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.     

Sirolimus may be associated with early recurrence of biliary obstruction in liver transplant patients undergoing endoscopic stenting of biliary strictures

Introduction. Recurrent biliary obstruction necessitating premature repeat endoscopic retrograde pancreatography (ERCP) remains a costly and morbid problem in patients undergoing treatment of post-or-thotopic liver transplantation (OLT) biliary strictures. We evaluated the relationship between prednisone or sirolimus use and early recurrence of biliary obstruction given their negative effects on collagen production and cholangiocyte regeneration.Methods. Medical records of adult patients who underwent OLT from 1998-2008 and developed anastomotic (ABS) and/or nonanastomotic (NABS) biliary strictures requiring endoscopic plastic stent therapy were reviewed. Outcome was early recurrence of biliary obstruction requiring repeat ERCP. Univariate and multivariable logistic regression analysis, adjusting for age, sex, and time from OLT to ERCP, were performed.Results. 35 patients with ABS and 9 patients with NABS underwent a total of 157 ERCPs. Median patient age was 56 years, 68% were male, and hepatitis C was the most common OLT indication (52%). Early recurrence of biliary obstruction ocurred following 17.1% of ERCPs. In univariate analysis, neither prednisone nor sirolimus was associated with early recurrence of biliary obstruction. In multivariate analysis, however, sirolimus use was associated with increased incidence of early recurrent biliary obstruction (OR = 2.53; 95% CI: 0.77-8.32; p = 0.12); this was more pronounced at doses > 3 (OR = 4.27; 95% CI: 0.62-29.3; p = 0.14) than at ≤ 3 mg/day (OR = 2.24; 95% CI: 0.62-8.13; p = 0.22) and statistically significant in patients with ABS only (OR = 1.44 per mg increase in sirolimus dose; 95% CI 1.02-2.03; p = 0.037).Conclusions. Sirolimus use, particularly at higher doses and patients with ABS, may be associated with an increased risk of early recurrence of biliary obstruction requiring repeat ERCP for post-OLT biliary strictures. Additional studies are needed to further investigate these findings and elucidate other risk factors.     

Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy

BACKGROUND: Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. METHODS: From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. RESULTS: A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree. CONCLUSION: When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures.     

Complications of the treatment of endoscopic biliary strictures developing after liver transplantation

Background

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Endoscopic management by the conventional methods of biliary dilatation and/or stent placement has been successful, but sometimes severe complications occur, necessitating prolonged therapy. The aim of this study is to clarify the complications of the endoscopic approach for endoscopic dilatation and/or stent placement.

Method

Of 46 patients who underwent living-donor liver transplantation, 10 were diagnosed as having anatomic biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP). Two patients developing biliary strictures after deceased-donor liver transplantation were also enrolled in the study. For the purpose of comparison, 302 patients with a total of 550 consecutive ERCP cases (including 115 patients with 250 malignant bile duct strictures) were recruited in this study. Success rate, number of endoscopy sessions, the median procedure time for ERCP, and incidence of complications including post-ERCP pancreatitis were compared in the OLT cases and other cases.

Results

The following results were obtained in the OLT cases, malignant stricture cases, and all cases, respectively: mean number of endoscopy sessions was 3.62, 2.17, and 1.94 (P?=?0.0216, P?P?=?0.0327, P?=?0.0093); and severe pancreatitis occurred in 2 cases of OLT. In a univariate analysis for post-ERCP pancreatitis, OLT was extracted as the only significant risk factor.

Conclusions

Endoscopic maneuvering for biliary dilatation and/or stent placement following OLT was associated with a higher risk of post-ERCP pancreatitis than the use of the same technique for the treatment of malignant biliary stricture. Endoscopic treatment after OLT was a significant risk factor for post-ERCP pancreatitis.     

How do we manage post-OLT redundant bile duct?

AIM: To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a "redundant bile duct" (RBD). METHODS: Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stonessludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention. RESULTS: One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twentyone out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were     

Role of ERCP in asymptomatic orthotopic liver transplant patients with abnormal liver enzymes

OBJECTIVE: The safety and efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation and management of biliary tract complications after orthotopic liver transplantation (OLT) have been previously demonstrated. However, the role of ERCP in evaluating asymptomatic OLT patients with abnormal liver enzymes with a previously normal biliary tree remains poorly defined. We sought to assess the utility of ERCP in this subset of patients. METHODS: A retrospective analysis of-asymptomatic OLT patients with abnormal liver enzymes evaluated by ERCP was undertaken. In addition to ERCP, all these patients had a diagnostic abdominal Doppler ultrasound, and a percutaneous liver biopsy. All patients had choledochocholedochostomy at the time of transplant and normal T-tube cholangiograms 3 months postoperatively. A radiologist, blinded to clinical findings, interpreted the ultrasound as normal, biliary dilation, or vascular abnormalities. The same radiologist interpreted ERCP findings. A pathologist, blinded to clinical findings, graded liver biopsies as normal, diagnostic, or abnormal but nondiagnostic. RESULTS: Twenty-two patients underwent 23 ERCPs. Twenty-two of the 23 ERCPs were normal (96%), and one abnormal ERCP finding did not explain the liver enzyme abnormality. Liver biopsy was diagnostic in 13 of 22 (57%) and in each case the ERCP was normal. The remaining 10 liver biopsies were abnormal but nondiagnostic. Ultrasound was abnormal in five of 22 cases, but in the three cases suggesting biliary dilation, the ERCP was interpreted as normal. CONCLUSION: Routine use of ERCP in evaluation of asymptomatic OLT patients with liver function test abnormalities and normal cholangiograms at 3 months was not diagnostically useful. In this subset of patients, liver biopsy was usually abnormal and frequently diagnostic and should be the initial invasive diagnostic procedure.     

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 after Orthotopic Liver Transplantation

We reviewed the records of 20 liver transplant patients who underwent 28 procedures [endoscopic retrograde cholangiopancreatography (ERCP)] to rule out biliary obstruction, treat bile leaks, dilate and/or stent strictures, or remove stones and debris. Three patients (two with abnormal T-tube cholangiograms and one with hyperbilirubinemia) underwent ERCP to rule out obstruction. Therapeutic ERCP (sphincterotomy with balloon dilatation or stone extraction) was successful in 16 of 17 patients, including seven of nine in whom there was resolution of bile leaks without the use of stents or surgery. Mild pancreatitis occurring in one patient was the only complication experienced that was related to ERCP. We conclude that ERCP is a safe and important modality in the medical management of biliary tract complications after orthotopic liver transplantation.     

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.     

Complications after ERCP in patients with primary sclerosing cholangitis

BACKGROUND: There are conflicting data regarding the role of ERCP in patients with primary sclerosing cholangitis (PSC) and the risk of procedure-related complications. OBJECTIVE: We compared the complication rate after ERCP in a consecutive series of patients with PSC compared with control patients with biliary strictures who did not have PSC. DESIGN: Retrospective cross-sectional study. SETTING: A tertiary referral academic hospital. MAIN OUTCOME MEASUREMENTS: Incidence of complications after ERCP. PATIENTS AND RESULTS: A total of 85 ERCPs among 30 patients with PSC and 70 ERCPs among 45 control patients were reviewed. There was no significant difference in the overall complication rates between patients with and without PSC (11/85 [12.9%] vs 6/70 [8.6%], P = .45). Complications in PSC were more likely to occur after ERCP done to evaluate an acute sign or symptom than in elective cases (7/24 [29.2%] vs 4/61 [6.6%], P = .01). Patients with PSC who had complications had more total and acute ERCPs than did those without complications. There was no significant difference in the rate of complications in diagnostic versus therapeutic ERCPs nor between stent placement and dilation-only therapeutic ERCPs in the PSC population. LIMITATIONS: Retrospective study design and limited power related to the small sample sizes. CONCLUSIONS: Elective ERCP is safe and carries a modest risk in patients with PSC; however, ERCP for acute indications greatly increases the probability of postprocedure complications. The overall complication rate after therapeutic ERCP in patients with PSC is similar to that in patients without PSC.     

Endoscopic management of biliary complications after orthotopic liver transplantation

Opinion statement After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy , there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.     

Role of endoscopic retrograde cholangiopancreatography after orthotopic liver transplantation.

Twelve of 178 (7%) liver transplant patients underwent endoscopic retrograde cholangiopancreatography (ERCP) after transplantation. The indications for ERCP were persistent or late onset cholestasis, recurrent cholangitis, and suspected biliary leaks or strictures. The time between transplantation and ERCP ranged from 44 to 330 days (median 153 days). Biliary complications diagnosed by ERCP included biliary sludge in the form of casts, calculi, or debris (n = 7); bile leaks (n = 2); a biliary stricture (n = 1), and complete biliary obstruction (n = 1). One patient had a normal cholangiogram after transplantation. Biliary sludge was detected by ultrasound before ERCP in only one of six patients. Eight patients underwent endoscopic papillotomy, followed by clearance of biliary sludge in four and dilatation of a biliary stricture in one. Two patients bled after papillotomy but neither required surgical intervention. At a median follow up of 1.2 years (range 0.5-2.8 years), nine patients are well and three have died. ERCP provides both accurate diagnosis of biliary complications after liver transplantation and treatment that obviates the need for additional surgery in selected patients.     

Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study

BACKGROUND: EUS may be used to reduce the need of diagnostic ERCP. OBJECTIVE: Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic. DESIGN: A randomized study. SETTING: A university medical unit. PATIENTS: Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction. INTERVENTIONS: In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist. MAIN OUTCOME MEASUREMENTS: The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year. RESULTS: Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients. CONCLUSIONS: In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.     

Acute biliary conditions

Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.     

Endoscopic management of biliary complications after adult living donor liver transplantation

OBJECTIVES: Biliary complications and their treatment in adult cadaveric liver transplantation (CLT) are well described. However, biliary complications and their management in living donor liver transplantation (LDLT) are not well characterized. We assessed the role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of biliary complications following LDLT. METHODS: We performed a retrospective cohort analysis of all LDLT recipients with duct-to-duct anastomoses (n = 15). Specific data included referral for ERCP, diagnosis, and therapy. Comparisons were made to a 260 CLT recipient cohort. RESULTS: Greater percentage of LDLT recipients underwent ERCP (73%) compared to CLT recipients (25%; p= 0.001). Biliary complications diagnosed by ERCP in LDLT recipients consisted of bile leaks and strictures, and were more frequent than in CLT recipients (leaks: 53%vs 12%; p= 0.001; strictures: 27%vs 5%; p= 0.01). Most leaks occurred at T-tube sites (LDLT: 87%; CLT: 65%). Diagnosis and therapy of leaks required a median of 2 ERCP procedures in both groups. Bile leaks were successfully treated endoscopically in 100% and 84% of LDLT and CLT recipients, respectively (p= 0.56). Most biliary strictures were anastomotic (LDLT: 100%; CLT: 64%). Strictures were diagnosed and treated with a median of 1.5 and 2 ERCP procedures in the LDLT and CLT groups, respectively. The duration of endoscopic therapy was a median of 10 and 14 wk, and success rates were 75% and 62% (p= 1.0) in LDLT and CLT groups, respectively. CONCLUSIONS: LDLT is associated with increased biliary complications as compared to CLT. ERCP is useful for diagnosis, can successfully treat most LDLT-related biliary complications, and should be attempted prior to more invasive interventions.     

Complications of endoscopic retrograde cholangiopancreatography. A study in a small ERCP unit.

BACKGROUNDS AND AIM: endoscopic retrograde cholangiopancreatography (ERCP) is an established procedure to drain the biliary and pancreatic ducts. Nevertheless, there are complications which seem to be more common in centers performing less than 200 ERCPs per year. Sometimes, however, due to the distribution of health resources, it is necessary to perform this technique in centers with a smaller number of procedures. We present the experience of ERCP-related complications in a small unit. MATERIAL AND METHODS: this is a retrospective study on prospective data recorded during six years (1997-2002). In this period, two endoscopists working together performed 507 ERCPs, which yields an approximately average of 84 procedures per year. RESULTS: in 507 ERCPs performed during this period of time, 55 complications arose (10.85%), and four patients died (0.79%) as a consequence of the procedure. There were 28 pancreatitis (5.5%), eight post-sphincterotomy bleeding events (1.6%), seven bilioduodenal perforations (1.4%), eight sepsis episodes of biliary origin (1.6%), and other 4 different complications. There were 418 (82.4%) successful ERCPs--either diagnostic or therapeutic--,which gave rise to 46 (11%) complications. There were 89 (17.6%) failed diagnostic or therapeutic ERCPs, which gave rise to 9 (10.11%) complications (p = 0.8 between both groups). Thirty five (7%) ERCPs were exclusively diagnostic and caused 6 (17%) complications. The 187 procedures performed for choledocholithiasis originated 14 (7.4%) complications, and represented the group with the lowest morbidity rate (p = 0.04). CONCLUSIONS: the complications rate in our center is within the range of reported figures. ERCPs performed for choledocholithiasis was associated with the lowest complications rate. The risk-benefit ratio in the anticipated, purely diagnostic ERCP must be carefully weighed due to its morbidity.     

An endoscopic approach to biliary complications following orthotopic liver transplantation

Abstract: Biliary complications following orthotopic liver transplantation (OLT) may be associated with significant morbidity and mortality. In this report, we reviewed our endoscopic experience of managing post OLT biliary complications in 79 patients over a 12‐year period. Methods: OLT (n = 423) recipients between 10/86 and 12/98 were obtained from the transplant registry at the Johns Hopkins Hospital. OLT recipient who underwent at least one endoscopic retrograde cholangiography (ERC) were identified through a radiology database. Indications, findings and interventions performed were noted for each ERC report. Outpatient and inpatients medical records were reviewed for outcome and complications. Results: Seventy‐nine (79/423, 18.7%) patients had at least one ERC for suspected biliary complication. Sixty‐four (15.1%) patients had at least one or more biliary complications. The mean follow‐up for patients with abnormal ERC was 33.9 months. Nineteen patients had bile leaks; 10 of these patients had leak at the exit site of the T‐tube and five patients had at the anastomosis. Biliary stenting with or without endoscopic sphincterotomy led to resolution of bile leak in 16 patients. Three patients failed endoscopic therapy: one underwent surgery and two had percutaneous drainage. Twenty‐five patients presented with biliary strictures. Nineteen strictures were at the anastomotic or just proximal to the anastomosis, one at the hilum (ischemic in nature) and three were at the distal, recipient common bile duct; one had strictures at the anastomosis as well as the distal recipient bile duct and another had diffuse intrahepatic strictures. Seventeen patients in the stricture group improved with endoscopic intervention. One patient was re‐transplanted (diffuse intrahepatic strictures), but no patient underwent percutaneous drainage. Conclusions: ERC is safe and effective in the diagnosis and management of biliary complications following liver transplantation with choledochocholedochal anastomosis and obviates the need for surgical or percutaneous transhepatic approaches in majority of cases.     

Endoscopic retrograde cholangiopancreatography in infants and children.

BACKGROUND: Although many reports describe the use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in children, few mention therapeutic application of this technique in pediatric patients with pancreatic or biliary disease. METHODS: We report our 4-year experience of 80 ERCPs performed in 59 children for obstructive jaundice or cholestasis with dilatation of the biliary tree (32 children), biliary atresia (11), recurrent pancreatitis (8), and blunt trauma to the abdomen (8). RESULTS: The patients' ages ranged from 5 weeks to 18 years. The appropriate duct was cannulated in 94% of cases. Common bile duct sphincterotomy was performed in 35 patients and pancreatic duct sphincterotomy in one. Multiple procedures were done in 16 patients where biliary stents were inserted; in one patient with chronic pancreatitis and pancreaticolithiasis, pancreatic stent was inserted. Four patients developed mild pancreatitis, one had moderate pancreatitis and one had leak of contrast, which was treated by administration of clear fluids orally for one day. One patient with benign stenosis of the hepatic duct developed cholangitis after migration of the stent into the bowel lumen. CONCLUSION: Diagnostic and therapeutic ERCP can be done as safely and effectively in pediatric patients as in adults.     

肝移植术后胆管并发症的内镜治疗价值

目的评估肝移植术后胆管并发症内镜治疗的临床价值。方法我院从2001年3月至2006年10月进行的45例肝移植中,术后出现胆管并发症16例,其中胆漏1例,胆管狭窄8例,胆管狭窄并胆管结石2例。11例接受了内镜介入治疗计14次,包括内镜下放置鼻胆管外引流4例,放置支架内引流10例,气囊扩张10例,乳头括约肌小切开7例,乳头括约肌切开加取石2例。结果1例因内镜治疗时导丝无法通过狭窄段,改行PTC放置胆管支架,其余胆管并发症经内镜介入治疗有效。结论ERCP有助于肝移植术后胆管并发症诊断,治疗有效、安全,是肝移植术后胆管并发症首选治疗方法。     

Repeat endoscopic retrograde cholangiopancreaticography after failed initial precut sphincterotomy for biliary cannulation

AIM: To investigate the outcome of repeating endoscopic retrograde cholangiopancreaticography (ERCP) after initially failed precut sphincterotomy to achieve biliary cannulation.METHODS: In this retrospective study, consecutive ERCPs performed between January 2009 and September 2012 were included. Data from our endoscopy and radiology reporting databases were analysed for use of precut sphincterotomy, biliary access rate, repeat ERCP rate and complications. Patients with initially failed precut sphincterotomy were identified.RESULTS: From 1839 consecutive ERCPs, 187 (10%) patients underwent a precut sphincterotomy during the initial ERCP in attempts to cannulate a native papilla. The initial precut was successful in 79/187 (42%). ERCP was repeated in 89/108 (82%) of patients with failed initial precut sphincterotomy after a median interval of 4 d, leading to successful biliary cannulation in 69/89 (78%). In 5 patients a third ERCP was attempted (successful in 4 cases). Overall, repeat ERCP after failed precut at the index ERCP was successful in 73/89 patients (82%). Complications after precut-sphincterotomy were observed in 32/187 (17%) patients including pancreatitis (13%), retroperitoneal perforations (1%), biliary sepsis (0.5%) and haemorrhage (3%).CONCLUSION: The high success rate of biliary cannulation in a second attempt ERCP justifies repeating ERCP within 2-7 d after unsuccessful precut sphincterotomy before more invasive approaches should be considered.