Rapid-sequence endoscopic management of posttransplant anastomotic biliary strictures

doi:10.1016/j.gie.2007.08.046

Gastrointestinal Endoscopy

Volume 67, Issue 6, May 2008, Pages 879-885

https://doi.org/10.1016/j.gie.2007.08.046 Get rights and content

Background

Post-liver-transplant anastomotic biliary strictures generally have been managed through ERCP with gradual balloon dilation and placement of multiple stents over an extended period of time.

Objective

Our purpose was to evaluate the long-term outcome of rapid sequence dilation and to shorten the duration of stenting as a therapy for anastomotic biliary strictures.

Design

Prospective case series.

Setting

Academic tertiary referral center.

Interventions

ERCP with rapid-sequence balloon dilation of post-liver-transplant anastomotic biliary strictures followed by stenting with multiple stents over a short time period.

Main Outcome Measurement

Long-term anastomotic stricture resolution.

Results

Thirty-eight patients were prospectively enrolled into a standardized ERCP treatment protocol. The mean number of ERCPs per patient was 3.4 (range 2-6), the mean number of maximum stents inserted was 2.5 (range 1-6), and the mean total stenting period was 107 days (range 20-198 days); the mean follow-up time from completion of the endoscopic therapy was 360 days (range 140-1347 days). Long-term stricture resolution was achieved in 33 of the 38 (87%) patients.

Limitations

Lack of control group, relatively small patient population.

Conclusions

Accelerated dilation and shorter total length of stenting leads to long-term success in the majority of patients with post-liver-transplant anastomotic biliary strictures.

Section snippets

Methods

The study was approved by the institutional review board at the University of Florida, and was a prospective case series.

Patients

From January 2003 to December 2005, 236 adult patients underwent cadaveric OLT at Shands Hospital at the University of Florida in Gainesville. Ninety of the 236 (38%) were referred for ERCP with a suspicion of biliary tract conditions. All patients had abnormal liver chemistry values (Table 1). Before ERCP, all patients had transabdominal US and a liver biopsy as the initial evaluation of the abnormal liver chemistries. Seventy-nine (88%) of the 90 patients referred for ERCP had liver biopsy

Discussion

The main finding of this study is that patients with anastomotic post-OLT biliary strictures treated with this protocol of accelerated dilation and shortened stenting period (mean duration of stenting 107.6 days) have a high (87%) long-term success rate. The strengths of our study are (1) the study's prospective design, (2) the homogeneous group of patients (anastomotic post-OLT strictures), (3) all patients undergoing transplantion in our institution were considered for the study, and all

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Predictors of Early Repeat Endoscopic Retrograde Cholangiopancreatography After Liver Transplantation by Organ Donor Type
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Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for management of post-transplant biliary complications. We assess ERCP frequency and rate of early repeat ERCP and anastomotic stricture development across, living donor (LD), donation after cardiac death (DCD) and donation after brain death (DBD) liver transplant (LT) donor types.
We performed a single-center retrospective study of patients who underwent LT from January 2014 to December 2019. Proportion of patients requiring ERCP and number of ERCPs per patient were compared across donor types using analysis of variance and chi-squared methods. Logistic regression was used to assess the risk of early repeat ERCP, defined as ERCP within 28 days of preceding ERCP and anastomotic stricture development.
A total of 509 LTs, 352 (69.2%) DBD, 101 (19.8%) DCD, and 56 (11.0%) LD were performed during the study period. A greater proportion of LD (51.8%) recipients required ERCP compared with DBD (28.7%) recipients (P ≤ 0.01). LD and DCD recipients required significantly greater number of median (interquartile range [IQR]) ERCPs compared with DBD recipients (8 [4, 12] vs 3 [2, 5], P < 0.01 and 4 [2, 6] vs 3 [2, 5], P = 0.05). Risk of early repeat ERCP was significantly higher in LD (odds ratio 9.2; 95% confidence interval 4.6-18.5) and DCD (OR 2.3; 95% confidence interval 1.2-4.5) recipients compared with DBD recipients.
LD and DCD recipients experience higher ERCP frequency and greater risk of early repeat ERCP compared with DBD recipients. Our results suggest the need to tailor ERCP management protocols for post-LT biliary complications based on donor type.
One-step percutaneous transhepatic cholangioscopic lithotripsy in patients with choledocholithiasis
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In patients with a history of upper abdominal procedures or cholecystectomy, laparoscopic CBD exploration is challenging because the exposure of the CBD is severely restrained [13]. In the present study, the success rate of ERCP was 71.8%, which is within the reported range [5,27–37]. PTCSL might be a safe and effective treatment strategy for patients in whom laparoscopic CBD exploration cannot be performed.
Endoscopic retrograde cholangiopancreatography (ERCP) may be inappropriate for most patients with choledocholithiasis. This study aimed to evaluate one-step percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in the treatment of patients with choledocholithiasis who could not undergo ERCP (e.g., failed ERCP, altered anatomy, and/or contra-indications).
This was a retrospective single-centre series of 67 patients who underwent choledocholithiasis between November 2015 and March 2018: 35 with one-step PTCSL (Group A) and 32 with laparoscopic common bile duct (CBD) exploration (Group B).
Compared with Group B, Group A showed shorter duration of operation, length of stay in the hospital, postoperative hospital stay, postoperative drainage time, and time to oral intake (all P < 0.05). Intraoperative blood loss, costs, conversion to open surgery (one in group A vs. seven in group B; P = 0.023), and bile leakage (none in group A vs. four in group B; P = 0.047) were lower in Group A than in Group B. There were no significant differences between the two groups regarding the intraoperative clearance rate, ultimate clearance rate, and several postoperative complications.
One-step PTCSL could be an alternative for patients with choledocholithiasis, especially when ERCP is not feasible.
Diagnosis and management of benign biliary strictures post liver transplantation in adults
2021, Transplantation Reviews
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Adverse events per-patient varied considerably, at between 0% - 71% and patients required an average of 2.5–5 ERCPs to achieve resolution [34,35,44–53]. Although good rates of resolution of ABS can be achieved with MPS placement, one significant limitation of this technique is that these stents require regular exchange, meaning multiple procedures and hospital admissions for the patient [31,33–35]. An alternative approach of adding stents to previously placed stents, is the so-called sequential stent addition (SSA) technique.
Benign biliary strictures after liver transplantation are common and can lead to graft dysfunction and decreased patient survival. Post-transplant strictures are classified as anastomotic or non-anastomotic which differ in response to therapy. Risk factors for biliary strictures following transplantation include impaired blood supply, surgical factors, and biliary anomalies. Patients can present with biliary obstruction but most will be asymptomatic, with only abnormal graft function. MRCP is the most sensitive noninvasive tool for diagnosing biliary complications. In most centres worldwide endoscopy is used first-line in the management of anastomotic strictures, although there is significant variation in endoscopic technique employed; including dilation, placing a single or multiple plastic stents, a fully covered metal stent and most recently using intra-ductal fully covered metal stents. With the introduction of fully covered metal stents the number of interventions patients require has reduced and overall the clinical success of the endoscopic approach has steadily improved. Percutaneous and surgical treatments are now reserved for patients in whom endoscopic management fails or who have had Roux-en-Y anastomoses. However even in these cases, combined procedures with interventional radiology, or implementation of enteroscopy and EUS-guided approaches now means very few patients ultimately require surgical revision.
Endoscopic Management of Biliary Issues in the Liver Transplant Patient
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Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial
2018, Gastrointestinal Endoscopy
Biliary anastomotic stricture occurs in 15% to 20% of patients after deceased orthotopic liver transplantation (OLT). It is usually treated endoscopically with multiple plastic stents (MPSs), although the use of fully covered self-expandable metal stents (cSEMSs) is emerging. This study aims to compare the efficacy and safety of cSEMSs versus MPSs in these patients.
A single-center, open-label, randomized clinical trial was performed. Patients were randomized to single cSEMSs for 6 months or to MPS placement, exchanged every 3 months over 1 year. The primary outcome was stricture resolution. Crossover therapy was considered for failure or recurrence. Secondary outcomes were sustained improvement, morbidity, and mortality.
Between October 2009 and January 2014, 162 patients with post-OLT biliary adverse events were assessed for eligibility. Sixty-four were prospectively randomized (1:1) to cSEMSs or MPSs. Baseline characteristics were comparable. Technical success was 100%. Median follow-up was 36.4 and 32.9 months for the cSEMS and MPS groups, stricture resolution at last stent removal was achieved in 83.3% and 96.5% (P = .19), and stricture recurrence was observed in 32% and 0%, respectively (P < .01). Adverse events occurred in 23.3% and 6.4% of ERCPs in the cSEMS and MPS groups, respectively (P < .01), with 13.3% of acute pancreatitis in the cSEMS group and 2.1% in the MPS group (P < .01).
cSEMSs were comparable with MPSs regarding post-OLT biliary anastomotic stricture resolution. cSEMSs allowed fewer procedures and had a positive effect on cost. Duration of treatment with cSEMSs should be further investigated. Sphincterotomy should be considered for all patients. (Clinical trial registration number: NCT 01148199.)

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: See CME section; p. 932.

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Original articleClinical endoscopyRapid-sequence endoscopic management of posttransplant anastomotic biliary strictures

Background

Objective

Design

Setting

Interventions

Main Outcome Measurement

Results

Limitations

Conclusions

Section snippets

Methods

Patients

Discussion

Liver Transplant

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Liver Transplant

Original article
Clinical endoscopy
Rapid-sequence endoscopic management of posttransplant anastomotic biliary strictures