Elsevier

Gastrointestinal Endoscopy

Volume 51, Issue 2, February 2000, Pages 169-174
Gastrointestinal Endoscopy

Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation,☆☆

https://doi.org/10.1016/S0016-5107(00)70413-5Get rights and content

Abstract

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. (Gastrointest Endosc 2000;51:169-74.)

Section snippets

PATIENTS AND METHODS

Between January 1985 and December 1996, 721 liver transplants were performed in 641 patients who had undergone cholangiography for the primary purpose of treatment for anastomotic biliary strictures. Anastomotic strictures were defined as clinically significant when they were the dominant lesion identified at an ERCP performed for evaluation of jaundice, cholestasis or cholangitis. Patients with only modest strictures that did not appear to cause impairment of bile flow and those with

RESULTS

Overall, 15 patients underwent 23 ERCPs for post liver transplant anastomotic strictures. An end-to-end, donor-duct-to-recipient-duct biliary anastomosis (choledochocholedochostomy) had been performed in all patients. Among the 15 patients studied, 10 (66.7%) underwent a single procedure whereas 3 patients had 2, 1 had 3 and 1 had 4 ERCPs. Eleven patients (73%) were men and four (27%) were women. The average age was 50.6 years (range 15 to 66 years). Indications for transplantation included

DISCUSSION

Biliary tract complications are a significant source of morbidity after liver transplantation. Anastomotic strictures are among the most common of these complications. In a large series reported by Stratta et al.5 anastomotic strictures were noted in 8.3% of 105 patients. Similarly, among 1792 patients who underwent liver transplantation, Grief et al.1 noted 81 (4.5%) with anastomotic strictures. Despite their frequency, the ideal therapy for anastomotic strictures has yet to be defined. The

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  • Cited by (0)

    Reprint requests: Bret T. Petersen, MD, W19, Gastroenterology, Mayo Clinic, 201st St. S. W., Rochester, MN 55905.

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