 2023; 7:7021143. [PMID: 36723996 PMCID: PMC9891343 DOI: 10.1093/bjsopen/zrac163] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Biliary-enteric anastomosis (BEA) can be performed using continuous or interrupted suture techniques, but high-quality evidence regarding superiority of either technique is lacking. The aim of this study was to compare the suture techniques for patients undergoing BEA by evaluating the suture time as well as short- and long-term biliary complications. METHODS In this single-centre randomized clinical trial, patients scheduled for elective open procedure with a BEA between 21 January 2016 and 20 September 2017 were randomly allocated in a 1:1 ratio to have the BEA performed with continuous suture (CSG) or interrupted suture technique (ISG). The primary outcome was the time required to complete the anastomosis. Secondary outcomes were BEA-associated postoperative complications with and without operative revision of the BEA, including bile leakage, cholestasis, and cholangitis, as well as morbidity and mortality up to day 30 after the intervention and survival. RESULTS Altogether, 82 patients were randomized of which 80 patients received the allocated intervention (39 in ISG and 41 in CSG). Suture time was longer in the ISG compared with the CSG (median (interquartile range), 22.4 (15.0-28.0) min versus 12.0 (10.0-17.0) min, OR 1.26, 95 per cent c.i. 1.13 to 1.40; unit of increase of 1 min; P < 0.001). Short-term and long-term biliary complications were similar between groups. The incidence of bile leakage (6 (14.6 per cent) versus 4 (10.3 per cent), P = 0.738) was comparable between groups. No anastomotic stenosis occurred in either group. CONCLUSION Continuous suture of BEA is equally safe, but faster compared with interrupted suture. REGISTRATION NUMBER NCT02658643 (http://www.clinicaltrials.gov).
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Affiliation(s)
- Lena Seifert
- Correspondence to: Lena Seifert, Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany (e-mail: )
| | - Janusz von Renesse
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Adrian M Seifert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany,National Center for Tumor Diseases (NCT), Partner Site Dresden, Heidelberg, Germany,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Dresden, Heidelberg, Germany
| | - Dorothée Sturm
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Ronny Meisterfeld
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Nuh N Rahbari
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany,National Center for Tumor Diseases (NCT), Partner Site Dresden, Heidelberg, Germany,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Dresden, Heidelberg, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany,National Center for Tumor Diseases (NCT), Partner Site Dresden, Heidelberg, Germany,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Partner Site Dresden, Heidelberg, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Sharma ZD, Karunakaran M, Bansal RK, Gandhi A, Singh MK, Soin AS, Puri R, Sud R. Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy. ANZ J Surg 2022; 93:911-917. [PMID: 36262090 DOI: 10.1111/ans.18123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/30/2022] [Accepted: 10/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis. METHODS A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up. RESULTS Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P = 0.002), longer duration for resolution (282.5 vs. 201.5 days, P = 0.095) and more number of stents. CONCLUSIONS Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.
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Affiliation(s)
- Zubin Dev Sharma
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Monish Karunakaran
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India.,Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.,College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon, India
| | - Ashish Gandhi
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Rajesh Puri
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Randhir Sud
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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Endoscopic Bridge-and-Seal of Bile Leaks Using a Fully Covered Self-Expandable Metallic Stent above the Papilla. J Clin Med 2022; 11:jcm11206019. [PMID: 36294340 PMCID: PMC9604735 DOI: 10.3390/jcm11206019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background/Aims: Endoscopic management by endoscopic sphincterotomy with or without plastic stents or fully covered self-expandable metallic stents (FCSEMSs) is widely accepted as the current standard of care for postoperative bile leaks. Biliary stents are placed across the papilla, not above the papilla. We investigated the safety and effectiveness of the bridge-and-seal technique for bile leaks by the placement of FCSEMS above the papilla. Methods: This was a retrospective study of FCSEMS placement above the papilla for bile leaks between October 2016 and July 2021. FCSEMS was placed above the papilla to bridge and seal the leak. The main outcome measures were the resolution of bile leaks and adverse events. Results: Seven patients with postoperative bile leaks underwent FCSEMS above the papilla. The locations of bile leaks were 1 cystic duct remnant; 2 intrahepatic bile duct; 1 hepatic duct; 2 common bile duct and 1 anastomosis. The technical success rate of FCSEMS placement was 100%, and resolution of bile leaks was achieved in five patients (71.4%). All the adverse events were observed after FCSEMS removal; as follows: 1 moderate cholangitis; 2 mild post-ERCP pancreatitis; and 1 mild remnant cholecystitis. Conclusions: FCSEMS placement above the papilla can be a treatment option for postoperative bile leaks.
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Recent Advances in Pancreato-Biliary Endoscopic Intervention: How to Resolve Unmet Needs in Pancreato-Biliary Diseases Endoscopically. J Clin Med 2022; 11:jcm11133637. [PMID: 35806922 PMCID: PMC9267574 DOI: 10.3390/jcm11133637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
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Eslami O, Moazzami B, Zabala ZE, Roushan N, Dashti H, Fakhar N, Saberi H, Jafarian A, Toosi MN. Anastomotic biliary stricture following liver transplantation and management analysis: 15 years of experience at a high-volume transplant center. Indian J Gastroenterol 2022; 41:231-239. [PMID: 35838868 DOI: 10.1007/s12664-022-01245-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 01/18/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The occurrence of anastomotic biliary stricture (BS) remains an essential issue following liver transplantation (LT). The present study aimed to compare our findings regarding the incidence of anastomotic BS to what is known. METHODS The present study is a single-center, retrospective cohort study of a total number of 717 consecutive patients (426 men and 291 women) who had undergone LT from January 2001 to March 2016. Multivariable Cox regression analysis was conducted to evaluate the risk factors associated with anastomotic BS development. RESULTS Post-transplant anastomotic BS developed in 70 patients (9.8%). In the Cox multivariate analysis (a stepwise forward conditional method), factors including biliary leak (hazard ratio [HR]: 6.61, 95% confidence interval [CI]: 3.08-17.58, p < 0.001), hepatic artery thrombosis (HR: 2.29, 95% CI: 1.03-5.88; p = 0.003), and acute rejection (HR: 2.18, 95% CI: 1.16-3.37; p = 0.006) were identified as independent risk factors for the development of anastomotic BS. Surgery in 6 cases (66.7%), followed by endoscopic retrograde cholangiopancreatography (ECRP) with a metal stent in 18 cases (62.1%), percutaneous transhepatic biliary drainage in 9 (20.9%), and ERCP with a single plastic stent in 8 (18.2%), had the highest effectiveness rates in the management of BS, respectively. CONCLUSIONS Risk factors including biliary leak, hepatic artery thrombosis, and acute rejection were independently associated with an anastomotic BS. ERCP with a metal stent may be considered as an effective treatment procedure with a relatively low complication rate in the management of benign post-LT anastomotic BS.
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Affiliation(s)
- Omid Eslami
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Gastroenterology and Hepatology Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Bobak Moazzami
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA.
| | - Zohyra E Zabala
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Nader Roushan
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Habibollah Dashti
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasir Fakhar
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hazhir Saberi
- Department of Radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Jafarian
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohssen Nassiri Toosi
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Liver Transplantation, Imam Khomeini Hospital, Tehran University of Medical Science, Keshavarz Blvd, Tehran, Iran.
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Forde JJ, Bhamidimarri KR. Management of Biliary Complications in Liver Transplant Recipients. Clin Liver Dis 2022; 26:81-99. [PMID: 34802665 DOI: 10.1016/j.cld.2021.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.
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Affiliation(s)
- Justin J Forde
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA
| | - Kalyan Ram Bhamidimarri
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Suite A, Miami, FL 33136, USA.
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11
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Parlak E, Simsek C, Koksal AS, Eminler AT, Unal E, Ciftci TT, Akinci D, Yilmaz S. The Classification of Biliary Strictures in Patients With Right-Lobe Liver Transplant Recipients and Its Relation to Traversing the Stricture With a Guidewire. Transplantation 2022; 106:328-336. [PMID: 33724243 DOI: 10.1097/tp.0000000000003738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traversing the stricture with a guidewire is a prerequisite for the endoscopic treatment of biliary strictures after living donor liver transplantation. We aimed to evaluate the effect of variations in the biliary anastomosis and strictures on the success of endoscopic treatment and suggest a cholangiographic classification. METHODS The 125 strictures among the 104 patients with right-lobe living donor liver transplantation were reviewed. The strictures were classified by the anastomosis pattern according to the number (1, 2, or >2), location (common bile, hepatic, or cystic duct), the angle between the proximal and distal sites of the anastomosis, and the contrast enhancement pattern. The relationship between the success rate of traversing the anastomosis and the classification was evaluated. RESULTS Of the 125 biliary strictures, 86 (68.8%) could be passed via endoscopically. Thirty-three strictures were managed either percutaneously (n = 13) or by magnetic compression anastomosis (n = 20). Compared with the round, the triangular (odds ratio [OR], 6.5), the intermediate form (OR, 17.7), and the end-to-side anastomosis (OR, 5.1) were associated with an increased chance of traversing. The contrast enhancement pattern of the strictures and the bile ducts was also related to the successful rate of the endoscopic treatment (P < 0.001). The success rate was higher in the patients with the angle between the proximal and distal sites of the anastomosis approximated was small (0°-30° = 74%, 30°-60° = 69%, 60°-90° = 63%, >90° = 41%). CONCLUSIONS The type of biliary anastomoses and stricture affect the success rate of endoscopic treatment. These data may play role in making decision about the type of anastomosis during the surgery.
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Affiliation(s)
- Erkan Parlak
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Cem Simsek
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Aydin Seref Koksal
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Emre Unal
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Turkmen Turan Ciftci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Devrim Akinci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sezai Yilmaz
- Department of Surgery, Faculty of Medicine, Liver Transplant Institute, Inonu University, Malatya, Turkey
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12
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Kwon CI, Choi SH, Kim KS, Moon JP, Park S, Jeon J, Kim G, Jang JY, Sung MJ, Ko KH, Son JS. Preventive effect of biodegradable stents on biliary stricture and fibrosis after biliary anastomosis in a porcine model. Ann Surg Treat Res 2022; 102:90-99. [PMID: 35198512 PMCID: PMC8831087 DOI: 10.4174/astr.2022.102.2.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/29/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The current drain tubes for preventing surgically biliary anastomotic stricture are not naturally and easily removed. If a drain tube using biodegradable material is easily available and the degradation time of the tube is well controlled, surgical anastomotic stricture and fibrosis could be prevented. The aim of this animal study was to evaluate the preventive effect of novel biodegradable stents (BS) on biliary stricture and fibrosis after duct-to-duct (DD) biliary anastomosis. Methods Ten mini-pigs were allocated to the control group (n = 5) and or the stent group (n = 5). The common bile duct was exposed through surgical laparotomy and then resected transversely. In the stent group, a 4-mm or 6-mm polydioxanone/magnesium sheath-core BS was inserted according to the width of the bile duct, followed by DD biliary anastomosis. In the control group, DD biliary anastomosis was performed without BS insertion. Results In the stent group, stents were observed without deformity for up to 4 weeks in all animals. Eight weeks later, histopathologic examination revealed that the common bile duct of the anastomosis site was relatively narrower in circumference in the control group compared to the stent group. The degree of fibrosis in the control group was more marked than in the stent group (3.84 mm vs. 0.68 mm, respectively; P < 0.05). Conclusion Our study showed that novel BS maintained their original shape and radial force for an adequate time and then disappeared without adverse events. The BS could prevent postoperative complications and strictures after DD biliary anastomosis.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kyu Seok Kim
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jong Pil Moon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Sehwan Park
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jinkyung Jeon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Young Jang
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Je Sung
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jun Sik Son
- Korea Textile Development Institute, Daegu, Korea
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13
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Kuwatani M, Kawakubo K, Sakamoto N. Possible reasons for the regrettable results of patency of an inside stent in endoscopic transpapillary biliary stenting. Dig Endosc 2022; 34:334-344. [PMID: 33949009 DOI: 10.1111/den.14006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/16/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
Endoscopic biliary decompression is a minimally invasive procedure for cholestasis since the first endoscopic retrograde cholangiopancreatography-guided biliary stenting performed by Soehendra and Reynders-Frederix. Among the endoscopic biliary decompression, endoscopic transpapillary biliary stenting (EBS), is a mainstream choice and presently has two methods of placement: stenting above the sphincter of Oddi (SO) (suprapapillary) and stenting across the SO (transpapillary). Stent patency is the most important concern for patients, endoscopists and physicians because it can affect both the life prognosis and treatment schedule of patients. Biliary stent occlusion can occur because of several factors. Among them, direct food impaction, biofilm formation, and sludge formation play important roles and are presumed to be theoretically overcome by EBS above the SO. Thus, EBS above the SO is expected to result in a longer patency than EBS across the SO. In the literature, there have been six comparative studies on EBS for distal biliary obstruction in which the stent was placed above or across the SO, including two randomized controlled trials (RCTs) with negative results of stenting above the SO. With respect to EBS for hilar biliary obstruction, there have been no RCTs, whereas four retrospective comparative studies with negative results and four retrospective comparative studies showing positive results of stenting above the SO have been reported. In this review, we focused on EBS above and across the SO, and summarized the positive and negative results of the two types of stenting to promote effective clinical practice and to provide a basis for future studies.
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Affiliation(s)
- Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Hokkaido, Japan
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Hokkaido, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Hokkaido, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Hokkaido, Japan
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14
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Nishikawa Y, Uza N, Hata K, Marui S, Kuwada T, Matsumori T, Maruno T, Shiokawa M, Kuriyama K, Kurita A, Yazumi S, Kodama Y, Yoshizawa A, Anazawa T, Ito T, Uemoto S, Seno H. Long-term Outcomes of Stent Placement Inside the Bile Duct for Biliary Strictures After Living Donor Liver Transplantation. Liver Transpl 2022; 28:88-97. [PMID: 34327805 DOI: 10.1002/lt.26247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
In living donor liver transplantation (LDLT), anastomotic biliary stricture is a serious and refractory complication. In this study, we reviewed the transition of post-LDLT anastomotic biliary strictures and evaluated long-term outcomes of stent placement inside the bile duct, which is referred to as an "inside-stent." Of 805 consecutive adult LDLT recipients in our institution (2000-2018), we reviewed 639 patients with duct-to-duct biliary reconstruction and analyzed chronological changes of post-LDLT biliary strictures. Moreover, we focused on the year 2006 when various surgical modifications were introduced and compared the details of post-LDLT biliary strictures before and after 2006, especially focusing on the long-term outcome of inside-stent placement. The proportion of left lobe grafts had increased from 1.8% before 2005 to 39.3% after 2006 (P < 0.001) to maximize the living donor safety. Overall, post-LDLT anastomotic biliary strictures occurred in 21.3% of the patients with a median follow-up period of 106.1 months, which was decreased from 32.6% before 2005 to 12.8% after 2006 (P < 0.001). Anastomotic biliary strictures were less frequent in patients with left lobe grafts than with right lobe grafts (9.4% versus 25.4%; P < 0.001). The overall technical success rate of inside-stent placement was 82.4%, with an improvement from 75.3% before 2005 up to 95.7% after 2006 (P < 0.01). Furthermore, the stricture resolution rate remained high at approximately 90% throughout the observation period. Increased use of left lobe grafts with several surgical modifications significantly reduced post-LDLT anastomotic biliary strictures, leading to favorable long-term outcomes of inside-stent placements for this condition.
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Affiliation(s)
- Yoshihiro Nishikawa
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Norimitsu Uza
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichiro Hata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Saiko Marui
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kuwada
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoaki Matsumori
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takahisa Maruno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Shiokawa
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Katsutoshi Kuriyama
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Shiga, Japan
| | - Akira Kurita
- Digestive Disease Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Shujiro Yazumi
- Digestive Disease Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yuzo Kodama
- Department of Gastroenterology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Atsushi Yoshizawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Anazawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Seno
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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15
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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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16
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The role of stent placement above the papilla (inside-stent) as a bridging therapy for perihilar biliary malignancy: an initial experience. Surg Today 2021; 51:1795-1804. [PMID: 33835263 DOI: 10.1007/s00595-021-02268-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/21/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Although endoscopic naso-biliary drainage (ENBD) is a popular preoperative biliary drainage (PBD) method for patients with perihilar biliary malignancy (PHBM), patient discomfort caused by the nasal tube remains a problem. This study aimed to analyze the safety and efficacy of PBD with the placement of a plastic stent above the papilla [inside-stent (IS)] as a bridging therapy. METHODS The outcomes of 78 patients with potentially resectable PHBM, of whom 29 underwent IS placement and 49 underwent ENBD were evaluated. RESULTS The stent-associated complication rates were not different between the two groups (7% in the IS group and 10% in the ENBD group, P = 0.621). Catheter dislocation occurred less frequently (0% vs. 22%, P = 0.016), and the median time to recurrent biliary obstruction was longer (not reached vs. 32 days, P = 0.039) in the IS group than in the ENBD group. Among the patients who underwent resection, their postoperative severe complication rates were not substantially different (26% vs. 25%, P = 0.923). CONCLUSION IS placement is a possible alternative to ENBD as a bridge to a definitive operation for patients with resectable PHBM and a prospective trial to prove its feasibility and safety is therefore warranted.
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17
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Jang SI, Cho JH, Lee DK. Magnetic Compression Anastomosis for the Treatment of Post-Transplant Biliary Stricture. Clin Endosc 2020; 53:266-275. [PMID: 32506893 PMCID: PMC7280848 DOI: 10.5946/ce.2020.095] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
A number of different conditions can lead to a bile duct stricture. These strictures are particularly common after biliary operations, including living-donor liver transplantation. Endoscopic and percutaneous methods have high success rates in treating benign biliary strictures. However, these conventional methods are difficult to manage when a guidewire cannot be passed through areas of severe stenosis or complete obstruction. Magnetic compression anastomosis has emerged as an alternative nonsurgical treatment method to avoid the mortality and morbidity risks of reoperation. The feasibility and safety of magnetic compression anastomosis have been reported in several experimental and clinical studies in patients with biliobiliary and bilioenteric strictures. Magnetic compression anastomosis is a minimally traumatic and highly effective procedure, and represents a new paradigm for benign biliary strictures that are difficult to treat with conventional methods.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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18
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Kim KS, Kim JM, Lee JS, Choi GS, Joh JW. Long-term Outcome of the Rendezvous Technique in Patients With Severe Biliary Anastomotic Stricture That Cannot Cannulate After Liver Transplant. Transplant Proc 2020; 52:1812-1817. [PMID: 32482445 DOI: 10.1016/j.transproceed.2020.02.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nearly all publications related to endoscopic treatment of biliary anastomotic stricture after liver transplant have reported cases that can be cannulated. However, very few publications discuss endoscopic treatment of biliary anastomotic stricture (BAS) in which the guide wire does not pass through the stricture site. The purpose of this article is to analyze the long-term outcome of the Rendezvous technique in severe strictures through which guide wires cannot cannulate. METHODS Between 2010 and 2017, a total of 29 patients who underwent Rendezvous technique because of severe BAS after liver transplant were included in the study. RESULTS Twenty-nine patients who underwent the Rendezvous technique showed a 100% technical success rate. Ten patients (34.4%) required stent removal; the mean stenting period was 14.9 (SD, 5.6) months (range, 6.65-24.14 months). A total of 19 patients were maintained without stent removal; the stent-maintaining period was 13.1 (SD, 8.4) months (range, 3.48-38.61 months). Two patients receiving left lobe grafts maintained the stents for 27.1 (SD, 16.2) months. In left lobe graft, the duct anastomosis position moves to the right posteroinferior side of the patient. CONCLUSIONS Our results suggest that the stenting period of the Rendezvous technique was longer in severe BAS than in cannulated endoscopic retrograde cholangiopancreatography cases. Especially in the left liver, the position of the duct anastomosis changed to the right posteroinferior of the patient. Thus, the donor duct and the recipient duct are angulated, kinking worsens, and the stenting period becomes longer.
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Affiliation(s)
- Kyeong Sik Kim
- Department of Surgery, Soon Chun Hyang University Seoul Hospital, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery-Transplantation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Ji Soo Lee
- Department of Surgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Gyu Sung Choi
- Department of Surgery-Transplantation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Won Joh
- Department of Surgery-Transplantation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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19
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Choi JH, Paik WH. Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture. Clin Endosc 2020; 53:255-260. [PMID: 32438779 PMCID: PMC7280849 DOI: 10.5946/ce.2020.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/27/2020] [Indexed: 11/14/2022] Open
Abstract
Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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20
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Koizumi M, Kumagi T, Kuroda T, Imamura Y, Kanemitsu K, Ogawa K, Takada Y, Hiasa Y. Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation. BMC Gastroenterol 2020; 20:92. [PMID: 32252630 PMCID: PMC7137274 DOI: 10.1186/s12876-020-01226-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Endoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist. Methods We evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent. Results A total of 98 ERC sessions (median 6: range 1–14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8–1736) and 99 days (range; 7–356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically. Conclusions The endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.
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Affiliation(s)
- Mitsuhito Koizumi
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Teru Kumagi
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Taira Kuroda
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yoshiki Imamura
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kozue Kanemitsu
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kohei Ogawa
- Hepato-Biliary-Pancreatic Surgery and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yasutsugu Takada
- Hepato-Biliary-Pancreatic Surgery and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoichi Hiasa
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
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21
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Mukund A, Choudhury A, Das S, Pamecha V, Sarin SK. Salvage PTBD in post living donor liver transplant patients with biliary complications-a single centre retrospective study. Br J Radiol 2020; 93:20191046. [PMID: 31971831 PMCID: PMC7362925 DOI: 10.1259/bjr.20191046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/05/2020] [Accepted: 01/21/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To study the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in complex and technically challenging post-liver transplant (LT) biliary complications and analyse the reason for failure of endoscopic retrograde cholangiopancreatography (ERCP). METHODS AND MATERIALS Hospital data were searched for all LT patients with biliary complications requiring salvage PTBD (upon failure of ERCP) from January 2010 to May 2017. Patients who underwent primary PTBD were excluded. Patients clinical and biochemical parameters were analysed for clinical, biochemical and imaging response, stent-free survival and the reason for ERCP failure. RESULTS Salvage PTBD was performed in 32 patients with post-LT biliary stricture/bile leak presenting with deranged liver function in 12 (37.5%), cholangitis in 12 (37.5%) and cholangitis with cholangitic abscess in remaining 8 (25%) patients. Of 32 patients, 20 (62.5%) already had plastic biliary stent placed by ERCP, while in remaining (n = 12, 37.5%) a wire could not be negotiated across stricture by ERCP. These patients were found to have long/tortuous stricture (n = 18, 56.3%) and multiple duct disconnection at anastomosis (n = 14, 43.7%). Immediate as well as sustained (persisting for a year or more) clinical and biochemical improvement was seen in 26 (81.3%) patients, while failure of resolution of sepsis and death occurred in remaining 6 (18.8%). CONCLUSION Salvage PTBD is an effective treatment in difficult-to-treat post-LT biliary strictures with deranged liver functions with or without cholangitis/cholangitic abscess. It can reduce graft loss with improved clinical outcome. Post-LT ductal anatomy at anastomosis is important to decide the appropriate approach (ERCP/PTBD). ADVANCES IN KNOWLEDGE (1). PTBD as a salvage procedure in difficult anatomy or upon failure of ERCP-based intervention is effective and a good alternative strategy. (2). Postoperative surgical anatomy (type & length of stricture, number of ductanastomosis, location and graft-recipient duct alignment) is the key factor indeciding the appropriate therapeutic procedure.
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Affiliation(s)
- Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Swati Das
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobiliary Pancreatic surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
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22
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Chiu Y. Endoscopic management for post‐living donor liver transplantation anastomotic biliary stricture: The common failure‐causing problems and their solutions. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Yi‐Chun Chiu
- Division of Hepato‐Gastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Taiwan
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23
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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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24
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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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25
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Rao HB, Koshy AK, Sudhindran S, Prabhu NK, Venu RP. Paradigm shift in the management of bile duct strictures complicating living donor liver transplantation. Indian J Gastroenterol 2019; 38:488-497. [PMID: 32065353 DOI: 10.1007/s12664-019-01000-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023]
Abstract
AIM Validation of new metrics to identify functionally significant obstruction (FSO), to better define biliary strictures complicating living donor liver transplantation (LDLT). METHODS All LDLT recipients who presented with cholestasis were studied. Novel metrics for FSO are as follows: (1) magnetic resonance cholangiopancreatography (MRCP) ductal ratio (MDR): The ratio between hepatic duct and recipient duct diameter on the MRCP taken at presentation; (2) endoscopic retrograde cholangiography (ERC) ductal ratio (EDR): The ratio between hepatic duct and recipient duct diameter on the first ERC done for suspected biliary strictures; (3) delayed contrast drainage (DCD): > 50% contrast retained above the anastomotic site, in more than three consecutive fluoroscopic images taken at least 15 min after contrast instillation. Association between these metrics and endotherapy response was analyzed along with patient demographics, intraoperative variables (cold ischemia time, blood transfusions, biliary anastomosis) and perioperative complications (hepatic artery thrombosis [HAT], bile leak). Favorable response to endotherapy was defined as symptomatic relief with ≥ 80% reduction in total bilirubin/alkaline phosphatase. RESULTS A total of 83 LDLT recipients presented with altered liver function tests. Favorable response was seen in 18/39 patients (46.2%). On univariate analysis, HAT, multiple biliary anastomoses, graft-to-recipient weight ratio (GRWR), MDR, EDR and DCD were significant (p value ≤ 0.05). On multivariate analysis, only MDR ≥ 1.15 was an independent predictor of favorable response to endotherapy (OR 48 [95% CI 7.096-324.71]). CONCLUSION A paradigm shift in the approach to management of biliary strictures complicating LDLT is proposed whereby a multidimensional definition of FSO can help in reliable patient selection for endotherapy and improve patient outcome as a whole.
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Affiliation(s)
- Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India
| | - Anoop K Koshy
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India
| | - S Sudhindran
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences, Kochi, 682 041, India
| | - Nirmal K Prabhu
- Department of Radiology, Amrita Institute of Medical Sciences, Kochi, 682 041, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, 682 041, India.
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26
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Sato T, Kogure H, Nakai Y, Hamada T, Takahara N, Mizuno S, Kawaguchi Y, Akamatsu N, Kaneko J, Hasegawa K, Tada M, Tsujino T, Isayama H, Koike K. Long-term outcomes of endoscopic treatment for duct-to-duct anastomotic strictures after living donor liver transplantation. Liver Int 2019; 39:1954-1963. [PMID: 31436017 DOI: 10.1111/liv.14219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The anastomotic biliary stricture is a clinically important complication after living donor liver transplantation (LDLT) with a duct-to-duct anastomosis. Although endoscopic management of post-LDLT biliary strictures using balloon dilation (BD) and plastic stents (PSs) has provided acceptable short-term outcomes, long-term outcomes and prognostic factors for treatment success remain unclear. METHODS We included 96 patients with post-LDLT biliary strictures who were endoscopically managed between 2003 and 2016. BD was utilized as a first-line treatment strategy, and PS placement was carried out for refractory cases. Potential prognostic factors for biliary stricture resolution were analysed using logistic regression analyses. RESULTS Endoscopic treatment was technically successful in 84 patients (87.5%). The overall rate of biliary stricture resolution was 44.8% (43 of 96 patients) with a median follow-up duration of 90.9 months (interquartile range, 30.9-122.3 months). Bile duct kinking was associated with a lower rate of biliary stricture resolution (odds ratio, 0.33; 95% confidence interval, 0.13-0.87). After successful endoscopic treatment, biliary strictures recurred in 22 patients (57.9%) after BD, and in one patient (4%) after PS treatment. CONCLUSIONS Despite a high technical success rate, endoscopic treatment only provided a low rate of resolution of anastomotic biliary strictures among LDLT patients and required prolonged treatment duration. Alternative strategies including the use of a covered metal stent should be evaluated to further improve the treatment outcomes of post-LDLT biliary strictures, particularly in those accompanied by the bile duct kinking.
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Affiliation(s)
- Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Tsujino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Miyuki clinic, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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27
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Biliary Complications Following Pediatric Living Donor Liver Transplantation: Risk Factors, Treatments, and Prognosis. Transplantation 2019; 103:1863-1870. [DOI: 10.1097/tp.0000000000002572] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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28
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Novel Application of Internal-External Drainage Catheter as Biliary Stent for Percutaneous Transhepatic Treatment of Biliary Strictures in Living Donor Liver Transplantation Recipient Patients. Transplant Proc 2019; 51:2469-2472. [PMID: 31405740 DOI: 10.1016/j.transproceed.2019.01.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/21/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Although endoscopic management is considered as the first-line treatment for biliary strictures, it may be challenging in living donor liver transplant recipients due to the complex nature of duct-to-duct reconstruction. In this study we present the use of a pigtail drainage catheter as a biliary stent to treat biliary strictures after a living donor liver transplant. METHODS Twenty-seven patients with biliary strictures were treated with our novel technique. In this technique, a pigtail catheter was trimmed into 3 parts (proximal, middle, and distal portions). A suture string was passed through the distal hole of the middle portion, which was then reversed and used as a stent while the proximal portion was used as a pusher. Following balloon dilation of the stenotic segment, the distal, reversed middle, and proximal portions were loaded over the guidewire. After proper placement of the stent, the retractor suture string, pusher, and guidewire were removed. The stent was removed during the third or fourth month of placement through endoscopic retrograde cholangiopancreatography (ERCP) in all patients. RESULTS No significant complications developed during the procedure or follow-up period. Ten patients required re-stenting by ERCP during the same session. The mean follow-up period was 2 years. Cholestase enzymes and bilirubin levels were within normal limits in all patients during follow-up. CONCLUSION Stents derived from drainage catheter facilitate treatment of biliary strictures in patients not eligible for the retrograde approach. This stent is cheap, easy to implement, can be easily removed by ERCP, and re-stenting can be applicable in retrograde if needed.
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29
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Endoscopic treatment of biliary complications after duct-to-duct biliary anastomosis in pediatric liver transplantation. Langenbecks Arch Surg 2019; 404:875-883. [DOI: 10.1007/s00423-019-01804-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
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30
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Sanada Y, Katano T, Hirata Y, Yamada N, Okada N, Onishi Y, Yasuda Y, Mizuta K. Long‐term outcome of percutaneous transhepatic biliary drainage for biliary strictures following pediatric liver transplantation. Clin Transplant 2019; 33:e13570. [DOI: 10.1111/ctr.13570] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/21/2019] [Accepted: 04/11/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Takumi Katano
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Yuta Hirata
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Naoya Yamada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Noriki Okada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Yasuharu Onishi
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | | | - Koichi Mizuta
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
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31
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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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32
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Larghi A, Tringali A, Rimbaş M, Barbaro F, Perri V, Rizzatti G, Gasbarrini A, Costamagna G. Endoscopic Management of Benign Biliary Strictures After Liver Transplantation. Liver Transpl 2019; 25:323-335. [PMID: 30329213 DOI: 10.1002/lt.25358] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023]
Abstract
Biliary strictures represent some of the most frequent complications encountered after orthotopic liver transplantation. They comprise an array of biliary abnormalities with variations in anatomical location, clinical presentation, and different pathogenesis. Magnetic resonance cholangiography represents the most accurate noninvasive imaging test that can provide detailed imaging of the whole biliary system-below and above the anastomosis. It is of particular value in those harboring complex hilar or intrahepatic strictures, offering a detailed roadmap for planning therapeutic procedures. Endoscopic therapy of biliary strictures usually requires biliary sphincterotomy plus balloon dilation and stent placement. However, endoscopic management of nonanastomotic biliary strictures is much more complex and challenging as compared with anastomotic biliary strictures. The present article is a narrative review presenting the results of endoscopic treatment of biliary strictures occurring after liver transplantation, describing the different strategies based on the nature of the stricture and summarizing their outcomes.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Mihai Rimbaş
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Federico Barbaro
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Instituts Hospitalo-Universitaires - University of Strasbourg Institute of Advanced Study, Strasbourg, France
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33
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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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34
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Chantarojanasiri T, Kogure H, Hamada T, Nakai Y, Isayama H. Usefulness of stent placement above the papilla, so-called, 'inside stent'. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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35
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Dhondt E, Vanlangenhove P, Van Vlierberghe H, Troisi R, De Bruyne R, Huyck L, Defreyne L. Benign anastomotic biliary strictures untreatable by ERCP: a novel percutaneous balloon dilatation technique avoiding indwelling catheters. Eur Radiol 2018; 29:636-644. [DOI: 10.1007/s00330-018-5526-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/16/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023]
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36
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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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37
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Woo YS, Lee KH, Lee KT, Lee JK, Kim JM, Kwon CHD, Joh JW, Kang D, Cho J. Postoperative changes of liver enzymes can distinguish between biliary stricture and graft rejection after living donor liver transplantation: A longitudinal study. Medicine (Baltimore) 2017; 96:e6892. [PMID: 28984750 PMCID: PMC5737986 DOI: 10.1097/md.0000000000006892] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/24/2017] [Accepted: 04/20/2017] [Indexed: 12/13/2022] Open
Abstract
There is no known useful clinical parameter that can specifically predict a biliary stricture and differentiate it from other related complications after living donor liver transplantations (LDLT). The aims of this study were to determine whether the changes of liver enzymes can predict postoperative biliary stricture apart from other complications. We reviewed the medical records of 203 patients who underwent LDLT with duct to duct anastomosis from 2008 to 2010. The longitudinal changes of liver enzyme over time and the occurrence of complication were evaluated. A total of 124 patients had no complication up to 2 years after LDLT, and 74 patients had complications including biliary stricture and graft rejection. Complications developed more frequently in patients who's alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) did not return to the baseline plateau at 30 days after LDLT (ALP; P = .045, GGT; P = .047). Aspartate transaminase (AST) and alanine transaminase (ALT) increased continuously until the diagnosis of complication in both stricture and rejection groups with more rapid increase in enzymes in the rejection versus stricture group (P < .05). In addition, AST and ALT were 2-fold higher in the rejection than the stricture group at the diagnosis of each complication (AST; P < .05, ALT; P < .05). The increasing slope and final levels of AST and ALT are potentially helpful parameters to differentiate rejection and stricture, the 2 most common posttransplantation complications.
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Affiliation(s)
- Young Sik Woo
- Department of Interanl Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine
| | - Kwang Hyuck Lee
- Department of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | | | | | | | | | | | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Departments of Epidemiology and Social, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, USA
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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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Azzam AZ, Tanaka K. Biliary complications after living donor liver transplantation: A retrospective analysis of the Kyoto experience 1999-2004. Indian J Gastroenterol 2017; 36:296-304. [PMID: 28744748 DOI: 10.1007/s12664-017-0771-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 07/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM In living donor liver transplantation (LDLT), biliary complications continue to be the most frequent cause of morbidity and may contribute to mortality of recipients although there are advances in surgical techniques. This study will evaluate retrospectively the short-term and long-term management of biliary complications. METHODS During the period from May 1999, to May 2004, 505 patients underwent 518 LDLT in the Department of Liver Transplantation and Immunology, Kyoto University Hospital, Japan. The data was collected and analyzed retrospectively. RESULTS The recipients were 261 males (50.4%) and 257 females (49.6%). Biliary complications were reported in 202/518 patients (39.0%), included; biliary leakage in 79/518 (15.4%) patients, leakage followed by biloma in 13/518 (2.5%) patients, leakage followed by stricture in 9/518 (1.8%) patients, and biliary strictures in 101/518 (19.3%) patients. Proper management of the biliary complications resulted in a significant (p value 0.002) success rate of 96.5% compared to the failure rate which was 3.5%. CONCLUSION Careful preoperative evaluation and the proper intraoperative techniques in biliary reconstruction decrease biliary complications. Early diagnosis and proper management of biliary complications can decrease their effect on both the patient and the graft survival over the long period of follow up.
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Affiliation(s)
- Ayman Zaki Azzam
- General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Koichi Tanaka
- Kobe International Frontier, Medical Center Medical Corporation, Kobe, Japan
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Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017; 10:297-311. [PMID: 28600688 DOI: 10.1007/s12328-017-0754-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.
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Affiliation(s)
- Takeshi Tsujino
- Miyuki Clinic, 1-8-3 Renko-ji, Tama, Tokyo, 2060021, Japan.
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Rao HB, Ahamed H, Panicker S, Sudhindran S, Venu RP. Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome. World J Gastrointest Pathophysiol 2017; 8:77-86. [PMID: 28573070 PMCID: PMC5437505 DOI: 10.4291/wjgp.v8.i2.77] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/23/2017] [Accepted: 04/18/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To identify factors predicting outcome of endoscopic therapy in bile duct strictures (BDS) post living donor liver transplantation (LDLT). METHODS Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms (Pruritus, Jaundice, cholangitis), intra-op variables (cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis (HAT), bile leak, infections], stricture morphology (length, donor and recipient duct diameters) and relevant laboratory data both pre- and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0. RESULTS Forty-one patients were included (age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients (48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy (multiple endoscopic retrograde cholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome (P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak (> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis (P < 0.05). CONCLUSION Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.
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Roos FJM, Poley JW, Polak WG, Metselaar HJ. Biliary complications after liver transplantation; recent developments in etiology, diagnosis and endoscopic treatment. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624111 DOI: 10.1016/j.bpg.2017.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Biliary complications are considered to be the Achilles' heel of liver transplantation. The most common complications are leaks and bile duct strictures. Strictures can arise at the level of the anastomosis (anastomotic strictures; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). Endoscopic treatment via endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the preferred therapy for these complications. This review will focus on the diagnostic modalities, new insights in etiology of biliary complications and outcomes after different endoscopic therapies, in both deceased donor transplantation and living-donor liver transplantations. Advances in recent therapies, such as the use of self-expendable metal stents (SEMS) and endoscopic therapy for patients with a bilio-digestive anastomosis will be discussed.
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Aparício DPDS, Otoch JP, Montero EFDS, Khan MA, Artifon ELDA. Endoscopic approach for management of biliary strictures in liver transplant recipients: A systematic review and meta-analysis. United European Gastroenterol J 2016; 5:827-845. [PMID: 29026597 DOI: 10.1177/2050640616681909] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022] Open
Abstract
The most common biliary complication after liver transplantation is anastomotic stricture (AS) and it can occur isolated or in combination with other complications. Liver graft from a cadaveric donor or a living donor has an influence on the incidence of biliary strictures as well as on the response to endoscopic treatment. Endoscopic treatment using balloon dilation and insertion of biliary stents by endoscopic retrograde cholangiopancreatography (ERCP) is the initial approach to these complications. AIM The aim of this article is to compare different endoscopic techniques to treat post-liver transplantation biliary strictures. METHODS The search was carried out on MEDLINE, EMBASE, Scielo-LILACS and Cochrane Library databases through June 2015. A total of 1100 articles were retrieved. Ten clinical trials were analyzed, and seven were included in the meta-analysis. CONCLUSIONS The endoscopic treatment of AS was equally effective when compared the use of fully covered self-expandable metal stents (FCSEMS) vs. plastic stents, but the use of FCSEMS was associated with a lower complication risk. The treatment of AS with balloon dilation or balloon dilation associated with plastic stents presented similar results. Deceased donor liver transplantation reduced the risk of biliary stenosis and the endoscopic treatment in these patients was more effective when compared with Living donor liver transplantation.
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Affiliation(s)
| | | | | | - Muhammad Ali Khan
- Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN 38103, USA
| | - Everson Luiz de Almeida Artifon
- University of São Paulo, Pancreatic and Biliary Endoscopy Department/Hospital das Clínicas, University of São Paulo, SP, Brazil
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Lee DW, Jo HH, Abdullah J, Kahaleh M. Endoscopic Management of Anastomotic Strictures after Liver Transplantation. Clin Endosc 2016; 49:457-461. [PMID: 27744664 PMCID: PMC5066406 DOI: 10.5946/ce.2016.130] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 12/17/2022] Open
Abstract
Endoscopic treatment of biliary strictures involving plastic stent placement has been used widely. The use of self-expandable metal stents (SEMSs) has been described for anastomotic strictures following liver transplantation (LT). This review aimed to assess and compare the efficacy of plastic stents with SEMS in LT patients. Information was retrieved regarding technical success, stricture resolution, the number of endoscopic retrograde cholangiography procedures, follow-up, immediate, and late complications. Eight studies involving plastic stents had a stricture resolution rate of 84.5%, with the rates ranging from 63% to 100%. These rates are comparable with the stricture resolution rate of 75% determined from six studies that involved 236 patients who received metal stents and the rates ranged from 53% to 81%. The observed success rate for metal stents used to manage post-LT anastomotic biliary strictures was below the reported rate for multiple plastic stents. Hence, the currently available metal stents should not be offered for the management of post-LT anastomotic biliary strictures.
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Affiliation(s)
- Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hyeong Ho Jo
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Juveria Abdullah
- Department of Internal Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Michel Kahaleh
- Department of Internal Medicine, Weill Cornell Medical College, New York, NY, USA
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Woo YS, Lee JK, Noh DH, Park JK, Lee KH, Lee KT. SpyGlass cholangioscopy-assisted guidewire placement for post-LDLT biliary strictures: a case series. Surg Endosc 2016; 30:3897-3903. [PMID: 26684207 DOI: 10.1007/s00464-015-4695-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/17/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Anastomotic biliary strictures are common in patients that undergo living donor liver transplantation. Although endoscopic management has the advantage over percutaneous approaches, the initial success rate for the endoscopic management is unsatisfactory. The SpyGlass system can be a useful device in patients with a severe anastomotic stricture. METHODS The SpyGlass cholangioscopy-assisted guidewire placement was performed in 15 patients with a difficult guidewire placement in which the guidewire could not transverse the stricture with conventional methods for 10 min or more. RESULTS The visualization rate of the stricture orifice was 93.3 % (14 of 15 patients). The total success rate of the SpyGlass cholangioscopy-assisted guidewire placement was 60 % (9 of 15 patients). No procedure-related complications occurred during or after the SpyGlass cholangioscopy-assisted guidewire placement. CONCLUSIONS This series demonstrated that the SpyGlass cholangioscopy-assisted guidewire placement is a useful method when the guidewire passage of the strictures site is impossible by conventional methods.
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Affiliation(s)
- Young Sik Woo
- Division of Gastroenterology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Republic of Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Dong Hyo Noh
- Division of Gastroenterology, Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Departments of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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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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Kobayashi T, Miura K, Ishikawa H, Soma D, Zhang Z, Yuza K, Hirose Y, Takizawa K, Nagahashi M, Sakata J, Kameyama H, Kosugi S, Wakai T. Successful Endoscopic Management of Acute Necrotic Pancreatitis and Walled Off Necrosis After Auxiliary Partial Orthotopic Living-Donor Liver Transplantation: A Case Report. Transplant Proc 2016; 48:1212-1214. [PMID: 27320589 DOI: 10.1016/j.transproceed.2015.12.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 12/30/2015] [Indexed: 01/06/2023]
Abstract
Endoscopic management of acute necrotic pancreatitis and walled off necrosis is less invasive than surgical treatment and has become the 1st choice for treating pancreatic necrosis and abscess. We treated a case of acute necrotic pancreatitis and walled off necrosis after auxiliary partial orthotopic living-donor liver transplantation (APOLT). A 24-year-old woman was admitted to our university hospital for removal of the internal biliary stent, which had already been placed endoscopically for the treatment of biliary stricture after APOLT. She had been treated for acute liver failure by APOLT 10 years before. After we removed the internal stent with the use of an endoscopic retrograde approach, she presented with severe abdominal pain and a high fever. Her diagnosis was severe acute pancreatitis after endoscopic retrograde cholangiography (ERC). Her symptoms worsened, and she had multiple organ failure. She was transferred to the intensive care unit (ICU). Immunosuppression was discontinued because infection treatment was necessary and the native liver had already recovered sufficiently. After she had been treated for 19 days in the ICU, she recovered from her multiple organ failure. However, abdominal computerized tomography demonstrated the formation of pancreatic walled off necrosis and an abscess on the 20th day after ERC. We performed endoscopic ultrasonography-guided abscess drainage and repeated endoscopic necrosectomy. The walled off necrosis diminished gradually in size, and the symptoms disappeared. The patient was discharged on the 87th day after ERC. This is the 1st report of a case of acute necrotic pancreatitis and walled off necrosis that was successfully treated by endoscopic management after APOLT.
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Affiliation(s)
- T Kobayashi
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
| | - K Miura
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - H Ishikawa
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - D Soma
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Z Zhang
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - K Yuza
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Y Hirose
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - K Takizawa
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - M Nagahashi
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - J Sakata
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - H Kameyama
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - S Kosugi
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - T Wakai
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Wadhawan M, Kumar A. Management issues in post living donor liver transplant biliary strictures. World J Hepatol 2016; 8:461-470. [PMID: 27057304 PMCID: PMC4820638 DOI: 10.4254/wjh.v8.i10.461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Biliary complications are common after living donor liver transplant (LDLT) although with advancements in surgical understanding and techniques, the incidence is decreasing. Biliary strictures are more common than leaks. Endoscopic retrograde cholangiopancreatography (ERCP) is the first line modality of treatment of post LDLT biliary strictures with a technical success rate of 75%-80%. Most of ERCP failures are successfully treated by percutaneous transhepatic biliary drainage (PTBD) and rendezvous technique. A minority of patients may require surgical correction. ERCP for these strictures is technically more challenging than routine as well post deceased donor strictures. Biliary strictures may increase the morbidity of a liver transplant recipient, but the mortality is similar to those with or without strictures. Post transplant strictures are short segment and soft, requiring only a few session of ERCP before complete dilatation. Long-term outcome of patients with biliary stricture is similar to those without stricture. With the introduction of new generation cholangioscopes, ERCP success rate may increase, obviating the need for PTBD and surgery in these patients.
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Abu-Gazala S, Olthoff KM, Goldberg DS, Shaked A, Abt PL. En Bloc Hilar Dissection of the Right Hepatic Artery in Continuity with the Bile Duct: a Technique to Reduce Biliary Complications After Adult Living-Donor Liver Transplantation. J Gastrointest Surg 2016; 20:765-71. [PMID: 26676929 DOI: 10.1007/s11605-015-3047-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/25/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Techniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants. METHODS This was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection. RESULTS A total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3%, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs. 23.5%., respectively, p = 0.049). CONCLUSION En bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.
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Affiliation(s)
- Samir Abu-Gazala
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA.
| | - Kim M Olthoff
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - David S Goldberg
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Abraham Shaked
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
| | - Peter L Abt
- Division of Transplantation, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Dulles, Philadelphia, PA, 19104, USA
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50
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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: 47] [Impact Index Per Article: 5.2] [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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