IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT?

ABSTRACT BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS: Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS: At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION: Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

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Endoscopic Management of Biliary Complications after Liver Transplant

Digestive Disease Interventions ◽

10.1055/s-0039-3400493 ◽

2019 ◽

Vol 03 (04) ◽

pp. 295-304

Author(s):

Ali Akram ◽

Robert Klapheke ◽

Wilson Kwong

Keyword(s):

Liver Transplant ◽

Endoscopic Therapy ◽

Deceased Donor ◽

Biliary Complications ◽

Definitive Treatment ◽

Endoscopic Management ◽

Donor Liver ◽

Stent Deployment ◽

Anastomotic Strictures ◽

Donor Liver Transplant

AbstractOrthotropic liver transplant (OLT) is the definitive treatment for patients with end stage liver disease of all etiologies. Biliary complications are common after OLT and living donor liver transplant (LDLT). Approximately, 15% of patients undergoing deceased donor liver transplant develop strictures and this number is even higher in LDLT recipients (28–32%).1 2 Common biliary complications include anastomotic and non-anastomotic strictures, bile leaks, biliary casts, and stones.3 Endoscopic therapy has become the mainstay of management of these biliary conditions. Endoscopic therapy involves sphincterotomy, dilation, and stent deployment to maintain patency of the bile duct and provide adequate drainage. This article will review current literature regarding endoscopic management of biliary complications after liver transplant and discuss recent endoscopic advances that can reduce the need for reoperation.

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A unique type of fully covered metal stent for the management of post liver transplant biliary anastomotic strictures

BMC Gastroenterology ◽

10.1186/s12876-020-01479-6 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Ben Warner ◽

Phillip Harrison ◽

Muhammad Farman ◽

John Devlin ◽

David Reffitt ◽

...

Keyword(s):

Liver Transplant ◽

Liver Function Tests ◽

Stent Insertion ◽

Complication Rates ◽

Metal Stent ◽

Unique Type ◽

Anastomotic Strictures ◽

Stricture Recurrence

Abstract Background We report our experience of treating anastomotic strictures using a novel type of fully covered metal stent (FCSEMS). This stent, known as the Kaffes Stent, is short-length with an antimigration waist and is easily removable due to long retrieval wires deployed within the duodenum. Methods Sixty-two patients underwent ERCP and Kaffes stent insertion for post-transplant anastomotic strictures following confirmation of a stricture on MRCP. These patients were retrospectively analysed for immediate and long-term stricture resolution, improvement in symptoms and liver function tests (LFTs), stricture recurrence and complication rates. Results Of the 56 patients who had their stent removed at the time of analysis, 54 (96%) had immediate stricture resolution and 42 continued to have long-term resolution (mean follow-up period was 548 days). Of the 16 patients with symptoms of biliary obstruction, 13 had resolution of their symptoms. Overall, there was a significant improvement in LFTs after stent removal compared to before stent insertion. Complication rates were 15% with only one patient requiring biliary reconstruction. Conclusions The Kaffes stent is effective and safe at resolving post liver transplant biliary anastomotic strictures.

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Endoscopic treatment for biliary complications after liver transplant

Digestive and Liver Disease ◽

10.1016/s1590-8658(06)80407-x ◽

2006 ◽

Vol 38 ◽

pp. S151

Author(s):

I. Tarantino ◽

M. Traina ◽

L. Barresi ◽

M. Di Pisa ◽

R. Volpes ◽

...

Keyword(s):

Liver Transplant ◽

Endoscopic Treatment ◽

Biliary Complications

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The Role of Endoscopy in the Treatment of Biliary Complications after Orthotopic Liver Transplantation

Russian Journal of Gastroenterology Hepatology Coloproctology ◽

10.22416/1382-4376-2019-29-1-62-67 ◽

2019 ◽

Vol 29 (1) ◽

pp. 62-67

Author(s):

Alexey V. Kurenkov ◽

Yury S. Teterin ◽

Oleg D. Olisov ◽

Petr A. Yartsev ◽

Murad S. Novruzbekov ◽

...

Keyword(s):

Liver Transplantation ◽

Orthotopic Liver Transplantation ◽

Endoscopic Treatment ◽

Biliary Complications ◽

Long Term Results ◽

Biliary Strictures ◽

Anastomotic Strictures ◽

Invasive Method ◽

Nasobiliary Drainage

Aim:to improve the results of treating patients with anastomotic biliary strictures of the bile ducts after orthotopic liver transplantation.Materials and methods.This study is based on the results of the endoscopic treatment of 36 patients with biliary complications after orthotopic liver transplantation, who were admitted to the N.V. Sklifosovsky Research Institute for Emergency Medicine from December 2001 to December 2017. The endoscopic treatment program included diagnostic ERCP, endoscopic papillosphincterotomy (EPST), bilioduodenal stenting, nasobiliary drainage, balloon dilatation.Results.Against the background of the staged endoscopic treatment, the stable remission of anastomotic biliary strictures (ABS) was achieved in 17 (53.1 %) patients, with 4 of them (12.5 %) showing a successfully resolved insufficiency of biliobiliary anastomosis (BBA). The average duration of endoscopic treatment was 12 ± 1.9 months. The number of ERCPs performed for each patient varied from 1 to 12 and averaged 3. In the majority of patients (75 %) who received one or more courses of endoscopic treatment, a successful correction of anastomotic strictures with no recurrence within 2–5 years was achieved.Conclusion.Staged endoscopic treatment is established to be highly effective in patients with anastomotic biliary strictures and the insufficiency of bilobiliary anastomoses occurred after orthotopic liver transplantation. Such a treatment allows good long-term results to be achieved by a minimally invasive method.

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DOZ047.73: Endoscopic treatment of esophageal atresia

Diseases of the Esophagus ◽

10.1093/dote/doz047.73 ◽

2019 ◽

Vol 32 (Supplement_1) ◽

Author(s):

T Vogiatzoglou ◽

S Arrigo ◽

P Gandullia

Keyword(s):

Esophageal Atresia ◽

Endoscopic Treatment ◽

Anastomotic Stricture ◽

Symptom Relief ◽

Balloon Catheter ◽

Therapeutic Endoscopy ◽

Upper Gastrointestinal Endoscopy ◽

Anastomotic Strictures ◽

Tertiary Center ◽

Therapeutic Alternatives

Abstract Aim of the Study The aim of this study was to provide an overview of endoscopic treatment in children after reconstruction of esophageal atresia. Methods This study, conducted at a single tertiary center, reviewed patients requiring endoscopic treatment during a 15-year period, from 2004 to 2018. Collected data include number, frequency, complications, and effectiveness of esophageal anastomotic dilations. Results A total of 55 children with esophageal atresia (EA) underwent upper gastrointestinal endoscopy. Of those, 37 required therapeutic endoscopy with dilation procedures for anastomotic strictures. Thirty-five patients underwent dilations using only through-the-scope (TTS) balloon (BD),1 patient using only a Savary bougie (SB), and 1 using both. A total of 126 dilations were performed using BD in 36 patients and 6 dilations using SB in 2 patients. Specifically, in children treated only with BD were performed 1 dilation in 6 children (17.1%), 2 in 6 children (17.1%), 3 in 7 children (20%), 4 in 6 children (17.1%), 5 in 6 children (17.1%), 7 in 2 children (5.7%), and 8 in 2 children (5.7%). Balloon catheter sizes ranged from 6 mm to 15 mm. In 2 patients (5.4%) stents were placed, 1 and 6 stents, respectively. Intralesional triamcinolone was injected in 8 patients (21.6%) as additional therapy. Major complications included perforation in 4 patients (10,8%), resolved with conservative treatment. All patients had clinical improvement in the follow-up. Conclusion Currently, endoscopic treatment for esophageal anastomotic stricture is the first procedure adopted in clinical practice after the surgical approach, since it is regarded safe and effective. Balloon dilations are preferred in our overview as a treatment option for esophageal anastomotic strictures. Symptom relief is reported in all cases, while the rate of complications is very low. Sometimes, refractory strictures influence the patient's quality of life and therapeutic alternatives such as stent placement should be considered.

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The Effectiveness of Standardised Endoscopic Therapy in Managing Post-Oltx Biliary Anastomotic Strictures: A Prospective Liver Transplant Centre Experience

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2007.03.489 ◽

2007 ◽

Vol 65 (5) ◽

pp. AB227

Author(s):

Andrew P. Holt ◽

Douglas Thorburn ◽

Geoffrey H. Haydon

Keyword(s):

Liver Transplant ◽

Endoscopic Therapy ◽

Transplant Centre ◽

Anastomotic Strictures

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Radial incision and cutting combined with balloon dilation for refractory pancreaticojejunostomy anastomotic strictures

Endoscopy International Open ◽

10.1055/a-1372-3628 ◽

2021 ◽

Vol 09 (04) ◽

pp. E578-E582

Author(s):

Tadahisa Inoue ◽

Mayu Ibusuki ◽

Rena Kitano ◽

Yuji Kobayashi ◽

Tomohiko Ohashi ◽

...

Keyword(s):

Clinical Success ◽

Anastomotic Stricture ◽

Balloon Dilation ◽

Recurrence Rates ◽

Pancreatic Stone ◽

Radial Incision ◽

Anastomotic Strictures ◽

The Mean ◽

Stricture Recurrence

Abstract Background and study aims Endoscopic balloon dilation (BD) and temporary stent placement for pancreaticojejunostomy anastomotic stricture (PJAS) achieves good short-term outcomes; however, stricture recurrences remain frequent. We examined the feasibility of performing radial incision and cutting (RIC) combined with BD for refractory PJAS. Patients and methods Five consecutive patients with refractory PJAS who underwent RIC with BD between 2015 and 2018 were retrospectively investigated. We evaluated the technical and clinical success, adverse event (AE), and recurrence rates associated with RIC with BD. Results In all five patients, technical and clinical success were achieved. Pancreatic stone removal was simultaneously performed in one patient. The mean procedure time was 18 minutes (range 12–23 minutes). There were no procedure-related AEs. All patients were followed for over 2 years, with a mean follow-up period of 33 months (range 24–40 months). During the follow-up period, none of the patients developed stricture recurrence and all anastomoses remained patent. Conclusions This is the first report of RIC with BD for the treatment of refractory PJAS, showing favorable results. This combined procedure might be a useful option for treating refractory PJAS.

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Endoscopic Treatment of Early Biliary Complications in Liver Transplant Recipients

Annals of Transplantation ◽

10.12659/aot.896786 ◽

2015 ◽

Vol 20 ◽

pp. 741-746 ◽

Cited By ~ 3

Author(s):

Konrad Kobryń ◽

Sławomir Kozieł ◽

Marta Poręcka ◽

Krzysztof Kobryń ◽

Wacław Hołówko ◽

...

Keyword(s):

Liver Transplant ◽

Endoscopic Treatment ◽

Biliary Complications ◽

Transplant Recipients ◽

Liver Transplant Recipients

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Salvage PTBD in post living donor liver transplant patients with biliary complications—a single centre retrospective study

British Journal of Radiology ◽

10.1259/bjr.20191046 ◽

2020 ◽

Vol 93 (1108) ◽

pp. 20191046 ◽

Cited By ~ 1

Author(s):

Amar Mukund ◽

Ashok Choudhury ◽

Swati Das ◽

Viniyendra Pamecha ◽

Shiv Kumar Sarin

Keyword(s):

Liver Transplant ◽

Graft Loss ◽

Bile Leak ◽

Good Alternative ◽

Surgical Anatomy ◽

Biliary Complications ◽

Salvage Procedure ◽

Hospital Data ◽

Key Factor ◽

Donor Liver Transplant

Objective: To study the outcome of salvage percutaneous transhepatic biliary drainage (PTBD) in complex and technically challenging post-liver transplant (LT) biliary complications and analyse the reason for failure of endoscopic retrograde cholangiopancreatography (ERCP). Methods and materials: Hospital data were searched for all LT patients with biliary complications requiring salvage PTBD (upon failure of ERCP) from January 2010 to May 2017. Patients who underwent primary PTBD were excluded. Patients clinical and biochemical parameters were analysed for clinical, biochemical and imaging response, stent-free survival and the reason for ERCP failure. Results: Salvage PTBD was performed in 32 patients with post-LT biliary stricture/bile leak presenting with deranged liver function in 12 (37.5%), cholangitis in 12 (37.5%) and cholangitis with cholangitic abscess in remaining 8 (25%) patients. Of 32 patients, 20 (62.5%) already had plastic biliary stent placed by ERCP, while in remaining (n = 12, 37.5%) a wire could not be negotiated across stricture by ERCP. These patients were found to have long/tortuous stricture (n = 18, 56.3%) and multiple duct disconnection at anastomosis (n = 14, 43.7%). Immediate as well as sustained (persisting for a year or more) clinical and biochemical improvement was seen in 26 (81.3%) patients, while failure of resolution of sepsis and death occurred in remaining 6 (18.8%). Conclusion: Salvage PTBD is an effective treatment in difficult-to-treat post-LT biliary strictures with deranged liver functions with or without cholangitis/cholangitic abscess. It can reduce graft loss with improved clinical outcome. Post-LT ductal anatomy at anastomosis is important to decide the appropriate approach (ERCP/PTBD). Advances in knowledge: (1). PTBD as a salvage procedure in difficult anatomy or upon failure of ERCP-based intervention is effective and a good alternative strategy. (2). Postoperative surgical anatomy (type & length of stricture, number of ductanastomosis, location and graft-recipient duct alignment) is the key factor indeciding the appropriate therapeutic procedure.

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