Endoscopic Management of Bile Leakage after Liver Transplantation

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks.

Methods

Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed.

Results

In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases.

Conclusions

ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.     

Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-to-Duct Anastomosis: Long-Term Outcome and Its Related Factors after Endoscopic Treatment

Background/Aims

Biliary stricture is the most common and important complication after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis. This study evaluated the efficacy and long-term outcome of endoscopic treatment for biliary stricture after LDLT, with the aim of identifying the factors that influence the outcome.

Methods

Three hundred and thirty-nine adults received RL-LDLTs with duct-to-duct biliary anastomosis between January 2000 and May 2008 at Kangnam St. Mary''s Hospital. Endoscopic retrograde cholangiography (ERC) was performed in 113 patients who had biliary stricture after LDLT. We evaluated the incidence of post-LDLT biliary stricture and the long-term outcome of endoscopic treatment for biliary stricture. The factors related to the outcome were analyzed.

Results

Biliary strictures developed in 121 (35.7%) patients, 95 (78.5%) of them within 1 year of surgery. The mean number of ERCs performed per patient was 3.2 (range, 1 to 11). The serum biochemical markers decreased significantly after ERC (p<0.001). Stent insertion or stricture dilatation during ERC was successful in 90 (79.6%) patients. After a median follow-up period of 33 months from the first successful treatment with ERC, 48 (42.5%) patients achieved treatment success and 12 (10.6%) patients remained under treatment. The factors related to the outcome of endoscopic treatment were nonanastomotic stricture and stenosis of the hepatic artery (p=0.016).

Conclusions

Endoscopic treatment is efficacious and has an acceptable long-term outcome in the management of biliary strictures related to RL-LDLT with duct-to-duct biliary anastomosis. Nonanastomotic stricture and stenosis of the hepatic artery are correlated with a worse outcome of endoscopic treatment.     

经内镜细胞刷检查对胆管恶性狭窄性病变的诊断价值

目的 探讨经内镜细胞刷检查对胆管恶性狭窄性病变的诊断价值,分析影响诊断的因素.方法 对ERCP检查发现可疑胆管恶性狭窄的144例患者行胆管细胞刷检查.2004年-2006年在胆管内来回拉刷10次 2007年-2009年在狭窄部位来回拉刷20次,并重复操作2次.专业病理医师固定阅片,对照术后病理诊断和（或）临床最终诊断,分析细胞刷检查诊断胆管狭窄病变的作用.结果 最终诊断96例为胆管恶性狭窄,48例良性狭窄.恶性狭窄患者中78例细胞刷检查阳性（敏感度81.3%）,18例阴性 良性狭窄患者细胞刷检查均为阴性（特异度100.0%） 总体准确率87.5%.2007年-2009年间恶性狭窄性病变细胞刷检出率为87.7%（50/57）,2004年-2006年间检出率仅为71.8%（28/39）,差异有统计学意义（P＜0.05）.细胞刷检查阳性率与肿瘤来源及狭窄部位无明显关系.术后发生4例轻度胰腺炎、3例胆管炎、2例胆管出血,无严重并发症发生.结论 胆管细胞刷检查对恶性胆管狭窄病变具有较高的特异度和敏感度,于狭窄部位反复拉刷和重复操作有助于提高细胞刷检阳性率.     

28例次活体肝移植术后胆道并发症的内镜诊疗体会

目的 回顾性分析活体肝移植术后胆道并发症的临床特点,探讨内镜处置相关问题的有效方式.方法 21例活体肝移植胆道并发症患者接受ERCP诊疗,根据胆道造影所见给予相应治疗,观察内镜治疗的效果.结果 21例患者中43.8%处于术后早期,共接受28次内镜诊疗,其中发现胆管吻合口狭窄19例(90.4%),目.多数存在成角畸形;发现吻合口胆漏9例(42.9%).内镜治疗的操作成功率为85.7%,包括鼻胆管引流5例次、单支架引流10例次、气囊扩张和(或)多支架支撑9例次、胆漏腔引流2例次.随访中3例胆漏患者经治疗漏门已愈合,2例吻合口狭窄已基本消除.结论 活体肝移植术后胆道并发症发生率高且上发生早,吻合口严重狭窄伴成角畸形多见,合并胆漏的发生率较高;采用"先治漏,后治窄"的原则进行内镜治疗可取得满意的疗效.     

Clinical Features and Outcomes of Endoscopic Treatment for Stones in Stemware-Shaped Common Bile Ducts: A Multicenter Data Analysis

Background/Aims

Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs.

Methods

Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure.

Results

The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of <1 cm or ≥1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively.

Conclusions

The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.     

ERCP诊治胆管乳头状瘤

目的 探讨ERCP在诊治胆管乳头状瘤中的临床应用价值.方法 回顾性分析2000年1月至2008年12月ERCP检查时发现的6例胆管乳头状瘤患者的临床资料.结果 6例患者中男性3例,女性3例,年龄52～83岁,平均72.8岁.患者均表现为复发性胆管炎或黄疸,其中表现为持续性右上腹疼痛5例,腹痛伴有皮肤、巩膜黄染4例,伴有寒战、高热3例.2例曾行部分肝叶切除术.5例在内镜下可见十二指肠乳头肿大,肿大的乳头开口类似鱼嘴样改变;1例见乳头占位性病变;乳头内均可见透明胶冻状粘液流出.造影下6例均表现为胆总管扩张,合并肝外胆管扩张3例,合并右肝内胆管扩张、主胰管扩张各1例.扩张的胆管内可见不规则、絮状飘浮的充盈缺损影,取石球囊清理胆道时常可见充盈缺损形状改变.5例多次行ERCP术,于内镜下置入内支架或行鼻胆管引流术(ENBD),已存活10～30个月.1例83岁患者球囊、网篮清理胆道、ENBD 10 d后死于胆管炎.结论 ERCP在胆管乳头状瘤诊断中具有典型的内镜学及影像学特征;对于术后复发或失去手术机会的患者,内镜下治疗是一种安全、方便、有效的方法.     

ERCP在手术后胆漏中的诊治作用

目的探讨ERCP对肝胆术后胆漏诊断及治疗作用。方法对2003年1月至2008年12月接受ERCP诊治的120例肝胆术后胆漏患者进行回顾性分析。结果120例胆漏患者中,诊断肝外胆漏（Ⅰ型）71例、肝内胆管漏（Ⅱ型）39例、胆囊管漏（Ⅲ型）10例。其中76例行内镜下鼻胆管引流术（ENBD）,35例行胆管内支架引流术（ERBD）,3例行ERBD＋ENBD,2例单纯行经内镜乳头括约肌切开术（EST）,1例放置可回收金属支架行金属支架引流（EMBE）,3例内镜治疗失败。共完整随访98例,占81．7％（98／120）,其中有效治愈胆漏85例,有效治愈率为86．7％（85／98）,平均胆漏愈合时问为（18．2±7．0）d。各型胆漏中,Ⅲ型胆漏有效治愈率最高,为100．0％,且该型胆漏愈合时间最短,为（8．2±3．5）d;在Ⅰ型和Ⅱ型胆漏中,对应非肝移植术后胆漏有效治愈率明显高于肝移植术后（P〈0．01）,且愈合时间明显变短（P〈0．01）。结论ERCP是诊治肝胆术后胆漏的一种安全、有效的手段,具有重要的临床价值,可作为肝胆术后胆漏诊治的首选方法,对于Ⅲ型胆漏治疗效果尤佳。     

改良多点引流法治疗肝移植术后胆道并发症的价值

目的:探讨改良多点引流法对肝移植术后胆道并发症的影响。方法:研究对象为2018年5月—2020年5月上海中医药大学附属曙光医院肝移植术后因胆道并发症行经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）治疗的125例患者。按EXCEL产生随机数...     

双导丝插管技术在肝移植术后胆道并发症致胆总管插管困难病例中的应用价值探讨

目的探讨双导丝插管技术在肝移植术后胆道并发症致ERCP插管困难病例中的应用价值。方法91例肝移植术后胆道并发症致ERCP插管困难患者,在判定困难插管的10min插管时间内导丝已进入胰管的6例患者纳入双导丝组,其他85例患者按抽签单双号方式随机分为2组。双导丝组44例,男41例、女3例,年龄30～61岁,平均41岁;常规组47例,男41例、女6例,年龄33—56岁,平均43岁。2组均尝试插管20min后终止,对2组胆总管插管成功率、获得成功插管的时间、术后并发症发生情况进行统计学分析。结果双导丝组胆总管插管成功率为36／44（81．8％）,常规组为33／47（70．2％）,2组差异无统计学意义（P〉0．05）。双导丝组获得成功插管的时间为（11．7±3．2）min,明显短于常规组的（16．8±2．8）min（P〈0．05）。双导丝组术后高淀粉酶血症发生率为25．0％（11／44）,常规组为21．3％（10／47）,2组差异无统计学意义（P〉0．05）;2组术后均无严重感染、大出血和穿孔并发症发生,常规组术后确诊2例轻度胰腺炎,双导丝组无一例发生胰腺炎。结论双导丝插管技术能较快地获得成功胆总管插管,未较常规插管明显增加并发症发生率,可在肝移植术后致ERCP插管困难病例中尝试使用。     

内镜治疗109例恶性胆道梗阻的临床分析

目的探讨经内镜治疗恶性胆道梗阻的临床应用价值。方法回顾分析近4年来经内镜治疗恶性胆道梗阻患者109例的临床资料,并进行生存率分析。结果操作成功率94．8％,减黄总体有效率89．9％,内镜治疗后1周肝功能明显好转,术后并发胰腺炎4例（3．7％）、胆管炎2例（1．8％）;ERBD术后3个月、6个月及1年的预计存活率分别为83．6％、69．1％及28．8％,EMBE术后3个月、6个月及1年的预计存活率分别为96．4％、80．4％及36．3％,两组存活率差异无统计学意义。结论对于无法实行根治性手术的恶性胆道梗阻患者采取经内镜下介入治疗不失为一种安全有效的治疗方案。     

ERCP治疗肝移植术后胆道并发症的疗效评价

目的探讨ERCP在治疗肝移植术后胆道并发症方面的作用。方法回顾性分析2004年10月至2007年10月采用ERCP治疗39例肝移植术后胆道并发症患者的临床资料。对25例胆道狭窄患者（吻合口狭窄14例,非吻合口狭窄11例）行括约肌切开、胆管扩张、鼻胆管引流和塑料内支架置放术等治疗;对6例胆漏患者行鼻胆管引流及塑料内支架置放术等治疗;对16例胆道结石和胆泥形成患者（其中合并胆道狭窄8例）行括约肌切开、鼻胆管冲洗引流及取石网篮取石等治疗。结果ERCP手术成功率为95．9％（94／98）,未出现严重并发症。吻合口狭窄的ERCP治愈率为100％（14／14）,非吻合口狭窄的ERCP治愈率为27．3％（3／11）,胆漏的ERCP治愈率为83．3％（5／6）,结道结石和胆泥形成患者的ERCP治愈率为81．3％（13／16）。结论ERCP治疗肝移植术后胆道并发症安全性较高、疗效较好、严重并发症发生率较低。     

Biliary strictures after liver transplantation

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

肝移植术后胆栓形成过程中内镜的诊治价值

目的 探讨内镜逆行胰胆管造影（ERCP）在肝移植术后胆栓形成过程中的诊断治疗价值.方法 71例肝移植术后出现肝功能异常、磁共振检查提示胆道内异物的患者,采用ERCP明确诊断并给予相应的治疗,对其临床资料进行回顾性分析.结果 71例患者共接受188次ERCP诊疗,多数患者伴有不同程度的吻合口和（或）胆管狭窄.术后＜3个月者均取出胆泥,3～6个月者取少量色素样结石,＞6个月者取出铸型胆栓,平均每位患者行2.6次内镜治疗,肝移植术后平均（22.7±15.6）个月形成铸型胆栓.术后发生胰腺炎2例,胆管炎3例,发生率2.6%（5/188）,均经保守治疗控制.随访56例,经内镜处理后患者肝功能均有明显改善,42例达到内镜治愈标准,10例因胆管广泛硬化性改变而行二次肝移植,4例死于移植术以外原因.结论 ERCP处理肝移植术后胆栓形成过程中的胆泥、小结石和胆栓安全可行,近期疗效较好,并可反复进行.     

原位肝脏移植术后胆瘘的类型与治疗

目的探讨原位肝脏移植术后胆瘘的类型、方法选择及不同方式的治疗结果。方法回顾性分析2000年1月—2019年3月于西安交通大学第一附属医院住院治疗的24例肝移植术后胆瘘患者资料。根据是否合并狭窄将胆瘘分为4型。患者均接受内镜或介入治疗,包括经内镜鼻胆管引流术（endoscopic nasobiliary drainage,ENBD）、经内镜胆道内支架放置术（endoscopic retrograde biliary drainage,ERBD）或经皮经肝胆道引流术（percuteneous transhepatic cholangial drainage,PTCD）。观察指标为胆瘘发现时间、胆瘘位置、 经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography,ERCP)及PTCD并发症、腹腔或胆道引流管拔出时间、新发胆道狭窄等。结果24例胆瘘于肝移植术后（46.5±36.6） d（6~122 d）发现。Ⅰ～Ⅳ型胆瘘分别有6例、14例、2例和2例。22例胆瘘治愈,总体治愈率91.7%。24例均首先接受ERCP,技术成功率及治愈率分别为87.5%（21/24）和85.7%（18/21）。Ⅰ～Ⅳ型胆瘘ERCP的治愈率分别为6/6、84.6%(11/13)、1/2和0,ENBD与ERBD的胆瘘治愈比列分别为8/10和6/8。5例ERCP未成功者接受PTCD治疗,成功及临床治愈比例分别为4/5和3/4。术后胆道感染发生率为33.3%（8/24）,Ⅱ型胆瘘胆管炎发生率高于Ⅰ型 [35.7%(5/14)比16.7%(1/6)],合并非吻合口狭窄者比合并吻合口狭窄者更易发生胆管炎[83.3%(5/6)比16.7%(3/18)]。结论原位肝移植术后胆瘘首选ERCP,次选PTCD。Ⅰ～Ⅳ型胆瘘分别优选ENBD、ENBD联合ERBD、ENBD及PTCD治疗。     

The Comparison of Endoscopic Biliary Drainage in Malignant Hilar Obstruction by Cholangiocarcinoma: Bilateral Metal Stents versus Multiple Plastic Stents

Background/AimsFor the management of hilar malignant biliary obstruction (HMBO), endoscopic biliary drainage (EBD) is preferred over percutaneous transhepatic biliary drainage (PTBD) because of its convenience. However, there is no established guideline for malignant hilar obstruction that requires multiple stenting. In this study, we compared the efficacy of bilateral metal stents (BMS) versus multiple plastic stents (MPS).MethodsIn this retrospective study, we analyzed 102 patients who underwent EBD with either BMS or MPS due to HMBO caused by hilar cholangiocarcinoma between 1996 and 2018 at Samsung Medical Center. We compared the successful drainage rates, cholangitis events, overall complications, mortality, and conversion rates to PTBD between the two groups.ResultsThe successful drainage rates in the BMS group and the MPS group were 71.4% (25/35) and 65.6% (44/67), respectively, with no significant difference. The MPS group had a higher cholangitis risk (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.21 to 3.58) and higher 6-month mortality (HR, 2.91; 95% CI, 1.26 to 6.71) than the BMS group. There were no significant differences in overall complications or the conversion rate to PTBD between the groups.ConclusionsIn patients with malignant HMBO, the BMS group showed better outcomes in terms of the cholangitis rate and 6-month mortality than the MPS group. Therefore, if possible, bilateral metal stenting is recommended for HMBO caused by hilar cholangiocarcinoma.     

经胰管弓式隔膜乳头预切开术和针式乳头预切开术在困难胆管插管中的应用研究

目的评价经胰管弓式隔膜乳头预切开术处理ERCP困难胆管插管的应用价值。方法回顾2006年1月至2008年7月109例ERCP胆总管插管困难患者进行经胰管弓式隔膜乳头预切开术（下称经胰管组,56例）和常规针式乳头预切开术（下称常规针刀组,53例）的临床资料,比较两种方法插管成功率及并发症发生率。结果109例患者中的97例在乳头预切开术后可成功插入胆管,经胰管组成功率96．4％（54／56）,常规针刀组成功率81．1％（43／53）,两者差异具统计学意义（P〈0．05）。109例中11例出现并发症,包括急性胰腺炎5例、出血4例、胆道感染2例。其中,经胰管组急性胰腺炎2例,常规针刀组急性胰腺炎3例,出血4例,胆道感染2例。两组比较,经胰管组总的并发症发生率低于常规针刀组（3．6％比17．0％,P〈0．05）,术后胰腺炎、出血、感染发生率也分别低于后者,但均无统计学意义。结论内镜经胰管弓式隔膜乳头预切开术超选胆总管成功率高于针式乳头预切开术,而且并发症较低,是处理选择性胆总管插管较困难患者的安全和有效的办法。