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Kugiyama N, Hashigo S, Nagaoka K, Watanabe T, Ushijima S, Uramoto Y, Yoshinari M, Morinaga J, Gushima R, Tateyama M, Tanaka M, Naoe H, Sugawara Y, Hibi T, Tanaka Y. Clinical usefulness of inside stents in anastomotic biliary strictures after liver transplantation. DEN OPEN 2024; 4:e305. [PMID: 37900614 PMCID: PMC10606956 DOI: 10.1002/deo2.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 10/31/2023]
Abstract
Background Endoscopic biliary stenting is a standard treatment for biliary strictures after liver transplantation. Plastic stents are often replaced before stent dysfunction to prevent the development of cholangitis and jaundice. Therefore, the precise duration of stent patency is unclear. Methods We compared retrospectively the stent patency period and stent dysfunction rate between inside stents (IS) and conventional plastic stents (PS) in 48 patients with post-transplant strictures, distinguishing endoscopic biliary stenting with and without stent dysfunction at stent replacement. Results In observations focused on the first treatment, the median patency periods were 369 days for IS (n = 18) and 154 days for PS (n = 30; p = 0.01), significantly longer for IS. The 1-year cholangitis incidence rate was lower for IS (20% vs. 43%, p = 0.04). Additionally, no stent dislocation was observed for IS, but this occurred for 33.3% of PS (p = 0.004). Comparing all endoscopic biliary stenting, including second and subsequent procedures, IS again had a longer patency period than PS (356 days, n = 89, vs. 196 days, n = 127, p = 0.009). Conclusions IS had a significantly longer patency period than PS, suggesting that IS replacement could be reduced to once per year for patients who prefer less frequent stent replacement.
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Affiliation(s)
- Naotaka Kugiyama
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Shunpei Hashigo
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Katsuya Nagaoka
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Takehisa Watanabe
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Shinya Ushijima
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Yukiko Uramoto
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Motohiro Yoshinari
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Jun Morinaga
- Department of Clinical InvestigationKumamoto University HospitalKumamotoJapan
| | - Ryosuke Gushima
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Masakuni Tateyama
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | | | - Hideaki Naoe
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
| | - Yasuhiko Sugawara
- Department of Pediatric Surgery and TransplantationKumamoto University HospitalKumamotoJapan
| | - Taizo Hibi
- Department of Pediatric Surgery and TransplantationKumamoto University HospitalKumamotoJapan
| | - Yasuhito Tanaka
- Department of Gastroenterology and HepatologyKumamoto University HospitalKumamotoJapan
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Taniai T, Furukawa K, Haruki K, Yanagaki M, Hamura R, Akaoka M, Tsunematsu M, Onda S, Shirai Y, Uwagawa T, Ikegami T. Multimodal Management for Refractory Biliary Stricture After Living Donor Liver Transplantation. Transplant Proc 2023:S0041-1345(23)00249-X. [PMID: 37105831 DOI: 10.1016/j.transproceed.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/18/2023] [Accepted: 04/01/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Biliary stricture is a common complication of living donor liver transplantation (LDLT). Endoscopic retrograde biliary drainage (ERBD) is the primary treatment of biliary stricture, which is sometimes refractory. This study aimed to evaluate the risk factors for biliary stricture after LDLT and present successful management for refractory biliary stricture. METHODS Data from 26 patients who underwent LDLT were retrospectively analyzed. The relationship between the incidence of biliary strictures and clinical variables, including pre/intra/postoperative factors, was assessed. RESULTS Univariate analysis showed that ABO incompatibility (P = .037) was a significant risk factor for biliary strictures. Case 1 was a 57-year-old woman who underwent LDLT using a left-lobe graft for primary biliary cholangitis (PBC) and developed a biliary stricture 1 month after surgery. Percutaneous transhepatic cholangiodrainage (PTCD) and embolization of the portal vein and hepatic artery were performed. Thereafter, ethanol was injected into the biliary duct, and the intervention was successfully completed. Case 2 was a 54-year-old woman who underwent LDLT using a right-lobe graft and duct-to-duct biliary reconstruction for PBC. Internal plastic stent insertion by ERBD was unsuccessful due to the significantly bending bile duct. After PTCD, the gun-site technique for the posterior branch and dual hepatic vascular embolization of the anterior branch was performed. The patient was followed up without an external fistula tube. CONCLUSION ABO incompatibility was a risk factor for refractory biliary stricture. Appropriate procedures should be chosen based on stricture types.
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Affiliation(s)
- Tomohiko Taniai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuru Yanagaki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoga Hamura
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Munetoshi Akaoka
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Uwagawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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The Role of Microbiota in Liver Transplantation and Liver Transplantation-Related Biliary Complications. Int J Mol Sci 2023; 24:ijms24054841. [PMID: 36902269 PMCID: PMC10003075 DOI: 10.3390/ijms24054841] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Liver transplantation as a treatment option for end-stage liver diseases is associated with a relevant risk for complications. On the one hand, immunological factors and associated chronic graft rejection are major causes of morbidity and carry an increased risk of mortality due to liver graft failure. On the other hand, infectious complications have a major impact on patient outcomes. In addition, abdominal or pulmonary infections, and biliary complications, including cholangitis, are common complications in patients after liver transplantation and can also be associated with a risk for mortality. Thereby, these patients already suffer from gut dysbiosis at the time of liver transplantation due to their severe underlying disease, causing end-stage liver failure. Despite an impaired gut-liver axis, repeated antibiotic therapies can cause major changes in the gut microbiome. Due to repeated biliary interventions, the biliary tract is often colonized by several bacteria with a high risk for multi-drug resistant germs causing local and systemic infections before and after liver transplantation. Growing evidence about the role of gut microbiota in the perioperative course and their impact on patient outcomes in liver transplantation is available. However, data about biliary microbiota and their impact on infectious and biliary complications are still sparse. In this comprehensive review, we compile the current evidence for the role of microbiome research in liver transplantation with a focus on biliary complications and infections due to multi-drug resistant germs.
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Sharma ZD, Karunakaran M, Bansal RK, Gandhi A, Singh MK, Soin AS, Puri R, Sud R. Cholangioscopic classification of post-living donor liver transplantation biliary strictures can predict their natural history and response to therapy. ANZ J Surg 2022; 93:911-917. [PMID: 36262090 DOI: 10.1111/ans.18123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/30/2022] [Accepted: 10/08/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study aimed to assess the morphology of post-living donor liver transplant (LDLT) anastomotic biliary strictures using cholangioscopy and assess the impact of morphology on its prognosis. METHODS A single centre, prospective, observational study was conducted at a tertiary care teaching hospital from August 2014 to July 2016. Single operator cholangioscopy (SOC) was used to assess post-LDLT anastomotic biliary strictures at presentation in 24 patients. Analysis included demographic and biochemical characteristics, time to stricture development, endoscopic procedural details, time to remodelling and development of recurrence on follow-up. RESULTS Two distinct patterns of strictures were identified, type I with minimal inflammatory changes and type II with severe inflammatory changes. Guidewire cannulation was successful in 23 out of 24 (95.8%) patients. There was no significant difference between the two types of strictures based on aetiology of liver disease, CTP and MELD scores, time taken for the development or laboratory parameters at presentation. However, type II strictures required more sessions of dilatation (4 vs. 2; P = 0.002), longer duration for resolution (282.5 vs. 201.5 days, P = 0.095) and more number of stents. CONCLUSIONS Addition of cholangioscopy tends to improve stricture cannulation rates at ERCP. It offers a useful classification of post-LDLT strictures with prognostic and therapeutic significance. Type II strictures tend to require more sessions of endotherapy than type I strictures over a longer duration for remodelling.
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Affiliation(s)
- Zubin Dev Sharma
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Monish Karunakaran
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India.,Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.,College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon, India
| | - Ashish Gandhi
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | | | - Arvinder Singh Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Rajesh Puri
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
| | - Randhir Sud
- Department of Gastroenterology, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India
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Long-term Clinical Outcomes and Predictive Factors for Living-donor Liver Transplant Recipients With Biliary Strictures. Transplantation 2022; 106:1990-1999. [PMID: 35771085 DOI: 10.1097/tp.0000000000004201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Biliary strictures frequently occur in living-donor liver transplant (LDLT) recipients. However, long-term clinical outcomes and their associated factors are unclear. METHODS We analyzed an historical cohort of 228 recipients who underwent LDLT with post-liver transplantation biliary strictures. Endoscopic retrograde cholangiography or percutaneous transhepatic biliary drainage were performed to treat biliary strictures. Patients that experienced persistent jaundice over 3 mo after the initial treatment were defined as a remission-failure group. RESULTS Median observation period was 8.5 y after the diagnosis of biliary stricture. The 15-y graft survival (GS) rate was 70.6%, and 15-y rate of developing portal hypertension (PH) was 26.1%. Remission failure occurred in 25.0% of study participants. In the multivariate analysis, biopsy-proven acute rejection, and portal vein/hepatic artery abnormalities were risk factors for remission failure. Development of PH, retransplantation, and death were significantly more frequent in the remission-failure group. Remission failure and PH were associated with poor GS. In multivariate analyses, hepatic artery abnormality and biloma were common significant factors that were associated with a poor GS and development of PH. CONCLUSIONS The insufficient blood supply reflected by hepatic artery abnormality and biloma might be the most important factor that can predict poor long-term survival in LDLT patients with biliary strictures. Future large-scale prospective studies are needed to validate our observations.
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Chun JW, Yi NJ, Kim H, Paik WH. [Liver Graft Failure after Plastic Stent Removal of an Anastomotic Biliary Stricture]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2022; 79:217-221. [PMID: 35610552 DOI: 10.4166/kjg.2022.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/18/2022] [Accepted: 03/20/2022] [Indexed: 11/03/2022]
Abstract
A biliary anastomotic stricture developed 13 months after living donor liver transplantation in a 19-year-old male with congenital hepatic fibrosis. Endoscopic management with balloon dilation followed by the placement of a 7F plastic stent was performed for the anastomotic stricture. After 6 months of indwelling of the stent, the plastic stent was removed because the stenosis and cholestasis were improved. One month after stent removal, he was admitted for acute liver graft failure owing to cholestatic hepatitis, and required retransplantation secondary to graft loss.
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Affiliation(s)
- Jung Won Chun
- Center for Liver and Pancreatobiliary Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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7
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Kim MS, Hong SK, Woo HY, Cho JH, Lee JM, Yoon KC, Choi Y, Yi NJ, Lee KW, Suh KS. Optimal Intervention for Initial Treatment of Anastomotic Biliary Complications After Right Lobe Living Donor Liver Transplantation. Transpl Int 2022; 35:10044. [PMID: 35529595 PMCID: PMC9073559 DOI: 10.3389/ti.2022.10044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/23/2022] [Indexed: 12/23/2022]
Abstract
Background: This study evaluated endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) as interventions for patients with anastomotic biliary complications (ABC) after living donor liver transplantation (LDLT). Methods: Prospectively collected data of patients who were diagnosed with ABC after LDLT between January 2013 and June 2017 were retrospectively reviewed. Results: There were 57 patients who underwent LDLT with a right liver graft using duct-to-duct biliary reconstruction and experienced ABC. Among the patients with RAD involvement, there were no significant differences in the intervention success (p = 0.271) and patency rates (p = 0.267) between ERCP and PTBD. Similarly, among the patients with RPD involvement, there were no significant differences in the intervention success (p = 0.148) and patency rates (p = 0.754) between the two procedures. Graft bile duct variation (p = 0.013) and a large angle between the recipient and graft bile duct (R-G angle) (p = 0.012) significantly increased the likelihood of failure of ERCP in the RAD. When the R-G angle was greater than 47.5°, the likelihood of ERCP failure increased. Conclusion: We recommend PTBD when graft bile duct variation is presented in patients with RAD involvement and/or when the R-G angle is greater than 47.5°.
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Affiliation(s)
- Min Seob Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hye Young Woo
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Hyung Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Chul Yoon
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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8
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Parlak E, Simsek C, Koksal AS, Eminler AT, Unal E, Ciftci TT, Akinci D, Yilmaz S. The Classification of Biliary Strictures in Patients With Right-Lobe Liver Transplant Recipients and Its Relation to Traversing the Stricture With a Guidewire. Transplantation 2022; 106:328-336. [PMID: 33724243 DOI: 10.1097/tp.0000000000003738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traversing the stricture with a guidewire is a prerequisite for the endoscopic treatment of biliary strictures after living donor liver transplantation. We aimed to evaluate the effect of variations in the biliary anastomosis and strictures on the success of endoscopic treatment and suggest a cholangiographic classification. METHODS The 125 strictures among the 104 patients with right-lobe living donor liver transplantation were reviewed. The strictures were classified by the anastomosis pattern according to the number (1, 2, or >2), location (common bile, hepatic, or cystic duct), the angle between the proximal and distal sites of the anastomosis, and the contrast enhancement pattern. The relationship between the success rate of traversing the anastomosis and the classification was evaluated. RESULTS Of the 125 biliary strictures, 86 (68.8%) could be passed via endoscopically. Thirty-three strictures were managed either percutaneously (n = 13) or by magnetic compression anastomosis (n = 20). Compared with the round, the triangular (odds ratio [OR], 6.5), the intermediate form (OR, 17.7), and the end-to-side anastomosis (OR, 5.1) were associated with an increased chance of traversing. The contrast enhancement pattern of the strictures and the bile ducts was also related to the successful rate of the endoscopic treatment (P < 0.001). The success rate was higher in the patients with the angle between the proximal and distal sites of the anastomosis approximated was small (0°-30° = 74%, 30°-60° = 69%, 60°-90° = 63%, >90° = 41%). CONCLUSIONS The type of biliary anastomoses and stricture affect the success rate of endoscopic treatment. These data may play role in making decision about the type of anastomosis during the surgery.
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Affiliation(s)
- Erkan Parlak
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Cem Simsek
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Aydin Seref Koksal
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Ahmet Tarik Eminler
- Department of Gastroenterology, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Emre Unal
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Turkmen Turan Ciftci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Devrim Akinci
- Department of Radyology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sezai Yilmaz
- Department of Surgery, Faculty of Medicine, Liver Transplant Institute, Inonu University, Malatya, Turkey
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Real-Time 3D Imaging of Post-Transplant Biliary Stricture: A Novel Application of Existing Technology. Am J Gastroenterol 2021; 116:2145-2146. [PMID: 34003177 PMCID: PMC8500276 DOI: 10.14309/ajg.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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10
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Rao HB, Koshy AK, Priya K, Nair P, Sudhindran S, Venu RP. Endoscopic management of high-grade biliary strictures complicating living donor liver transplantation using soehendra stent retrievers. Scand J Gastroenterol 2021; 56:1103-1108. [PMID: 34242116 DOI: 10.1080/00365521.2021.1944300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Biliary strictures following living donor liver transplantation (LDLT) are usually managed by endoscopic retrograde cholangiography (ERC) with stricture dilation and stent placement. While current endoscopic techniques are successful in most cases, high-grade biliary strictures (HGBS) pose a challenge using currently employed techniques which have a low rate of technical success. AIMS In this study, we have explored the safety and efficacy of Soehendra stent retrievers (SSR) for the dilation of HGBS complicating LDLT. METHODS This was a prospective cohort study where all patients with anastomotic biliary strictures following LDLT from January 2016 till February 2018 were included. Patients with HGBS defined as the exclusive passage of 0.018-inch guidewire, were included in Group 1. In these patients, 5 Fr Soehendra stent retrievers were used to dilate HGBS over guidewire, using torsional movements. Technical success, safety and clinical response was compared with patients who required Per-cutaneous transhepatic cholangiography (PTC) with rendezvous procedure due to a failed ERC, before the commencement of the study (Group 2). RESULTS Ten patients with HGBS were included into Group 1. Technical success defined as successful placement of a biliary stent across the stricture was achieved in all the patients in group 1. Favorable response to endotherapy was higher in group 1(8/10 patients (80%)) as compared to group 2(6/14 patients (42.8%)). There were no post procedure complications in patients of group 1, while 3 patients developed cholangitis in group 2. CONCLUSIONS HGBS can be successfully treated with SSR for stricture dilation. It is safe with no significant complications and requires fewer procedures.
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Affiliation(s)
- Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Anoop K Koshy
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Krishna Priya
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - Priya Nair
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
| | - S Sudhindran
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences, Kochi, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Kochi, India
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11
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Espinosa W, Chiu Y, Kuo C, Liang C, Lu L, Wu C. Risk factors of post‐endoscopic retrograde cholangiopancreatography pancreatitis among living‐donor liver transplant recipients with biliary complications. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Wendell Espinosa
- Department of Internal Medicine Dr. Pablo O. Torre Memorial Hospital Bacolod Philippines
| | - Yi‐Chun Chiu
- Division of Hepato‐Gastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung City Taiwan
| | - Chung‐Mou Kuo
- Division of Hepato‐Gastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung City Taiwan
| | - Chih‐Ming Liang
- Division of Hepato‐Gastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung City Taiwan
| | - Lung‐Sheng Lu
- Division of Hepato‐Gastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung City Taiwan
| | - Cheng‐Kun Wu
- Division of Hepato‐Gastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung City Taiwan
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12
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Jang SI, Chung TR, Cho JH, Lee KH, Joo SM, Choi JH, Kim SI, Lee DK. Short fully covered self-expandable metal stent for treatment of proximal anastomotic benign biliary stricture after living-donor liver transplantation. Dig Endosc 2021; 33:840-848. [PMID: 33043522 DOI: 10.1111/den.13871] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/08/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Non-surgical methods have high success rates for treating benign biliary strictures (BBSs), but treatment of proximal strictures is difficult. Recent studies have reported that fully covered self-expandable metal stents (FCSEMSs) are useful for treating refractory BBSs. We investigated the efficacy of a short and removable FCSEMS with an anti-migration design for treatment of proximal BBSs. METHODS Fully covered self-expandable metal stents were inserted endoscopically in patients with BBSs after living donor liver transplantation (LDLT). Each FCSEMS was initially maintained for 3 months and subsequently exchanged every 3 months until the stricture resolved. Adverse events and stricture recurrence after FCSEMS removal were assessed during follow-up. RESULTS A total of 63 patients with a median age of 57 years were enrolled in this study; 50 were male. The most common underlying disease was hepatocellular carcinoma and the previous operation was LDLT. The mean duration from surgery to diagnosis of stricture was 8.5 months, and the mean stent indwelling time was 4.2 months. The technical success and stricture resolution rate were 100%. The recurrence rate was 23.8% and the adverse event rate was 12.7%. All stents were removable, and asymptomatic stent migration was observed in four patients (6.4%). CONCLUSIONS The newly designed FCSEMS is effective in the treatment of proximal BBSs after LDLT.
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Affiliation(s)
- Sung Ill Jang
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Ryong Chung
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hun Lee
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Moon Joo
- Department of, Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hye Choi
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sae In Kim
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Departments of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Lin J, Ko CJ, Lin KH, Lin PY, Hsieh CE, Chou CT, Chen YL, Hung YJ. Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation. Asian J Surg 2021; 44:742-748. [PMID: 33468384 DOI: 10.1016/j.asjsur.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/13/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND /Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates. METHODS Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis. RESULTS At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p = 0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p = 0.018). CONCLUSION This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.
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Affiliation(s)
- Joseph Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Jan Ko
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuo-Hua Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Yi Lin
- Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chia-En Hsieh
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chen-Te Chou
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Molecular Biotechnology, College of Biotechnology and Bioresources, Dayeh University, Changhua City, Taiwan; Department of Radiology, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yao-Li Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan; College of Nursing and Health Sciences, Dayeh University, Changhua City, Taiwan.
| | - Yu-Ju Hung
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan.
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14
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Keane MG, Devlin J, Harrison P, Masadeh M, Arain MA, Joshi D. Diagnosis and management of benign biliary strictures post liver transplantation in adults. Transplant Rev (Orlando) 2021; 35:100593. [PMID: 33388638 DOI: 10.1016/j.trre.2020.100593] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Margaret G Keane
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - John Devlin
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Philip Harrison
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
| | - Maen Masadeh
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Mustafa A Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, USA.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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15
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Park JK, Yang JI, Lee JK, Park JK, Lee KH, Lee KT, Joh JW, Kwon CHD, Kim JM. Long-term Outcome of Endoscopic Retrograde Biliary Drainage of Biliary Stricture Following Living Donor Liver Transplantation. Gut Liver 2020; 14:125-134. [PMID: 30970446 PMCID: PMC6974332 DOI: 10.5009/gnl18387] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/12/2018] [Accepted: 12/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Biliary strictures remain one of the most challenging aspects after living donor liver transplantation (LDLT). The aim of this study was to assess long-term outcome of endoscopic treatment of biliary strictures occurring after LDLT and to identify risk factors of recurrent biliary strictures following endoscopic retrograde biliary drainage (ERBD) in LDLT. Methods A total of 1,106 patients underwent LDLT from May 1995 to May 2014. We compared the risk factors between patients with and without recurrent biliary strictures. Results Biliary strictures developed in 24.0% of patients. Technical success rate of ERBD for biliary stricture after LDLT was 66.2% (145/219). Among 145 patients managed by endoscopic drainage, stricture resolution occurred in 69 with median duration of stent indwelling of 13.6 months (range, 0.5 to 67.3 months), and stricture recurrence was seen in 20 (21.3%) out of 94. The median recurrence-free duration after final endoscopic success was 13.1 months (range, 0.5 to 67.3 months). Older donor age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03 to 1.17; p=0.004) and non-B, non-C liver cirrhosis (HR, 5.10; 95% CI, 1.10 to 25.00; p=0.043) were associated with higher recurrence of biliary stricture. Conclusions Long-term stricture resolution rate after ERBD insertion for biliary stricture occurring after LDLT was 73.4%. Clinicians should pay careful attention during following-up to decide when to remove ERBD in patients who have factors associated with recurrent biliary strictures.
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Affiliation(s)
- Jae Keun Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Il Yang
- Division of Gastroenterology, Department of Internal Medicine, Good Gangan Hospital, Busan, Korea
| | - Jong Kyun Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyuck Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Taek Lee
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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16
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Biliary reconstruction and complications in living donor liver transplantation. Int J Surg 2020; 82S:138-144. [DOI: 10.1016/j.ijsu.2020.04.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
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17
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Choi JH, Paik WH. Unilateral Versus Bilateral Biliary Drainage for Post-Transplant Anastomotic Stricture. Clin Endosc 2020; 53:255-260. [PMID: 32438779 PMCID: PMC7280849 DOI: 10.5946/ce.2020.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/27/2020] [Indexed: 11/14/2022] Open
Abstract
Living donor liver transplantation is the most common type of liver transplantation in Asia. Post-transplant biliary stricture is frequent in living donor liver transplantation, and endoscopic management is considered to be the treatment of choice. However, endoscopic management is still challenging in patients who undergo right lobe living donor liver transplantation because of the anatomical alteration. In this article, we reviewed the recently updated results for proper endoscopic biliary drainage in post-living donor liver transplantation anatomical biliary stricture and compared unilateral and bilateral drainage.
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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18
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Koizumi M, Kumagi T, Kuroda T, Imamura Y, Kanemitsu K, Ogawa K, Takada Y, Hiasa Y. Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation. BMC Gastroenterol 2020; 20:92. [PMID: 32252630 PMCID: PMC7137274 DOI: 10.1186/s12876-020-01226-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Endoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist. Methods We evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent. Results A total of 98 ERC sessions (median 6: range 1–14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8–1736) and 99 days (range; 7–356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically. Conclusions The endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.
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Affiliation(s)
- Mitsuhito Koizumi
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Teru Kumagi
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Taira Kuroda
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yoshiki Imamura
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kozue Kanemitsu
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kohei Ogawa
- Hepato-Biliary-Pancreatic Surgery and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yasutsugu Takada
- Hepato-Biliary-Pancreatic Surgery and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoichi Hiasa
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
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19
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Mukund A, Choudhury A, Das S, Pamecha V, Sarin SK. Salvage PTBD in post living donor liver transplant patients with biliary complications-a single centre retrospective study. Br J Radiol 2020; 93:20191046. [PMID: 31971831 DOI: 10.1259/bjr.20191046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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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Affiliation(s)
- Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Swati Das
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobiliary Pancreatic surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, India
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20
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The Impact of Biliary Reconstruction Methods on Small Partial Liver Grafts. Transplant Direct 2020; 6:e523. [PMID: 32095509 PMCID: PMC7004631 DOI: 10.1097/txd.0000000000000966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is available in the text. Graft recipient weight ratios are lower in adult-to-adult living-donor liver transplantation than in adult-to-adult deceased-donor liver transplantation. Rapid liver regeneration is essential for increased recipient survival rates in adult-to-adult living-donor liver transplantation. However, the influence of biliary reconstruction methods, including choledocho-choledochostomy and choledocho-jejunostomy, on small partial liver grafts remains unknown. Herein, we investigate the impact of these biliary reconstruction methods on small partial liver grafts.
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21
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Ogiso S, Kamei H, Onishi Y, Kurata N, Jobara K, Kawashima H, Ogura Y. Decreased long‐term graft survival in persistent biliary complications after right‐lobe living‐donor liver transplantation. Clin Transplant 2019; 34:e13771. [PMID: 31846118 DOI: 10.1111/ctr.13771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Satoshi Ogiso
- Transplantation Surgery Nagoya University Hospital Nagoya Japan
| | - Hideya Kamei
- Transplantation Surgery Nagoya University Hospital Nagoya Japan
| | - Yasuharu Onishi
- Transplantation Surgery Nagoya University Hospital Nagoya Japan
| | - Nobuhiko Kurata
- Transplantation Surgery Nagoya University Hospital Nagoya Japan
| | - Kanta Jobara
- Transplantation Surgery Nagoya University Hospital Nagoya Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology Nagoya University Graduate School of Medicine Nagoya Japan
| | - Yasuhiro Ogura
- Transplantation Surgery Nagoya University Hospital Nagoya Japan
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22
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Creation of a Robotically Assisted Terminal Jejunogastrostomy Is Safe and Effective in Regaining Antegrade Enteral Bile Duct Access After Live Donor Liver Transplant With Roux Limb. Transplant Direct 2019; 5:e476. [PMID: 31576372 PMCID: PMC6708632 DOI: 10.1097/txd.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 11/26/2022] Open
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23
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Abdelgawad MS, Aly RA, Sherif AE. Impact of MRCP findings on the management of biliary strictures in post-living donor liver transplant. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0013-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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24
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Lee DW, Han J. Endoscopic management of anastomotic stricture after living-donor liver transplantation. Korean J Intern Med 2019; 34:261-268. [PMID: 30840808 PMCID: PMC6406087 DOI: 10.3904/kjim.2019.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 12/14/2022] Open
Abstract
The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.
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Affiliation(s)
- Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Correspondence to Jimin Han, M.D. Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Namgu, Daegu 42472, Korea Tel: +82-53-650-3442 Fax: +82-53-624-3281 E-mail:
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25
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Larghi A, Tringali A, Rimbaş M, Barbaro F, Perri V, Rizzatti G, Gasbarrini A, Costamagna G. Endoscopic Management of Benign Biliary Strictures After Liver Transplantation. Liver Transpl 2019; 25:323-335. [PMID: 30329213 DOI: 10.1002/lt.25358] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 02/07/2023]
Abstract
Biliary strictures represent some of the most frequent complications encountered after orthotopic liver transplantation. They comprise an array of biliary abnormalities with variations in anatomical location, clinical presentation, and different pathogenesis. Magnetic resonance cholangiography represents the most accurate noninvasive imaging test that can provide detailed imaging of the whole biliary system-below and above the anastomosis. It is of particular value in those harboring complex hilar or intrahepatic strictures, offering a detailed roadmap for planning therapeutic procedures. Endoscopic therapy of biliary strictures usually requires biliary sphincterotomy plus balloon dilation and stent placement. However, endoscopic management of nonanastomotic biliary strictures is much more complex and challenging as compared with anastomotic biliary strictures. The present article is a narrative review presenting the results of endoscopic treatment of biliary strictures occurring after liver transplantation, describing the different strategies based on the nature of the stricture and summarizing their outcomes.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Mihai Rimbaş
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Federico Barbaro
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Scientific Institute for Research, Hospitalization, and Health Care, Fondazione Policlinico Universitario A. Gemelli, Catholic University, Rome, Italy.,Instituts Hospitalo-Universitaires - University of Strasbourg Institute of Advanced Study, Strasbourg, France
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26
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Jang SI, Lee DK. Anastomotic stricture after liver transplantation: It is not Achilles' heel anymore! INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii180012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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27
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Facciorusso A, Rosca EC, Ashimi A, Ugoeze KC, Pathak U, Infante V, Muscatiello N. Management of anastomotic biliary stricture after liver transplantation: metal versus plastic stent. Ann Gastroenterol 2018; 31:728-734. [PMID: 30386124 PMCID: PMC6191877 DOI: 10.20524/aog.2018.0297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/29/2018] [Indexed: 12/29/2022] Open
Abstract
Background Post-transplant anastomotic biliary strictures remain refractory to endoscopic therapy in a considerable number of cases. The aim of this meta-analysis was to compare fully-covered self-expandable metal and plastic stents in the management of post-transplant biliary strictures. Methods A meta-analysis was performed using a random effects model; results were expressed as odds ratio (OR) and mean standardized difference. The primary outcome was stricture resolution, while recurrence rate after stent placement, treatment time, and safety of the procedure were the secondary outcomes. Results Through a systematic literature review until October 2017, we identified 7 studies, of which 4 were randomized controlled trials. Stricture resolution was slightly higher with metal stents, with no statistical difference between the two procedures (OR 1.38, 95% confidence interval [CI] 0.60-3.15; P=0.45) and low heterogeneity (I2=6%). Stricture recurrence showed a non-significant trend in favor of plastic stents (OR 1.82, 95%CI 0.52-6.31, P=0.35). Endoscopic retrograde cholangiopancreatography with placement of metal stents offered a significant improvement in terms of reduced treatment time (mean standardized difference: -3.58 months, 95%CI -6.23 to -0.93; P=0.008), but with more frequent complications, although not significantly so (OR 2.34, 95%CI 0.75-7.25; P=0.14). Sensitivity analysis confirmed all the findings. Conclusion Metal stents appear to be a promising tool that can decrease treatment time, although there is still no clear evidence of their superiority over plastic stents in terms of efficacy.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Italy (Antonio Facciorusso; Nicola Muscatiello)
| | - Elena Cecilia Rosca
- Department of Neurology, University of Medicine and Pharmacy "Victor Babes" Timisoara, Romania (Elena Cecilia Rosca)
| | - Adewale Ashimi
- Department of Obstetrics and Gynecology, Federal Medical Centre Birnin Kudu, Jigawa State, Nigeria (Adewale Ashimi)
| | - Kenneth C Ugoeze
- Department of Pharmaceutics & Pharmaceutical Technology, University of Port Harcourt, Nigeria (Kenneth C. Ugoeze)
| | - Utkarsha Pathak
- School of Environment, Guru Gobind Singh Indraprastha University, New Delhi, India (Utkarsha Pathak)
| | - Vanessa Infante
- Department of Infectious Diseases, University of Sao Paulo, Brasil (Vanessa Infante)
| | - Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Italy (Antonio Facciorusso; Nicola Muscatiello)
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Rao HB, Prakash A, Sudhindran S, Venu RP. Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions. World J Gastroenterol 2018; 24:2061-2072. [PMID: 29785075 PMCID: PMC5960812 DOI: 10.3748/wjg.v24.i19.2061] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/28/2018] [Accepted: 05/11/2018] [Indexed: 02/06/2023] Open
Abstract
Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area.
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Affiliation(s)
- Harshavardhan B Rao
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Arjun Prakash
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Surendran Sudhindran
- Department of Transplant and Vascular Surgery, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
| | - Rama P Venu
- Department of Gastroenterology, Amrita Institute of Medical Sciences, Amrita University, Kochi 682041, India
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29
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Internal biliary stenting in liver transplantation. Langenbecks Arch Surg 2018; 403:487-494. [DOI: 10.1007/s00423-018-1669-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
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30
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Woo YS, Lee KH, Lee KT, Lee JK, Kim JM, Kwon CHD, Joh JW, Kang D, Cho J. Postoperative changes of liver enzymes can distinguish between biliary stricture and graft rejection after living donor liver transplantation: A longitudinal study. Medicine (Baltimore) 2017; 96:e6892. [PMID: 28984750 PMCID: PMC5737986 DOI: 10.1097/md.0000000000006892] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is no known useful clinical parameter that can specifically predict a biliary stricture and differentiate it from other related complications after living donor liver transplantations (LDLT). The aims of this study were to determine whether the changes of liver enzymes can predict postoperative biliary stricture apart from other complications. We reviewed the medical records of 203 patients who underwent LDLT with duct to duct anastomosis from 2008 to 2010. The longitudinal changes of liver enzyme over time and the occurrence of complication were evaluated. A total of 124 patients had no complication up to 2 years after LDLT, and 74 patients had complications including biliary stricture and graft rejection. Complications developed more frequently in patients who's alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) did not return to the baseline plateau at 30 days after LDLT (ALP; P = .045, GGT; P = .047). Aspartate transaminase (AST) and alanine transaminase (ALT) increased continuously until the diagnosis of complication in both stricture and rejection groups with more rapid increase in enzymes in the rejection versus stricture group (P < .05). In addition, AST and ALT were 2-fold higher in the rejection than the stricture group at the diagnosis of each complication (AST; P < .05, ALT; P < .05). The increasing slope and final levels of AST and ALT are potentially helpful parameters to differentiate rejection and stricture, the 2 most common posttransplantation complications.
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Affiliation(s)
- Young Sik Woo
- Department of Interanl Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine
| | - Kwang Hyuck Lee
- Department of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | | | | | | | | | | | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine
- Departments of Epidemiology and Social, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
- Department of Epidemiology, Johns Hopkins Medical Institutions, Baltimore, USA
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31
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Ding Z, Tang XL, Lin R, Han C, Liu J. ERCP-related complication is not the only cause of GI bleeding in post-liver transplantation patients: A case report. Medicine (Baltimore) 2017; 96:e7716. [PMID: 28906357 PMCID: PMC5604626 DOI: 10.1097/md.0000000000007716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
RATIONALE Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for biliary complications in liver transplantation (LT) recipients as it is both diagnostic and therapeutic. The specific risks following ERCP among LT recipients have not been well studied. PATIENT CONCERNS A 56-year-old man with a history of orthotopic LT underwent endoscopic retrograde cholangiopancreatography (ERCP) as a treatment of biliary strictures, whereby a plastic stent was implanted. Thirteen days after ERCP the patient developed multiple episodes of hematemesis. DIAGNOSIS Digital subtraction angiography (DSA) of the hepatic artery and superior mesenteric artery showed a hepatic pseudoaneurysm (PA) in the left hepatic artery. The final diagnosis was bleeding from the PA. INTERVENTION Interventional embolization of the branch with PA was performed to stop the bleeding. OUTCOME The patient remained free of GI bleeding for 25 days after interventional embolization, but he developed another bout of bleeding and unfortunately passed away. LESSONS ERCP-related complication is not the only cause of post-ERCP bleeding, and that other primary causes should also be ruled out.
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32
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Management of biliary anastomotic strictures after liver transplantation. Transplant Rev (Orlando) 2017; 31:207-217. [DOI: 10.1016/j.trre.2017.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 02/06/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022]
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33
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Tsujino T, Isayama H, Kogure H, Sato T, Nakai Y, Koike K. Endoscopic management of biliary strictures after living donor liver transplantation. Clin J Gastroenterol 2017; 10:297-311. [PMID: 28600688 DOI: 10.1007/s12328-017-0754-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
Living donor liver transplantation (LDLT) is an effective alternative to deceased liver transplantation (DDLT) for end-stage liver disease. Although advances in surgical techniques, immunosuppressive management, and post-transplant care have improved the overall outcomes of LDLT, biliary strictures remain the major unsolved problem. Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered the first-line therapy for biliary strictures following LDLT with duct-to-duct reconstruction, with percutaneous and surgical interventions reserved for patients with unsuccessful management via ERCP. Endoscopic management of biliary strictures is technically more challenging in LDLT than in DDLT because of the complexity of the biliary anastomosis, in addition to the tortuous and angulated biliary system. Placement of one or more plastic stents after balloon dilation has been the standard strategy for post-LDLT stricture, but this requires multiple stent exchange to prevent stent occlusion until stricture resolution. Inside stents might prevent duodenobiliary reflux and thus have longer stent patency, obviating the need for multiple ERCPs. Newly developed covered self-expandable metallic stents with anti-migration systems are alternatives to the placement of multiple plastic stents. With the advent of deep enteroscopy, biliary strictures in LDLT patients with Roux-en-Y hepaticojejunostomy are now treatable endoscopically. In this review, we discuss the short- and long-term outcomes of endoscopic management of post-LDLT strictures as well as recent advances in this field.
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Affiliation(s)
- Takeshi Tsujino
- Miyuki Clinic, 1-8-3 Renko-ji, Tama, Tokyo, 2060021, Japan.
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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34
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Jang SI, Sung SY, Park H, Lee KH, Joo SM, Lee DK. Salvage therapy using self-expandable metal stents for recalcitrant anastomotic strictures after living-donor liver transplantation. Therap Adv Gastroenterol 2017; 10:297-309. [PMID: 28246547 PMCID: PMC5305021 DOI: 10.1177/1756283x16685059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Recently, there has been an increase in clinical success rates using nonsurgical methods to resolve anastomotic biliary strictures (ABSs) that develop after liver transplantation (LT). However, some strictures are particularly refractory and cannot be completely resolved by an endoscopic or percutaneous procedure. Consequently, the aim of this study was to examine the feasibility and efficacy of using a newly designed fully covered self-expandable metal stent (FCSEMS) to resolve refractory ABS. METHODS A total of 35 patients with an ABS that developed after LT, but could not be resolved by an endoscopic or percutaneous procedure, were included in this study. FCSEMSs were positioned endoscopically and removed after 2-3 months. After stent removal, the patients were followed to assess complications, including re-stenosis. RESULTS The mean period from LT to stricture was 13.7 months, and the mean duration of the stricture was 31.8 months. The type and mean number of procedures previously attempted were endoscopic retrograde cholangiopancreatography (ERCP) (9.1 ± 5.1) in 19 patients and percutaneous transhepatic biliary drainage (9.2 ± 4.8) in 16 patients. All patients had successful FCSEMS insertions and removals; the mean stent indwelling time was 3.2 months. The mean follow-up period was 18.7 months (range: 6.4-37.8 months). Stricture recurrence was observed in 6 of 29 patients (recurrence rate: 20.7%). The anastomotic stricture resolved with the FCSEMS insertion in 29 of 35 patients (clinical success rate: 82.9%). CONCLUSIONS The newly designed FCSEMS is a potentially feasible and effective treatment for anastomotic strictures that develop after LT but are not amenable to treatment by conventional procedures.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea Department of Medicine, The graduate school of Yonsei University, Seoul, South Korea
| | - Se Yong Sung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hun Lee
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung-Moon Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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35
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Aparício DPDS, Otoch JP, Montero EFDS, Khan MA, Artifon ELDA. Endoscopic approach for management of biliary strictures in liver transplant recipients: A systematic review and meta-analysis. United European Gastroenterol J 2016; 5:827-845. [PMID: 29026597 DOI: 10.1177/2050640616681909] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/25/2016] [Indexed: 12/14/2022] Open
Abstract
The most common biliary complication after liver transplantation is anastomotic stricture (AS) and it can occur isolated or in combination with other complications. Liver graft from a cadaveric donor or a living donor has an influence on the incidence of biliary strictures as well as on the response to endoscopic treatment. Endoscopic treatment using balloon dilation and insertion of biliary stents by endoscopic retrograde cholangiopancreatography (ERCP) is the initial approach to these complications. AIM The aim of this article is to compare different endoscopic techniques to treat post-liver transplantation biliary strictures. METHODS The search was carried out on MEDLINE, EMBASE, Scielo-LILACS and Cochrane Library databases through June 2015. A total of 1100 articles were retrieved. Ten clinical trials were analyzed, and seven were included in the meta-analysis. CONCLUSIONS The endoscopic treatment of AS was equally effective when compared the use of fully covered self-expandable metal stents (FCSEMS) vs. plastic stents, but the use of FCSEMS was associated with a lower complication risk. The treatment of AS with balloon dilation or balloon dilation associated with plastic stents presented similar results. Deceased donor liver transplantation reduced the risk of biliary stenosis and the endoscopic treatment in these patients was more effective when compared with Living donor liver transplantation.
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Affiliation(s)
| | | | | | - Muhammad Ali Khan
- Division of Gastroenterology, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN 38103, USA
| | - Everson Luiz de Almeida Artifon
- University of São Paulo, Pancreatic and Biliary Endoscopy Department/Hospital das Clínicas, University of São Paulo, SP, Brazil
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36
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Chok KSH, Lo CM. Systematic review and meta-analysis of studies of biliary reconstruction in adult living donor liver transplantation. ANZ J Surg 2016; 87:121-125. [PMID: 27862815 DOI: 10.1111/ans.13827] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/22/2016] [Accepted: 09/21/2016] [Indexed: 02/06/2023]
Affiliation(s)
| | - Chung Mau Lo
- Department of Surgery; The University of Hong Kong; Hong Kong China
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37
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Shin M, Joh JW. Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature. World J Gastroenterol 2016; 22:6173-6191. [PMID: 27468208 PMCID: PMC4945977 DOI: 10.3748/wjg.v22.i27.6173] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/25/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation (LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.
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38
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Biliary Anastomotic Stricture After Adult Living Donor Liver Transplantation With Duct-to-Duct Reconstruction. Transplantation 2016; 100:1500-6. [DOI: 10.1097/tp.0000000000001187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Lee ES, Han JK, Baek JH, Suh SW, Joo I, Yi NJ, Lee KW, Suh KS. Long-Term Efficacy of Percutaneous Internal Plastic Stent Placement for Non-anastomotic Biliary Stenosis After Liver Transplantation. Cardiovasc Intervent Radiol 2016; 39:909-15. [PMID: 26817760 DOI: 10.1007/s00270-016-1297-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/10/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE We aimed to evaluate the long-term efficacy of percutaneous management of non-anastomotic biliary stenosis after liver transplantation, using plastic internal biliary stents. MATERIALS AND METHODS This study included 35 cases (28 men, 7 women; mean age: 52.09 ± 8.13 years, range 34-68) in 33 patients who needed repeated interventional procedures because of biliary strictures. After classification of the biliary strictures, we inserted percutaneous biliary plastic stents through the T-tube or percutaneous transhepatic biliary drainage tracts. Stents were exchanged according to percutaneous methods at regular 2- to 6-month intervals. The stents were removed if the condition improved, as observed on cholangiogram as well as based on clinical findings. The median patient follow-up period after initial diagnosis and treatment was 6.04 years (range 0.29-9.95 years). We assessed treatment success rate and patient and graft survival times. RESULTS During the follow-up period, 14 patients (14/33, 42.42 %) were successfully treated and were tube-free. The median tube-free time, time without a stent, was 4.13 years (range 1.00-9.01). In contrast, internal plastic stents remained in 9 patients (9/33, 27.27 %) until the last follow-up. These patients had acceptable hepatic function. Among the remaining 10 patients, 3 (3/33, 9.09 %) were lost to regular follow-up and the other 7 (7/33, 21.21 %) patients died. The overall graft loss rate was 20.0 % (7/35). The median time from initial treatment to graft loss was 1.84 years (range 0.42-4.25). CONCLUSIONS Percutaneous plastic stents placement is technically feasible and clinically useful in patients with multiple biliary stenoses following liver transplantation.
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Affiliation(s)
- Eun Sun Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea.,Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea. .,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea. .,Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea.
| | - Ji-Hyun Baek
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea
| | - Suk-Won Suh
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 110-799, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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40
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Chang JH, Lee I, Choi MG, Han SW. Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 2016; 22:1593-1606. [PMID: 26819525 PMCID: PMC4721991 DOI: 10.3748/wjg.v22.i4.1593] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/02/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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41
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Ranjan P, Bansal RK, Mehta N, Lalwani S, Kumaran V, Sachdeva MK, Kumar M, Nundy S. Endoscopic management of post-liver transplant billiary complications: A prospective study from tertiary centre in India. Indian J Gastroenterol 2016; 35:48-54. [PMID: 26873087 DOI: 10.1007/s12664-016-0625-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/21/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplantation has become common in India over the last decade and biliary strictures after the procedure cause a significant morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective treatment modality for post-transplant biliary strictures so we decided to evaluate prospectively the outcomes of endoscopic treatment in post-living donor liver transplantation (LDLT) biliary strictures. METHODS We studied ten consecutive patients who had developed biliary strictures (out of 312 who had undergone liver transplantation between June 2009 and June 2013) and had been referred to the Department of Gastroenterology for management. All patients underwent liver function tests, ultrasound of the abdomen, magnetic resonance cholangiography and liver biopsy, if this was indicated. RESULTS Of these 312 patients who underwent liver transplantation, 305 had living donors (LDLT) and 7 deceased donors (DDLT). Ten patients in the LDLT group (3.3%) developed biliary strictures. There were seven males and three females who had median age of 52 years (range 4-60 years). The biliary anastomosis was duct-to-duct in all patients with one patient having an additional duct-to-jejunum anastomosis. The mode of presentation was cholangitis in four patients (40%), asymptomatic elevation of liver enzymes in four (40%) and jaundice in two patients (20%). The median time from transplantation to the detection of the stricture was 12 months (2-42.5 months). ERCP was attempted as initial therapy in all patients: seven were managed entirely by endoscopic therapy, and three required a combined percutaneous and endoscopic approach. Cholangiography demonstrated anastomotic stricture in all patients. A total of 32 sessions of ERCP were done with mean of 3.2 (2-5) endoscopic sessions and 3.4 (1-6) stents required to resolve the stricture. The median time from the first intervention to stricture resolution was 4 months (range 2-12 months). In four patients, the stents were removed after one session and in two patients each after two, three and four sessions. In six patients more than one stent was placed and all of them required dilatation of stricture. Seven patients completed treatment and are off stents at a median follow up period of 9.5 months (7-11 months). Two patients developed recurrence of their stricture after 7.5 months. Both had long strictures and required a combined endoscopic and percutaneous approach. There was one mortality due to sepsis secondary to cholangitis. CONCLUSIONS Post-LDLT biliary strictures can be successfully treated with ERCP, and most patients remain well on follow up (median 9.5 months). A combined endoscopic and percutaneous approach is useful when ERCP alone fails.
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Affiliation(s)
- Piyush Ranjan
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
| | - Rinkesh Kumar Bansal
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - S Lalwani
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - V Kumaran
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - M K Sachdeva
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - M Kumar
- Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - S Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
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42
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Kienlein S, Schoening W, Andert A, Kroy D, Neumann UP, Schmeding M. Biliary complications in liver transplantation: Impact of anastomotic technique and ischemic time on short- and long-term outcome. World J Transplant 2015; 5:300-309. [PMID: 26722658 PMCID: PMC4689941 DOI: 10.5500/wjt.v5.i4.300] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/29/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.
METHODS: We retrospectively reviewed 200 patients of our newly established liver transplantation (LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side (SS), end-to-end (EE) anastomosis or hepeaticojejunostomy (HJ). Biliary complications (BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion (ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography (ERCP)]. Laboratory results included alanine aminotransferase (ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional (e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC.
RESULTS: A total of 200 patients [age: 56 (19-72), alcoholic cirrhosis: n = 64 (32%), hepatocellular carcinoma: n = 40 (20%), acute liver failure: n = 23 (11.5%), cryptogenic cirrhosis: n = 22 (11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13 (6.5%), primary sclerosing cholangitis: n = 13 (6.5%), others: n = 25 (12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5% (n = 75) with anastomotic strictures (AS): n = 38 (19%), bile leak (BL): n = 12 (6%), biliary drain complication: n = 12 (6%); papillary stenosis (PS): n = 7 (3.5%), ITBL: n = 6 (3%). Clinically relevant were only 19% (n = 38). We established a comprehensive classification for AS with four grades according to clinical relevance. The reconstruction techniques [SS: n = 164, EE: n = 18, HJ: n = 18] showed no significant impact on the development of BCs in general (all n < 0.05), whereas in the HJ group significantly less AS were found (P = 0.031). The length of donor intensive care unit stay over 6 d had a significant influence on BC development (P = 0.007, HR = 2.85; 95%CI: 1.33-6.08) in the binary logistic regression model, whereas other reviewed variables had not [warm ischemic time > 45 min (P = 0.543), cold ischemic time > 10 h (P = 0.114), ALT init > 1500 U/L (P = 0.631), bilirubin init > 5 mg/dL (P = 0.595), donor age > 65 (P = 0.244), donor sex (P = 0.068), rescue organ (P = 0.971)]. 13% (n = 10) of BCs had no therapeutic consequences, 36% (n = 27) resulted in repeated lab control, 40% (n = 30) received ERCP and 11% (n = 8) surgical therapy. Fifteen (7.5%) patients developed cholangitis [AS (n = 6), ITBL (n = 5), PS (n = 3), biliary lesion BL (n = 1)]. One patient developed ITBL twelve months after LT and subsequently needed retransplantation. Rehospitalisation rate was 10.5 % (n= 21) [AS (n = 11), ITBL (n = 5), PS (n = 3), BL (n = 1)] with intervention or reinterventional therapy as main reasons. Retransplantation was performed in 5 (2.5%) patients [ITBL (n = 1), acute liver injury (ALI) by organ rejection (n = 3), ALI by occlusion of hepatic artery (n = 1)]. In total 21 (10.5%) patients died within the follow-up period. Out of these, one patient with AS developed severe fatal chologenic sepsis after ERCP.
CONCLUSION: In our data biliary reconstruction technique and ischemic times seem to have little impact on the development of BCs.
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Imamine R, Shibata T, Yabuta M, Shinozuka K, Kataoka M, Isoda H, Yoshizawa A, Uemoto S, Togashi K. Long-Term Outcome of Percutaneous Biliary Interventions for Biliary Anastomotic Stricture in Pediatric Patients after Living Donor Liver Transplantation with Roux-en-Y Hepaticojejunostomy. J Vasc Interv Radiol 2015; 26:1852-9. [DOI: 10.1016/j.jvir.2015.07.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 02/07/2023] Open
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Wan P, Xia Q, Zhang JJ, Li QG, Xu N, Zhang M, Chen XS, Han LZ. Bile duct kinking after adult living donor liver transplantation: Case reports and literature review. J Dig Dis 2015; 16:610-5. [PMID: 26031803 DOI: 10.1111/1751-2980.12263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Regeneration of the partial allograft and the growth of children may cause kinking of the biliary tract after pediatric living donor liver transplantation (LDLT), but bile duct kinking after adult LDLT is rarely reported. We herein presented two patients who suffered from anastomotic strictures caused by severe bile duct kinking after LDLT. The first patient was a 57-year-old woman with hepatitis B virus (HBV)-related liver cirrhosis, who developed biliary stricture 5 months after receiving right-lobe LDLT. Subsequently, endoscopic and percutaneous treatments were attempted, but both failed to solve the problem. The second was a 44-year-old woman also having HBV-related liver cirrhosis. Biliary stricture occurred 14 months after LDLT. Likewise, the guide wire failed to pass through the stricture when endoscopic interventions were conducted. Afterwards, both of the two cases underwent reexploration, showing that compensatory hypertrophy of the allografts resulted in kinking and sharp angulation of the bile ducts, and the anastomotic sites were found to be severely stenotic. Finally, re-anastomosis by Roux-en-Y procedure was successfully performed, and long-term stenosis-free survival was achieved in both of them. Our experience suggests that bile duct kinking after LDLT may play a role in the high incidence of anastomotic strictures in adult LDLT recipients, which may also result in the treatment failure of the non-surgical techniques for anastomotic strictures. Re-anastomosis in the form of Roux-en-Y hepaticojejunostomy is an effective surgical option for the treatment of such a condition.
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Affiliation(s)
- Ping Wan
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Jun Zhang
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Gen Li
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ning Xu
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming Zhang
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Song Chen
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Long Zhi Han
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Semenkov AV, Filin AV, Kim ÉF, Ushakova IA, Goncharova AV. [The results of biliary reconstructions after liver fragments transplantation]. Khirurgiia (Mosk) 2015:22-28. [PMID: 26356055 DOI: 10.17116/hirurgia2015822-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To analyze the results of repeated reconstructions of choleresis after living related liver fragments transplantation. MATERIAL AND METHODS The study included 268 recipients (145 women and 123 men) aged 5 months - 61 years (mean age 16,11 ± 14,62 years) who underwent liver fragments transplantation in the department of liver transplantation of cad. B.V. Petrovskiy Russian Research Surgery Center from 1997 to 2012. Biliary reconstructions were performed at different terms after transplantation in 37 patients (13.81%). Complications followed repeated reconstructions, the initial conditions for biliary anastomosis formation during transplantation, the results of biliary reconstructions after transplantation were analyzed. RESULTS In most cases despite the prevailing complications there is a combination of various biliary complications requiring biliary reconstruction. It was found that live rfragment used for transplantation, type of primary reconstruction of choler sis, number of bile ducts orifices of graft and biliary anastomoses do not demonstrate statistically significant effect on the incidence of post-transplant biliary reconstructions (p>0.05). Poor prognosis in patients with biliary complications required biliary reconstructionsis determined by the development of graft dysfunction. Early reconstruction before development of liver transplant dysfunction is necessary condition of successful treatment. In the case of graft dysfunction liver retransplantation is unique method of treatment.
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Affiliation(s)
- A V Semenkov
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - A V Filin
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - É F Kim
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - I A Ushakova
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
| | - A V Goncharova
- Acad. B.V. Petrovskiy Russian Research Centre of Surgery, Moscow, Russia
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Laurence JM, Sapisochin G, DeAngelis M, Seal JB, Miserachs MM, Marquez M, Zair M, Fecteau A, Jones N, Hrycko A, Avitzur Y, Ling SC, Ng V, Cattral M, Grant D, Kamath BM, Ghanekar A. Biliary complications in pediatric liver transplantation: Incidence and management over a decade. Liver Transpl 2015; 21:1082-90. [PMID: 25991054 DOI: 10.1002/lt.24180] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/03/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023]
Abstract
This study analyzed how features of a liver graft and the technique of biliary reconstruction interact to affect biliary complications in pediatric liver transplantation. A retrospective analysis was performed of data collected from 2001 to 2011 in a single high-volume North American pediatric transplant center. The study cohort comprised 173 pediatric recipients, 75 living donor (LD) and 98 deceased donor (DD) recipients. The median follow-up was 70 months. Twenty-nine (16.7%) patients suffered a biliary complication. The majority of leaks (9/12, 75.0%) and the majority of strictures (18/22, 81.8%) were anastomotic. There was no difference in the rate of biliary complications associated with DD (18.4%) and LD (14.7%) grafts (P = 0.55). Roux-en-Y (RY) reconstruction was associated with a significantly lower rate of biliary complications compared to duct-to-duct reconstruction (13.3% versus 28.2%, respectively; P = 0.048). RY anastomosis was the only significant factor protecting from biliary complications in our population (hazard ratio, 0.30; 95% confidence interval, 0.1-0.85). The leaks were managed primarily by relaparotomy (10/12, 83.3%), and the majority of strictures were managed by percutaneous biliary intervention (14/22, 63.6%). Patients suffering biliary complications had inferior graft survival (P = 0.04) at 1, 5, and 10 years compared to patients without biliary complications. Our analysis demonstrates a lower incidence of biliary complications with RY biliary reconstruction, and patients with biliary complications have decreased graft survival.
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Affiliation(s)
- Jerome M Laurence
- Liver Transplant Program.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Liver Transplant Program.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - John B Seal
- Liver Transplant Program.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Mar M Miserachs
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Max Marquez
- Liver Transplant Program.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Murtuza Zair
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Annie Fecteau
- Liver Transplant Program.,Divisions of General Surgery
| | - Nicola Jones
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Alexander Hrycko
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Simon C Ling
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Vicky Ng
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Mark Cattral
- Liver Transplant Program.,Divisions of General Surgery.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - David Grant
- Liver Transplant Program.,Divisions of General Surgery.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Binita M Kamath
- Liver Transplant Program.,Divisions of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Anand Ghanekar
- Liver Transplant Program.,Divisions of General Surgery.,Multi-Organ Transplant Program.,Division of General Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Macías-Gómez C, Dumonceau JM. Endoscopic management of biliary complications after liver transplantation: An evidence-based review. World J Gastrointest Endosc 2015; 7:606-616. [PMID: 26078829 PMCID: PMC4461935 DOI: 10.4253/wjge.v7.i6.606] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/21/2015] [Accepted: 03/18/2015] [Indexed: 02/05/2023] Open
Abstract
Biliary tract diseases are the most common complications following liver transplantation (LT) and usually include biliary leaks, strictures, and stone disease. Compared to deceased donor liver transplantation in adults, living donor liver transplantation is plagued by a higher rate of biliary complications. These may be promoted by multiple risk factors related to recipient, graft, operative factors and post-operative course. Magnetic resonance cholangiopancreatography is the first-choice examination when a biliary complication is suspected following LT, in order to diagnose and to plan the optimal therapy; its limitations include a low sensitivity for the detection of biliary sludge. For treating anastomotic strictures, balloon dilatation complemented with the temporary placement of multiple simultaneous plastic stents has become the standard of care and results in stricture resolution with no relapse in > 90% of cases. Temporary placement of fully covered self-expanding metal stents (FCSEMSs) has not been demonstrated to be superior (except in a pilot randomized controlled trial that used a special design of FCSEMSs), mostly because of the high migration rate of current FCSEMSs models. The endoscopic approach of non-anastomotic strictures is technically more difficult than that of anastomotic strictures due to the intrahepatic and/or hilar location of strictures, and the results are less satisfactory. For treating biliary leaks, biliary sphincterotomy and transpapillary stenting is the standard approach and results in leak resolution in more than 85% of patients. Deep enteroscopy is a rapidly evolving technique that has allowed successful treatment of patients who were not previously amenable to endoscopic therapy. As a result, the percutaneous and surgical approaches are currently required in a minority of patients.
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Choi Y, Lee KW, Kim H, Suh SW, Hong G, Lee HW, Yi NJ, Suh KS. Identification of a safe and adequate division point of the left-sided bile duct with magnetic resonance cholangiography during donor left lateral sectionectomy. Surgery 2015; 157:785-91. [DOI: 10.1016/j.surg.2014.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 10/05/2014] [Accepted: 11/17/2014] [Indexed: 01/28/2023]
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49
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Successful treatment of severe anastomotic stricture of a choledochojejunostomy after living donor liver transplantation with transhepatic cholangioscopy-guided balloon dilatation. Transplant Proc 2015; 46:999-1000. [PMID: 24767402 DOI: 10.1016/j.transproceed.2013.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 10/28/2013] [Indexed: 10/25/2022]
Abstract
Anastomotic stricture of the choledochojejunostomy is a common complication after living donor liver transplantation. Most anastomotic strictures can be treated by percutaneous transhepatic cholangiodrainage and/or double balloon endoscopy. However, in severe cases and/or in small infants, neither of these is possible. Our new technique, cholangiography accompanied by cholangioscopy, enabled successful guidewire placement and balloon dilatation in cases with severe anastomotic stricture.
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Fernández-Simon A, Díaz-Gonzalez A, Thuluvath PJ, Cárdenas A. Endoscopic retrograde cholangiography for biliary anastomotic strictures after liver transplantation. Clin Liver Dis 2014; 18:913-26. [PMID: 25438291 DOI: 10.1016/j.cld.2014.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biliary complications after liver transplantation (LT) are an important cause of morbidity and mortality. In most cases, an anastomosis of the bile duct is performed as a duct-to-duct reconstruction, which makes endoscopic therapy with endoscopic retrograde cholangiography (ERC) feasible. Biliary anastomotic strictures (AS) are the most common cause of biliary complications. The early detection of an AS, which can sometimes be challenging given that its clinical presentation is often subtle, is of key importance to obtain high treatment success. In this review, we focus on the management of AS after LT with a special emphasis on ERC.
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Affiliation(s)
- Alejandro Fernández-Simon
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Alvaro Díaz-Gonzalez
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain
| | - Paul J Thuluvath
- Medical Director, Institute for Digestive Health & Liver Disease, Mercy Medical Center, 301 Street, Paul Place, Baltimore, MD 21202, USA
| | - Andrés Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, University of Barcelona, Villarroel 170, Esc 3-2, Barcelona 08036, Spain.
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