Endoscopic management of biliary complications after orthotopic liver transplantation

BACKGROUND: Biliary complications are a serious problem in patients after liver transplantation and often require reoperation. This study was conducted to summarize the endoscopic diagnosis and management of biliary complications after orthotopic liver transplantation (OLT). METHODS: From December 2000 to November 2003, twelve endoscopic retrograde cholangiopancreatographies(ERCPs) were performed in 7 patients after OLT at Digestive Endoscopic Center of Changhai Hospital in Shanghai, China. The therapeutic maneuvers included endoscopic sphincterotomy (EST), biliary stent placement, balloon and basket extraction, irrigation, and nasobiliary tube placement. A retrospective study was made to determine the types of biliary tract complications after OLT. The success of ERCP and therapeutic maneuvers was also evaluated. RESULTS: Biliary tract complications including biliary stricture, biliary leak, biliary sludge, and stump leak of the cyst duct were treated respectively by endoscopic sphincterotomy with sludge extraction, stricture dilation or endoscopic retrograde biliary drainage. Two of the 3 patients with proximal common bile duct stricture were successfully treated with ERCP and stent placement. Four patients with anastomotic stricture and/without bile leak were treated successfully by dilation and stent placement or endoscopic nosobiliary drainage. No severe ERCP-related complications occurred. CONCLUSIONS: ERCP is an effective and accurate approach for the diagnosis of biliary tract complications after OLT, and placement of a stent is a safe initial treatment for biliary complications after liver transplantation.     

Role of endoscopic retrograde cholangiopancreatography in the diagnosis and treatment of biliary tract complications after orthotopic liver transplantation

BACKGROUND: Biliary complications are a major drawback of liver transplantation. AIM: To analyse, in a single centre, experience in endoscopic diagnosis and management of biliary complications after liver transplantation. PATIENTS: A total of 147 consecutive liver transplantations performed on 132 patients over a 5-year period. METHODS: Evaluation of the incidence and type of biliary-related complications and analysis of their diagnosis and endoscopic treatment by cholangiopancreatography in terms of success of the endoscopic approach, conversion to surgery and long-term patient and graft survival. RESULTS: Endoscopic retrograde cholangiopancreatography was performed on 30 patients (23%). Overall incidence of biliary complications as confirmed by endoscopic retrograde cholangiopancreatography was 17% (25 cases). Endoscopic retrograde cholangiopancreatography was negative in 5 cases (16%). Biliary complications were successfully treated by endoscopy in 84% of cases (21 out of 25 patients); 4 cases (16%) required a surgical approach (2 choledochojejunostomy, 2 retransplantation) due to failure to correct the problem endoscopically. Stenoses and biliary sludge associated with retained internal stent were almost always successfully managed by endoscopic retrograde cholangiopancreatography, while anastomotic leakage more frequently required a surgical approach. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography is a safe and effective approach for diagnosis and treatment of biliary-related complications after liver transplantation thereby reducing morbidity and mortality related to re-operation which is, however, required in selected cases.     

Management issues in post living donor liver transplant biliary strictures

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.     

A case of biliary stones and anastomotic biliary stricture after liver transplant treated with the rendez-vous technique and electrokinetic lithotritor

The paper studies the combined radiologic and endoscopic approach （rendez vous technique） to the treatment of the biliary complications following liver transplant. The ＂rendez-vous＂ technique was used with an electrokinetic lithotripter, in the treatment of a biliary anastomotic stricture with multiple biliary stones in a patient who underwent orthotopic liver transplant. In this patient, endoscopic or percutaneous transhepatic management of the biliary complication failed. The combined approach, percutaneous transhepatic and endoscopic treatment （rendez-vous technique） with the use of an electrokinetic lithotritor, was used to solve the biliary stenosis and to remove the stones. Technical success, defined as disappearance of the biliary stenosis and stone removal, was obtained in just one session, which definitively solved the complications. The combined approach of percutaneous transhepatic and endoscopic （rendez-vous technique） treatment, in association with an electrokinetic lithotritor, is a safe and feasible alternative treatment, especially after the failure of endoscopic and/or percutaneous trans-hepatic isolated procedures.     

Safety and efficacy of endoscopic retrograde cholangiopancreatography in patients with post-liver transplant biliary complications: results of a cohort study with long-term follow-up

Background/Aims

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

Methods

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

Results

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

Conclusions

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

Incidents and risk factors of biliary complications after orthotropic liver transplantation

Biliary complications (BC) especially stenosis and strictures are the most common complications after orthotropic liver transplantation (OLT) procedure in adult recipients. The intention of this study was analyzed BC in 273 patients after OLT for the last 4 years in our department.Retrospective study of 273 patients underwent cadaveric donor liver transplantation between January 2014 and December 2017. Most of them (n = 268) have anastomosed bile duct in end to end, rest of them (n = 5) underwent hepaticojejunostomy. Statistical analysis was performed using Fischer exact test and Student t test. A P value <.05 was considered significant.BC were developed in 48/273 transplants (17.6%). The most frequent was biliary stricture (n = 42, 87.5%) followed by bile leak (n = 4, 8.3%) and choledocholitiasis (n = 2, 4.2%). Treatment was usually using endoscopic retrograde cholangiopancreatography. Recipients with hypotension during and after OLT treated by norepinephrine have a higher index of BC.Self-expanding metal stents implantation seems to be more effective than repeated balloon dilatation of anastomotic strictures with subsequent plastic biliary stent placement and associated with similar complication rate. Good fluid management against inotropic therapy may reduce risk of BC.     

Comparative study of rendezvous techniques in post-liver transplant biliary stricture

AIM: To investigate the usefulness of a new rendezvous technique for placing stents using the Kumpe (KMP) catheter in angulated or twisted biliary strictures.METHODS: The rendezvous technique was performed in patients with a biliary stricture after living donor liver transplantation (LDLT) who required the exchange of percutaneous transhepatic biliary drainage catheters for inside stents. The rendezvous technique was performed using a guidewire in 19 patients (guidewire group) and using a KMP catheter in another 19 (KMP catheter group). We compared the two groups retrospectively.RESULTS: The baseline characteristics did not differ between the groups. The success rate for placing inside stents was 100% in both groups. A KMP catheter was easier to manipulate than a guidewire. The mean procedure time in the KMP catheter group (1012 s, range: 301-2006 s) was shorter than that in the guidewire group (2037 s, range: 251-6758 s, P = 0.022). The cumulative probabilities corresponding to the procedure time of the two groups were significantly different (P = 0.008). The factors related to procedure time were the rendezvous technique method, the number of inside stents, the operator, and balloon dilation of the stricture (P < 0.05). In a multivariate analysis, the rendezvous technique method was the only significant factor related to procedure time (P = 0.010). The procedural complications observed included one case of mild acute pancreatitis and one case of acute cholangitis in the guidewire group, and two cases of mild acute pancreatitis in the KMP catheter group.CONCLUSION: The rendezvous technique involving use of the KMP catheter was a fast and safe method for placing inside stents in patients with LDLT biliary stricture that represents a viable alternative to the guidewire rendezvous technique.     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。     

Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography

BACKGROUND: Biliary tract complications are frequent after orthotopic liver transplantation. Late biliary tract complications occurring after T-tube removal mostly include stones and strictures which may be associated with sepsis and worsening of the liver function. Endoscopic retrograde cholangiopancreatography (ERCP) has a role in the diagnosis and therapy of these complications. The aim of our study was to report our experience of endoscopic diagnosis and treatment of late biliary tract complications in liver-transplanted patients. METHODS AND RESULTS: One hundred and thirty-six adult liver-transplanted patients have been followed since 1988. Seventeen patients (12.5%) needed a total of 30 ERCP because of evidence of clinical and/or biochemical cholestasis: eight with biliary stricture; six with biliary stones; one with both stricture and stones; and two with normal ERCP findings. Interventional endoscopic procedures included 14 sphincterotomies, six stone removals, seven biliary balloon dilatations, seven biliary stent placements, 11 biliary stent replacements, seven nasobiliary catheter placements and one mechanical lithotripsy. No complications were seen. In all cases, ERCP was able to identify the location, entity and dimension of the late biliary tract complication, thus allowing a therapeutic strategy to be used. Two patients had medical cholestasis. Forty-seven per cent of patients with late biliary tract complications could definitely be cured by ERCP alone. The ERCP improved the patients' condition to allow subsequent surgery in five patients (33%). CONCLUSIONS: These results confirms that ERCP is a valuable diagnostic tool and should be considered as the first step in the non-surgical management of late biliary tract complications after orthotopic liver transplantation.     

Current management of biliary complications after liver transplantation: Emphasis on endoscopic therapy

Biliary complications occur in 5-25% of patients after liver transplantation and represent a major source of morbidity in this group of individuals. The major risk factor for most of these complications is ischemia of the bile tree usually due to obstruction or vascular insufficiency of the hepatic artery. The most common complications include biliary strictures (anastomostic and nonanastomotic), bile leaks, and biliary filling defects. The initial diagnostic approach starts with a high index of suspicion along with an abdominal ultrasound and Doppler exam. Magnetic resonance imaging is highly sensitive and is usually reserved for confirmation. The vast majority of these complications can be successfully treated with endoscopic retrograde cholangiography, however if this procedure cannot be performed a percutaneous approach or surgery is recommended. Nonanastomotic strictures and living donor recipients present a less favorable response to endoscopic management. This review focuses on the current diagnostic and therapeutic approaches for the management of biliary complications after liver transplantation.     

Risk factors of biliary intervention by imaging after living donor liver transplantation

AIM:To determine the risk factors of biliary intervention using magnetic resonance cholangiopancreatography(MRCP) after living donor liver transplantation(LDLT).METHODS: We retrospectively enrolled 196 patients who underwent right lobe LDLT between 2006 and 2010 at a single liver transplantation center. Direct duct-to-duct biliary anastomosis was performed in all 196 patients. MRCP images routinely taken 1 mo after LDLT were analyzed to identify risk factors for biliary intervention during follow-up, such as retrograde cholangiopancreatography or percutaneous transhepatic biliary drainage. Two experienced radiologists evaluated the MRCP findings, including the anastomosis site angle on three-dimensional images, the length of the filling defect on maximum intensity projection, bile duct dilatation, biliary stricture, and leakage.RESULTS: Eighty-nine patients underwent biliary intervention during follow-up. The anastomosis site angle [hazard ratio(HR) = 0.48; 95% confidence interval(CI), 0.30-0.75, P 0.001], a filling defect in the anastomosis site(HR = 2.18, 95%CI: 1.41-3.38,P = 0.001), and biliary leakage(HR = 2.52, 95%CI: 1.02-6.20, P = 0.048) on MRCP were identified in the multivariate analysis as significant risk factors for biliary intervention during follow-up. Moreover, a narrower anastomosis site angle(i.e., below the median angle of 113.3°) was associated with earlier biliary intervention(38.5 ± 4.2 mo vs 62. 1 ± 4.1 mo, P 0.001). Kaplan-Meier analysis comparing biliary intervention-free survival according to the anastomosis site angle revealed that lower survival was associated with a narrower anastomosis site angle(36.3% vs 62.0%, P 0.001).CONCLUSION: The biliary anastomosis site angle in MRCP after LDLT may be associated with the need for biliary intervention.     

Subcapsular liver hematoma after endoscopic retrograde cholangiopancreatography in a liver transplant recipient: Case Report

Endoscopic Retrograde Cholangiopancreatography (ERCP) is commonly performed in patients after liver transplantation. The most common indications for ERCP include treatment of bile leaks and anastomotic and nonanastomotic biliary strictures. In this report we describe an unusual complication of ERCP in a liver transplant recipient with a bile leak two months after orthotopic liver transplantation (OLT). After confirming a bile leak, a hydrophilic guide wire was placed in the intrahepatic duct, an endoscopic sphincterotomy was performed, and a biliary plastic stent was successfully placed over the wire across the bile leak. Within the following 24 hours the patient developed a sharp right-sided upper quadrant pain and a drop in his hemoglobin level. An abdominal CT scan demonstrated a subcapsular hepatic hematoma that was successfully managed conservatively.     

Endoscopic diagnosis and management of biliary complications following orthotopic liver transplantation

Nonoperative management of biliary complications (BC) with endoscopic retrograde cholangiopancreatography (ERCP) is a natural sequel to the emergence of choledochocholedochostomy as the preferred biliary reconstruction for orthotopic liver transplantation (OLT). Overall, therapeutic ERCP's efficacy for posttransplant BC is difficult to assess because most published data are retrospective, anecdotal, or in abstract form, and there are no prospective, randomized studies. Thus, endoscopic management of posttransplant BC must be individualized. While T-tube-related late bile leaks and ductal calculi are amenable to endoscopic therapy, its efficacy for strictures is more difficult to define. Refined surgical technique has prevented many unifocal anastomotic lesions, while multifocal strictures (for which endoscopic therapeutic experience is minimal) are increasingly prevalent. Whether endoscopic sphincterotomy is appropriate for posttransplant sphincter of Oddi dysfunction is controversial, because the disorder may be transient and the risk significant. Multicenter, prospective studies are needed to determine more accurately the optimal role of endoscopic therapy after OLT.     

微创治疗胆道非吻合口狭窄的价值

目的评估微创方法治疗肝移植术后胆道非吻合口狭窄（NABS）的价值。方法回顾性分析13例肝移植术后NABS患者的临床资料,比较不同类型NABS患者经内镜下逆行胰胆管途径（ERCP途径）及经皮肝穿刺胆管途径（PTCD途径）的微创治疗效果,并总结NABS患者再次肝移植的手术指征。结果4例行PTCD途径治疗,效果不佳,后期3例改ERCP途径治疗。8例微创治疗后有效,有效率8／13;余5例改手术治疗,其中再次肝移植4例、胆肠吻合1例。Ⅰ型（围肝门部狭窄）、Ⅱ型（肝门部＋肝内胆管狭窄）、Ⅲ型（肝内胆管多发狭窄）NABS患者微创治疗有效率分别为3／4、4／7、1／2。II型及Ⅲ型患者近一半（4／9）需再次肝移植,合并肝动脉狭窄的NABS患者再次肝移植率高达2／3。结论微创方法是治疗NABS的首选方案,主要依靠ERCP实施,PTCD疗效欠佳。根据胆管造影显现的狭窄类型,Ⅰ型患者微创治疗效果最佳。微创治疗无效的Ⅱ型及Ⅲ型患者,尤其是合并肝动脉狭窄者,应及时转手术治疗,以免错失手术机会。     

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate effi cacy and cost-effectiveness     

Endoscopic salvage therapy after failed biliary cannulation using advanced techniques: A concise review

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) begins with successful biliary cannulation. However, it is not always be successful. The failure of the initial ERCP is attributed to two main aspects: the papilla/biliary orifice is endoscopically accessible, or it is inaccessible. When the papilla/biliary orifice is accessible, bile duct cannulation failure can occur even with advanced cannulation techniques, including double guidewire techniques, transpancreatic sphincterotomy, needle-knife precut papillotomy, or fistulotomy. There is currently no consensus on the next steps of treatment in this setting. Therefore, this review aims to propose and discuss potential endoscopic options for patients who have failed ERCP due to difficult bile duct cannulation. These options include interval ERCP, percutaneous-transhepatic-endoscopic rendezvous procedures (PTE-RV), and endoscopic ultrasound-assisted rendezvous procedures (EUS-RV). The overall success rate for interval ERCP was 76.3% (68%-79% between studies), and the overall adverse event rate was 7.5% (0-15.9% between studies). The overall success rate for PTE-RV was 88.7% (80.4%-100% between studies), and the overall adverse event rate was 13.2% (4.9%-19.2% between studies). For EUS-RV, the overall success rate was 82%-86.1%, and the overall adverse event rate was 13%-15.6%. Because interval ERCP has an acceptably high success rate and lower adverse event rate and does not require additional expertise, facilities, or other specialists, it can be considered the first choice for salvage therapy. EUS-RV can also be considered if local experts are available. For patients in urgent need of biliary drainage, PTE-RV should be considered.     

Diagnostic and therapeutic single-operator cholangiopancreatoscopy in biliopancreatic diseases: Prospective multicenter study in Japan

AIM: To assess the utility and safety of single-operator cholangiopancreatoscopy(SOCPS) using the Spy Glass system in widespread clinical application for biliary and pancreatic diseases.METHODS: This study was a prospective case series conducted in 20 referral centers in Japan. There were 148 patients who underwent SOCPS; 124 for biliary diseases and 24 for pancreatic diseases. The attempted interventions were SOCPS examination, SOCPS-directed tissue sampling, and therapy for stone removal, among others. The main outcomes were related to the procedure success rate in terms of visualizing the target lesions, SOCPS-directed adequate tissue sampling, and complete stone removal. RESULTS: A total of 148 patients were enrolled for the diagnosis of indeterminate biliary and pancreatic lesions or treatment of biliary and pancreatic disease. The overall procedure success rate of visualizing the target lesions was 91.2%(135/148). The overall procedural success rates of visualizing the target lesions of diagnostic SOCPS in the bile duct and pancreatic duct were 95.5%(84/89) and 88.2%(15/17), respectively. Diagnosis: the overall adequate tissue for histologic examination was secured in 81.4% of the 86 patients who underwent biopsy under SOCPS(bile duct, 60/75, 80.0%; pancreatic duct, 10/11, 90.9%). The accuracy of histologic diagnosis using SOCPS-directed biopsies in indeterminate bile duct lesions was 70.7%(53/75). In the pancreatic duct, the accuracy of SOCPS visual impression of intraductal papillary mucinous neoplasm was 87.5%(14/16). Stone therapy: complete biliary and pancreatic stone clearance combined with SOCPS-directed stone therapy using electrohydraulic lithotripsy or laser lithotripsy was achieved in 74.2%(23/31) and 42.9%(3/7) of the patients, respectively. Others: SOCPS using the Spy Glass system was used in cannulation of the cystic duct in two patients and for passing across the obstructed self-expandable metallic stent for a malignant biliary stricture in two patients. All procedures were successful in both SOCPS-guided therapies. The incidence of procedure-related adverse events was 5.4%(8/148). CONCLUSION: SOCPS with direct visualization and biopsy for diagnosis and SOCPS-directed therapy for biliary and pancreatic diseases can be safely performed with a high success rate.     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.     

Role of endoscopy in the conservative management of biliary complications after deceased donor liver transplantation

The clinical outcome of patients receiving liver transplantation could be significantly affected by biliary complications, including strictures, leaks, stones and bilomas; early diagnosis and treatment of these conditions lead to markedly reduction in morbidity and mortality. Therapeutic gold standard is represented by conservative approaches, both endoscopic and percutaneous, based on the type of biliary reconstruction, the local availability of the procedures and specific expertise. In patients with previous transplantation, the difficult biliary access and the possible presence of concomitant complications (mainly strictures) further restrict the efficacy of the endoscopic and percutaneous treatments; on the other hand, surgery should generally be avoided because of the even increased morbidity and mortality due to technical and clinical issues. Here we review the most common biliary complications occurring after liver transplantation and discuss available treatment options including future perspectives such as endoscopic ultrasound-guided biliary access in patients with Roux-en-Y choledocho-jejunostomy or extracorporeal shock wave lithotripsy for difficult stones.