Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation

BACKGROUND: Optimal therapy for anastomotic biliary strictures occurring after orthotopic liver transplantation (OLT) remains to be defined. We reviewed our experience with endoscopic therapy for such strictures and contrasted it with reported data. METHODS: Endoscopic therapy was performed with balloon dilation alone; no patients received an endoprosthesis. Responses were characterized as good if the patient improved clinically and no subsequent procedures were required after one or more dilations within a 3-month period; partial if clinically significant obstruction resolved but cholestasis persisted or there was a need for further endoscopic management beyond the initial 3 months; poor if subsequent surgery or percutaneous procedures were required; and failed if endoscopic access or dilation could not be accomplished. RESULTS: Fifteen patients underwent 23 endoscopic retrograde cholangiopancreatographies for post-OLT anastomotic strictures. Postprocedure follow-up averaged 25.2 months. Cholangiography was successful in all 23 procedures; free duct access was achieved in 22 of 23 procedures. The strictures were successfully accessed for dilation in 11 of 15 patients and in 19 of 23 procedures. Outcome was deemed good in 4 (27%), partial in 3 (20%), and poor in 5 (33%) patients. Endoscopic therapy failed in 3 (20%). Poor outcomes were due to the early recognition of severe lesions (2 treated surgically) or to short-term responses to dilation alone (3). The procedural complication rate of 17.4% included 3 episodes of transient cholangitis (i.e., elevation of liver enzymes associated with fever that lasted less than 3 days) and 1 self-limited episode of postsphincterotomy bleeding, which required the transfusion of 2 units packed red blood cells. In published series the combined success rate of balloon dilation alone for treatment of anastomotic strictures is 41%, whereas for dilation plus stent placement it is 75%. CONCLUSION: Endoscopic balloon dilation alone is not a reliable method of therapy for anastomotic strictures occurring after OLT. Dilation followed by short- to intermediate-term stent placement appears to provide a more durable result.     

Endoscopic stent placement above the intact sphincter of Oddi for biliary strictures after living donor liver transplantation

Background and study aims

Biliary complications are one of the most serious morbidities after liver transplantation. Inside-stent is a plastic stent placed above the sphincter of Oddi without endoscopic sphincterotomy against biliary strictures. Our aims were to analyze the long-term efficacy of inside-stent placement in patients with biliary stricture after living donor liver transplantation.

Patients and methods

Ninety-four patients who experienced biliary stricture that employed duct-to-duct reconstruction were treated with inside-stent placement. Treatment outcomes, including stricture resolution, recurrence, inside-stent patency, and morbidity rate were evaluated retrospectively.

Results

Ninety-two patients could be evaluated. Resolution of stricture was eventually observed in 81 of 92 patients with an average of 1.4 sessions of endoscopic retrograde cholangiography. Of the 81 patients who achieved the resolution of the stricture, recurrent biliary stricture that required intervention occurred in 8 patients. Conversely, stricture remission was achieved 73 patients (90.1 %) during 53 months follow-up after stent removal. Median duration of patency of the initial stent was 189 (range 2–1228) days. Stent dislocation occurred in 10 patients. Adverse event related to inside-stent placement was pancreatitis in 18 cases (mild 13, moderate 5).

Conclusions

Inside-stent placement achieved long-term patency and high remission rate in patients with biliary stricture after liver transplantation.     

Endoscopic management of biliary strictures after liver transplantation

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

Endoscopic management of biliary strictures after liver transplantation

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

Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome

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 retrogradecholagiography, 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.     

Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after orthotopic liver transplantation

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Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation

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.     

Hepatobiliary scintigraphy for detecting biliary strictures after living donor liver transplantation

AIM:To investigate the diagnostic accuracy of hepatobiliary scintigraphy(HBS) in detecting biliary strictures in living donor liver transplantation(LDLT) patients.METHODS:We retrospectively reviewed 104 adult LDLT recipients of the right hepatic lobe with duct-toduct anastomosis,who underwent HBS and cholangiography.The HBS results were categorized as normal,parenchymal dysfunction,biliary obstruction,or bile leakage without re-interpretation.The presence of biliary strictures was determined by percutaneous...     

Results of endoscopic management of anastomotic biliary strictures after orthotopic liver transplantation.

BACKGROUND/AIMS: Anastomotic biliary strictures are common biliary complications after orthotopic liver transplantation. We assessed the success of endoscopic retrograde cholangio-pancreaticography (ERCP) in the treatment and outcome of post-liver transplantation anastomotic biliary strictures in a university hospital, retrospectively. METHODS: Thirty-three ERCPs were performed in 20 of 162 adult liver transplant recipients with duct to duct anastomosis. RESULTS: In five patients, ERCP failed because the stricture could not be passed with guidewire. Four patients were treated with balloon dilatation only; two of them are recurrence-free with a follow-up of 24 and 8 months. Eleven patients had balloon dilatation and plastic stent placement as their primary treatment modality. In six of them, the anastomosis remained patent for the rest of the follow-up (22+/-13 months). Five patients had stricture recurrence after first stenting which necessitated re-stenting; four of them required a third, and three had a fourth stenting. CONCLUSIONS: Endoscopic balloon dilatation and stenting are safe and effective means of treatment of anastomotic biliary strictures following liver transplantation.     

肝移植术后胆管吻合口狭窄和非吻合口狭窄内镜治疗的比较

目的 探讨肝移植术后患者胆管吻合口狭窄和非吻合口狭窄内镜治疗的疗效及相关因素.方法 收集2006年1月至2009年12月期间肝移植术后并发胆管狭窄行内镜治疗患者的临床及随访资料,评价内镜治疗的效果及其影响因素.结果 共56例患者入选研究:吻合口狭窄(AS)38例,非吻合口狭窄(NAS) 18例.NAS患者较AS肝移植术后更早发生[(4.45±1.47)月比(8.00±2.31)月,P=0.000].NAS患者较AS患者每人平均需要更多的ERCP操作[(6.20±1.28)次比(4.11±1.51)次,P=0.000]和支架数目[(10.20±3.59)个比(7.53±2.12)个,P=0.001];尽管AS和NAS的成功率无明显差异(86.8％比77.8％,P=0.448),但后者需要更长的治疗时间(P=0.000);NAS的复发率较AS高(50.0％比18.2％,P=0.033)且治疗成功到复发的时间短(P=0.044).AS治疗失败组较治疗成功组胆管狭窄长度更长[(13.00±3.61) cm比(6.63±2.09) cm,P=0.000];成功后复发组较未复发组狭窄长度更长[(10.48±1.07) cm比(5.86±1.55) cm,P=0.000]、狭窄直径更窄[(1.52±0.38) mm比(1.94±0.32) mm,P=0.001].NAS多发狭窄较单发狭窄成功率更低、复发率高,但均无统计学意义(62.5％比90.0％,P=0.275;66.7％比37.5％,P=0.592).结论 AS对于内镜治疗的应答要高于NAS.AS的狭窄长度可能与治疗成功和复发有关,而狭窄直径可能与治疗后复发有关.此外,NAS的多发病变也可能影响预后.     

Intrahepatic biliary strictures after liver transplantation

Biliary complication has been one of the most common complications after liver transplantation. Nonanastomotic strictures and dilatations involving the intrahepatic biliary tree have been recognized as biliary complications. These lesions were reported to be associated with hepatic artery thrombosis; prolonged preservation time; ABO-incompatible organs; and immunological injury, including injuries to vascular endothelial cells (chronic rejection) and the bile duct (primary sclerosing cholangitis). However, the etiology of these lesions appeared to be mostly related to ischemic injury. Anatomical research on the arterial supply of the bile duct has provided further insights into bile duct blood supply and its surgical implications. The biliary tract is supplied with arterial blood by a vasculature called the peribiliary vascular plexus. Any injury to the peribiliary vascular plexus may contribute to ischemic death of the biliary system mucosa. At many points, the process of liver transplantation exposes the endothelial cells and peribiliary vascular plexus to ischemic injury. The majority of intrahepatic biliary strictures (IHBS) are diffuse or bilateral. A percutaneous or an endoscopic approach has been used as the initial treatment. However, a low threshold for surgical intervention (retransplantation) should be adopted, because these patients demonstrate high mortality. The aim of this article is to review the anatomy, etiology, clinical picture, diagnosis, management, and prognosis of IHBS after liver transplantation.     

Endoscopic therapy of posttransplant biliary stenoses after right-sided adult living donor liver transplantation.

BACKGROUND & AIMS: Endoscopic treatment of biliary strictures after liver transplantation is a therapeutic challenge. In particular, outcomes of endoscopic therapy of biliary complications in the case of duct-to-duct anastomosis after living related liver transplantation are limited. The aim of this study was to evaluate the feasibility and success of an endoscopic treatment approach to posttransplant biliary strictures (PTBS) after right-sided living donor liver transplantation (RLDLT) with duct-to-duct anastomosis. METHODS: Ninety patients who received adult-to-adult RLDLT in our center were screened retrospectively with respect to endoscopic treatment of PTBS. Therapy was judged as successful when cholestasis parameters returned to normal and bile duct narrowing was reduced significantly after the completion of therapy. RESULTS: Forty of 90 RLDLT patients received duct-to-duct anastomosis, 12 (30%) showed PTBS. Seven of 12 patients were treated successfully by endoscopy; the remaining 5 patients were treated primarily by surgery. Most patients were treated by balloon dilatation followed by insertion of endoprostheses. A median of 2.5 dilatation sessions were necessary and the median treatment duration was 8 months. One patient developed endoscopy-treatable recurrent stenosis, no surgical intervention was necessary. Mild pancreatitis occurred in 7.9% and cholangitis in 5.3% of the procedures. One minor bleeding episode occurred during sphincterotomy. Bleeding was managed endoscopically. CONCLUSIONS: Endoscopic therapy of adult-to-adult right living related liver transplantation with duct-to-duct anastomosis is feasible and frequently is successful. The duct-to-duct anastomosis offers the possibility of endoscopic treatment. Endoscopic treatment of posttransplant biliary strictures is safe, with a low specific complication rate.