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Yu SH, Jo HS, Yu YD, Park PJ, Han HJ, Kim SJ, Kamarulzaman SH, Kim DS. Impact of Baseline Anti-ABO Antibody Titer on Biliary Complications in ABO-Incompatible Living-Donor Liver Transplantation. J Clin Med 2024; 13:4789. [PMID: 39200931 PMCID: PMC11355316 DOI: 10.3390/jcm13164789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/24/2024] [Accepted: 08/08/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Although advancements in desensitization protocols have led to increased ABO-incompatible (ABOi) living-donor liver transplantation (LDLT), a higher biliary complication rate remains a problem. This study evaluated the effect of baseline anti-ABO antibody titers before desensitization on biliary complications after ABOi LDLT. Methods: The study cohort comprised 116 patients in the ABO-compatible group (ABOc), 29 in the ABOi with the low titer (<1:128) group (ABOi-L), and 14 in the high titer (≥1:128) group (ABOi-H). Results: Biliary complications occurred more frequently in the ABOi-H group than in the ABOi-L and ABOc groups (7 [50.0%] vs. 8 [27.6%] and 24 [20.7%], respectively, p = 0.041). Biliary complication-free survival was significantly worse in the ABOi-H group than in the other groups (p = 0.043). Diffuse intrahepatic biliary strictures occurred more frequently in the ABOi-H group than in the other groups (p = 0.005). Multivariable analysis revealed that the high anti-ABO antibody titer (≥1:128) is an independent risk factor for biliary complications (hazard ratio 3.943 [1.635-9.506]; p = 0.002). Conclusions: A high baseline anti-ABO antibody titer (≥1:128), female sex, and hepatic artery complications are significant risk factors for biliary complications.
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Affiliation(s)
- Se-Hyeon Yu
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (S.-H.Y.); (Y.-D.Y.); (D.-S.K.)
| | - Hye-Sung Jo
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (S.-H.Y.); (Y.-D.Y.); (D.-S.K.)
| | - Young-Dong Yu
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (S.-H.Y.); (Y.-D.Y.); (D.-S.K.)
| | - Pyoung-Jae Park
- Division of Transplantation and Vascular Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea;
| | - Hyung-Joon Han
- Division of Hepatobiliopancreas and Transplant Surgery, Korea University Ansan Hospital, Ansan-si 05505, Republic of Korea; (H.-J.H.); (S.-J.K.)
| | - Sang-Jin Kim
- Division of Hepatobiliopancreas and Transplant Surgery, Korea University Ansan Hospital, Ansan-si 05505, Republic of Korea; (H.-J.H.); (S.-J.K.)
| | - Syahrul Hadi Kamarulzaman
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (S.-H.Y.); (Y.-D.Y.); (D.-S.K.)
| | - Dong-Sik Kim
- Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (S.-H.Y.); (Y.-D.Y.); (D.-S.K.)
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Li Z, Rammohan A, Gunasekaran V, Hong S, Chih-Yi Chen I, Kim J, Hervera Marquez KA, Hsu SC, Kirimker EO, Akamatsu N, Shaked O, Finotti M, Yeow M, Genedy L, Dutkowski P, Nadalin S, Boehnert MU, Polak WG, Bonney GK, Mathur A, Samstein B, Emond JC, Testa G, Olthoff KM, Rosen CB, Heimbach JK, Taner T, Wong TC, Lo CM, Hasegawa K, Balci D, Cattral M, Sapisochin G, Selzner N, Jeng LB, Broering D, Joh JW, Chen CL, Suh KS, Rela M, Clavien PA. Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases. Am J Transplant 2024; 24:1233-1246. [PMID: 38428639 DOI: 10.1016/j.ajt.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.
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Affiliation(s)
- Zhihao Li
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland; Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Vasanthakumar Gunasekaran
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Suyoung Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Itsuko Chih-Yi Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Kris Ann Hervera Marquez
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Shih-Chao Hsu
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
| | | | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan
| | - Oren Shaked
- Division of Transplantation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michele Finotti
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Marcus Yeow
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore
| | - Lara Genedy
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Silvio Nadalin
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Markus U Boehnert
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Glenn K Bonney
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore
| | - Abhishek Mathur
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin Samstein
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Jean C Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Giuliano Testa
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Kim M Olthoff
- Division of Transplantation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles B Rosen
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie K Heimbach
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Timucin Taner
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiffany Cl Wong
- Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Chung-Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan
| | - Deniz Balci
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Mark Cattral
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Long-Bin Jeng
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
| | - Dieter Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Chao-Long Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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Cho SH, Lee HS, Huh G, Oh D, Song TJ, Seo DW, Lee SK. Long-term outcomes of fully covered self-expandable metal stents for refractory biliary strictures after living donor liver transplantation: a retrospective study at a tertiary center. Surg Endosc 2024; 38:3223-3230. [PMID: 38649493 DOI: 10.1007/s00464-024-10837-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Endoscopic multiple plastic stents are an established first-line treatment for anastomotic biliary stricture (ABS) management after liver transplantation (LT). Fully covered self-expandable metallic stents (FCSEMSs) have recently been used with favorable outcomes, but long-term treatment outcomes remain an issue for ABS. We evaluated the long-term outcomes of FCSEMS for the management of refractory ABS after LT. METHODS We reviewed the prospectively collected and maintained endoscopic retrograde cholangiography database at Asan Medical Center to retrieve consecutive post-LT ABS cases that underwent an endoscopic FCSEMS placement between August 2009 and August 2019 after MPS placement failure. RESULTS A total of 34 patients were enrolled in this study. Technical success had been achieved in all subjects (100%). The median stent placement duration was 3.1 months (IQR 2.7-6.1). Stricture resolution was achieved in 26 patients (clinical success 76.5%, 95% confidence interval 62-91). Early adverse events developed in 3 patients (8.8%), including distal stent migration. Late adverse events occurred in 9 patients (26.5%), including cholangitis (n = 7, 20.6%) and asymptomatic distal stent migration (n = 2, 5.9%). The median follow-up period was 57.9 months (IQR 51.9-64.3). Stricture recurrence occurred in 3 of 26 patients who achieved clinical success (11.5%). CONCLUSIONS FCSEMS placement appears to be an effective and advisable intervention for refractory ABS as it can provide persistent stricture improvement over the long-term.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho Seung Lee
- Department of Internal Medicine, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Gunn Huh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Bhatti ABH, Khan S, Farooq MH, Ishtiaq W, Khan NY. Liver transplantation with interposition saphenous vein conduits for arterial reconstruction: Impact of morbidity and arterial ischemia time. Surgery 2023; 174:1263-1269. [PMID: 37709647 DOI: 10.1016/j.surg.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/05/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The outcomes of liver transplantation with hepatic arterial reconstruction using interposition saphenous vein conduits are not widely reported. Here, we share our experience using great saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation. METHODS This was a single-center retrospective review of patients who underwent living donor liver transplantation (n = 950). The saphenous vein conduits were used in 39 patients. We compared hepatic artery thrombosis, graft dysfunction, and 30-day and 1-year survival in the early (2012-2017) and late (2017-2020) transplant periods. RESULTS Among 39 patients (of whom 30 [76.9%] were males, median Model for End-Stage Liver Disease was 24 [interquartile range, 17-27], median age was 50 [interquartile range, 43-54]), saphenous vein conduits were placed on supra celiac aorta in 7 (17.9%), infrarenal aorta in 25 (64.1%), and other arteries in 7 (17.9%) patients. The number of biliary and hepatic vein anastomoses, total arterial ischemia time, portal vein-hepatic artery reperfusion time, and duration of surgery was different in the 2 groups (P < .05). The 30-day mortality was 5/21 (23.8%) and 0 in the early and late periods (P = .05). The 30-day survival was >90% in patients with portal vein-hepatic artery reperfusion time <240 minutes, ≤2 grade 3 complications, no graft dysfunction, and later period of transplantation (P < .05). The 1-year survival with standard transplantation, transplantation with saphenous vein conduits in the early and late period was 87%, 62%, and 89% (P = .022). CONCLUSION Liver transplantation with saphenous vein conduits is associated with acceptable outcomes. Major complications and arterial ischemia times are major determinants of outcomes.
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Affiliation(s)
- Abu Bakar H Bhatti
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan; Shifa Tameer-e-Millat University, Islamabad, Pakistan.
| | - Siddique Khan
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Mohammad H Farooq
- Department of Anesthesiology, Shifa International Hospital, Islamabad, Pakistan
| | - Wasib Ishtiaq
- Department of Surgical Critical Care, Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Y Khan
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
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5
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Odenwald MA, Roth HF, Reticker A, Segovia M, Pillai A. Evolving challenges with long-term care of liver transplant recipients. Clin Transplant 2023; 37:e15085. [PMID: 37545440 DOI: 10.1111/ctr.15085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/08/2023]
Abstract
The number of liver transplants (LT) performed worldwide continues to rise, and LT recipients are living longer post-transplant. This has led to an increasing number of LT recipients requiring lifelong care. Optimal care post-LT requires careful attention to both the allograft and systemic issues that are more common after organ transplantation. Common causes of allograft dysfunction include rejection, biliary complications, and primary disease recurrence. While immunosuppression prevents rejection and reduces incidences of some primary disease recurrence, it has detrimental systemic effects. Most commonly, these include increased incidences of metabolic syndrome, various malignancies, and infections. Therefore, it is of utmost importance to optimize immunosuppression regimens to prevent allograft dysfunction while also decreasing the risk of systemic complications. Institutional protocols to screen for systemic disease and heightened clinical suspicion also play an important role in providing optimal long-term post-LT care. In this review, we discuss these common complications of LT as well as unique considerations when caring for LT recipients in the years after transplant.
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Affiliation(s)
- Matthew A Odenwald
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Hannah F Roth
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Anesia Reticker
- Department of Pharmacy, University of Chicago Medicine, Chicago, USA
| | - Maria Segovia
- Department of Medicine, Section of Gastroenterology, Duke University School of Medicine, Durham, USA
| | - Anjana Pillai
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
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Khan BA, Khalid A, Saeed Z, Ihsan-Ul-Haq, Khan MY, Rashid S, Naveed A, Dar FS. Exploring safety and efficacy of rivaroxaban after living donor liver transplantation: a retrospective study. Langenbecks Arch Surg 2023; 408:308. [PMID: 37578661 DOI: 10.1007/s00423-023-03042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Thromboembolic complications remain a significant concern in postoperative patients, particularly those who have undergone liver transplantation. Warfarin has been the standard oral anticoagulant. Direct oral anticoagulants (DOACs) have several advantages over warfarin, including rapid onset of action and standardized dose guidelines. We aimed to assess the safety of rivaroxaban in living donor liver transplantation (LDLT) recipients. METHODS This study was a single-center, retrospective descriptive analysis of LDLT recipients who received rivaroxaban between December 2020 and April 2022. A total of 27 recipients received rivaroxaban postoperatively. Liver function tests, immunosuppression levels, serum creatinine, and INR were recorded before the initiation of rivaroxaban and then on post-therapy days 1, 7, 14, 28, 90, and 180. RESULTS Among the 27 recipients receiving rivaroxaban postoperatively, portal venous thrombosis was the most prevalent indication for anticoagulation (44.4%), followed by Budd-Chiari syndrome (29.6%). Nine patients had a twofold increase in either ALT or AST values, two of whom were treated for biliary strictures and the others for rejection. Eighteen patients were given tacrolimus, and eight were on cyclosporine, with one patient switched from tacrolimus to cyclosporine due to insufficient therapeutic levels. There were no incidents of bleeding or re-thrombosis during the 180-day follow-up period. CONCLUSION Rivaroxaban may be a safe and effective alternative in LDLT recipients with no significant adverse incidents. Further studies with larger sample sizes are needed to confirm these findings and determine this population's optimal dose and duration of rivaroxaban therapy.
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Affiliation(s)
- Bilal Ahmed Khan
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan.
| | - Abdullah Khalid
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Zubair Saeed
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Ihsan-Ul-Haq
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Muhammad Yasir Khan
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Sohail Rashid
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Ammara Naveed
- Gastroenterology and Hepatology Department, PKLI&RC, Lahore, Pakistan
| | - Faisal Saud Dar
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
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Biliary Complications After Liver Transplantation in the United States: Changing Trends and Economic Implications. Transplantation 2023; 107:e127-e138. [PMID: 36928182 DOI: 10.1097/tp.0000000000004528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Biliary complications (BCs) continue to impact patient and graft survival after liver transplant (LT), despite improvements in organ preservation, surgical technique, and posttransplant care. Real-world evidence provides a national estimate of the incidence of BC after LT, implications for patient and graft outcomes, and attributable cost not available in transplant registry data. METHODS An administrative health claims-based BC identification algorithm was validated using electronic health records (N = 128) and then applied to nationally linked Medicare and transplant registry claims. RESULTS The real-world evidence algorithm identified 97% of BCs in the electronic health record review. Nationally, the incidence of BCs within 1 y of LT appears to have improved from 22.2% in 2002 to 20.8% in 2018. Factors associated with BCs include donor type (living versus deceased), recipient age, diagnosis, prior transplant, donor age, and donor cause of death. BCs increased the risk-adjusted hazard ratio (aHR) for posttransplant death (aHR, 1.43; P < 0.0001) and graft loss (aHR, 1.48; P < 0.0001). Nationally, BCs requiring intervention increased risk-adjusted first-year Medicare spending by $39 710 (P < 0.0001). CONCLUSIONS BCs remain an important cause of morbidity and expense after LT and would benefit from a systematic quality-improvement program.
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8
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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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9
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Sasaki K, Ota H, Miyagi S, Tokodai K, Fujio A, Kashiwadate T, Miyazawa K, Matsumura M, Saitoh Y, Kanai N, Nishimaki H, Takase K, Unno M, Kamei T. Novel technique for recanalization of severe hepaticojejunal obstruction using a transseptal needle in a pediatric liver transplant recipient. Pediatr Transplant 2022; 26:e14160. [PMID: 34633121 DOI: 10.1111/petr.14160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoscopic and PTB interventions are common nonsurgical interventions for biliary anastomotic strictures that occur after liver transplantation. When these nonsurgical interventions fail, surgical re-anastomosis is considered; however, this is quite invasive and can cause additional injury that may lead to graft loss. We report a case in which conventional nonsurgical interventions failed, but a new method that involve the use of a transseptal needle-a device to create a transseptal left-heart access during cardiac catheter interventions-was successfully used in recanalization of the hepaticojejunal anastomotic obstruction. CASE A 21-year-old man, who had received living-donor liver transplantation for biliary atresia at the age of 23 months presented with recurrent cholangitis and liver dysfunction due to a biliary anastomotic stricture of the hepaticojejunostomy. Therapeutic interventions for biliary stricture, including the PTB approach, double-balloon enteroscopic approach, and rendezvous approach failed. We then performed needle puncture of the anastomotic obstruction using a transseptal needle and succeeded in recanalizing the complete anastomotic obstruction. To perform the procedures safely, we evaluated the organ and needle positions using biplane fluoroscopy and placed a balloon in the afferent jejunal limb as a target for puncture. The 12 Fr catheter via the biliary route was removed 7 months after the procedure, without using a catheter, there was no recurrent stricture or cholangitis for 26 months. CONCLUSION Using a transseptal needle to manage hepaticojejunal anastomotic obstruction can reduce the number of patients who need surgical re-anastomosis.
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Affiliation(s)
- Kengo Sasaki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiaki Kashiwadate
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koji Miyazawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Muneyuki Matsumura
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikatsu Saitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Norifumi Kanai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyasu Nishimaki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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10
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Heinemann M, Liwinski T, Adam R, Berenguer M, Mirza D, Malek-Hosseini SA, Heneghan MA, Lodge P, Pratschke J, Boudjema K, Paul A, Zieniewicz K, Fronek J, Mehrabi A, Acarli K, Tokat Y, Coker A, Yilmaz S, Karam V, Duvoux C, Lohse AW, Schramm C. Long-term outcome after living donor liver transplantation compared to donation after brain death in autoimmune liver diseases: Experience from the European Liver Transplant Registry. Am J Transplant 2022; 22:626-633. [PMID: 34605157 DOI: 10.1111/ajt.16864] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/22/2021] [Accepted: 09/20/2021] [Indexed: 01/25/2023]
Abstract
Knowledge of living donor liver transplantation (LDLT) for autoimmune liver diseases (AILDs) is scarce. This study analyzed survival in LDLT recipients registered in the European Liver Transplant Registry with autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis (PSC) and the non-autoimmune disorder alcohol-related cirrhosis. In total, 29 902 individuals enrolled between 1998 and 2017 were analyzed, including 1003 with LDLT. Survival from >90 days after LDLT for AILDs in adults was 85.5%, 74.2%, and 58.0% after 5, 10, and 15 years. Adjusted for recipient age, sex, and liver transplantation era, adult PSC patients receiving LDLT showed increased mortality compared to donation after brain death (DBD) (hazard ratio [HR] = 1.95, 95% confidence interval [CI] = 1.36-2.80, p < .001). Pediatric PSC patients showed also increased mortality >90 days after LDLT compared to DBD (HR = 3.00, 95% CI 1.04-8.70, p = .043). Multivariate analysis identified several risk factors for death in adult PSC patients receiving LDLT including a male donor (HR = 2.49, p = .025). Adult PSC patients with LDLT versus DBD conferred increased mortality from disease recurrence (subdistribution hazard ratio [subHR] = 5.36, p = .001) and biliary complications (subHR = 4.40, p = .006) in multivariate analysis. While long-term outcome following LDLT for AILD is generally favorable, PSC patients with LDLT compared to DBD might be at increased risk of death.
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Affiliation(s)
- Melina Heinemann
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timur Liwinski
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany
| | - Rene Adam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Villejuif, France
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Valencia, Valencia, Spain
| | - Darius Mirza
- Department of HPB Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Seyed Ali Malek-Hosseini
- Avicenna Center for Medicine and Organ Transplant, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Michael A Heneghan
- King's Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Peter Lodge
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Pontchaillou University Hospital, Rennes, France
| | - Andreas Paul
- Department of Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Koray Acarli
- Organ Transplantation Center, Memorial Hospital, Istanbul, Turkey
| | - Yaman Tokat
- Liver Transplantation Center, Florence Nightingale Hospital, Istanbul, Turkey
| | - Ahmet Coker
- Department of General Surgery, Ege University Medical School, Izmir, Turkey
| | - Sezai Yilmaz
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Vincent Karam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Villejuif, France
| | - Christophe Duvoux
- Department of Hepatology and Gastroenterology, University Hospital of Henri-Mondor, Creteil, France
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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11
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Lee AY, Lehrman ED, Perito ER, Kerlan RK, Kohi MP, Kolli KP, Taylor AG, Ostroff JW, Kang SM, Roberts JP, Rhee S, Rosenthal P, Fidelman N. Non-operative management of biliary complications after Liver Transplantation in pediatric patients: A 30-year experience. Pediatr Transplant 2021; 25:e14028. [PMID: 33951255 DOI: 10.1111/petr.14028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 01/05/2021] [Accepted: 02/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate the efficacy of percutaneous and endoscopic therapeutic interventions for biliary strictures and leaks following LT in children. METHODS Retrospective analysis of 49 consecutive pediatric liver transplant recipients (27 girls, 22 boys, mean age at transplant 3.9 years) treated at our institution from 1989 to 2019 for biliary leak and/or biliary stricture was performed. Minimally invasive approach was considered clinically successful if it resulted in patency of the narrowed biliary segment and/or correction of the biliary leak. RESULTS Forty-two patients had a stricture at the biliary anastomosis; seven had a biliary leak. After an average 13.8 years of follow-up, long-term clinical success with minimally invasive treatment (no surgery or re-transplant) was achieved for 24 children (57%) with biliary stricture and 4 (57%) with biliary leaks. Eight patients required re-transplant; however, only one was due to failure of both percutaneous and surgical management. For biliary strictures, failure of non-surgical management was associated with younger age at stricture diagnosis (p < .02). CONCLUSIONS Percutaneous and endoscopic management of biliary strictures and leaks after LT in children is associated with a durable result in >50% of children.
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Affiliation(s)
- Andrew Y Lee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Evan D Lehrman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Emily R Perito
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Robert K Kerlan
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Kanti P Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - James W Ostroff
- Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Sang-Mo Kang
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - John P Roberts
- Department of Surgery, Division of Transplant Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sue Rhee
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, University of California San Francisco, San Francisco, CA, USA
| | - Nicholas Fidelman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
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12
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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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13
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Puri Y, Rammohan A, Marcos A, Rela PM. Objective method for selective reconstruction of multiple graft arteries to potentially reduce biliary complications. Langenbecks Arch Surg 2021; 406:2149-2150. [PMID: 34324061 DOI: 10.1007/s00423-021-02281-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Yogesh Puri
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, No.07 CLC Works Road, Chromepet, Chennai, 600044, India.
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, No.07 CLC Works Road, Chromepet, Chennai, 600044, India
| | - Amadeo Marcos
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, No.07 CLC Works Road, Chromepet, Chennai, 600044, India
| | - Prof Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, No.07 CLC Works Road, Chromepet, Chennai, 600044, India
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14
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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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15
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Pamecha V, Sasturkar SV, Sinha PK, Mohapatra N, Patil N. Biliary Reconstruction in Adult Living Donor Liver Transplantation: The All-Knots-Outside Technique. Liver Transpl 2021; 27:525-535. [PMID: 37160038 DOI: 10.1002/lt.25862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/15/2020] [Accepted: 07/29/2020] [Indexed: 12/20/2022]
Abstract
Biliary complications (BCs) following living donor liver transplantation (LDLT) can lead to significant morbidity and occasional mortality. The present study describes our experience of the all-knots-outside technique (AKOT) of biliary reconstruction (BR) and its impact on BCs. A retrospective analysis was performed using prospectively collected data of 330 consecutive adult patients undergoing LDLT from July 2011 to February 2018 with a minimal follow-up of 24 months. Only 2.8% required hepaticojejunostomy and were excluded. In an initial 122 patients, BR was performed with the standard technique (ST), and AKOT was performed in the subsequent 208 patients. In the AKOT group, a single anastomosis was attempted even for multiple ducts whenever feasible. A major BC was defined as requiring endoscopic, percutaneous, or surgical interventions. In the AKOT group, significantly more patients received a left lobe graft (5.7% versus 18.3%; P = 0.001), had shorter warm ischemia time (44.6 versus 27 minutes; P < 0.001), and had a left hepatic artery (LHA) in the right lobe that was used for arterial reconstruction (48 [39.3%] versus 122 [58.6%]; P = 0.003). The incidence of BCs in the entire cohort was 47 (14.2%). For the ST versus AKOT groups, the overall BCs (27/122 [22.1%] versus 20/208 [9.6%]; P = 0.003) and major BCs (20.5% versus 6.7%; P < 0.001) decreased significantly. In the multivariate analysis, the number of bile ducts (hazard ratio [HR], 4.18; 95% confidence interval [CI], 1.62-10.78; P = 0.003), number of anastomoses (HR, 2.03; 95% CI, 1.03-4.02; P = 0.04), and technique of anastomosis (HR, 0.36; 95% CI, 0.19-0.68; P = 0.002) predicted BCs. In conclusion, in adult LDLT, with standardization of the donor and recipient surgery, preferential use of LHA for right lobe arterial reconstruction, reduction in the number of anastomoses, and AKOT for BR significantly decreased the incidence of BCs.
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Affiliation(s)
- Viniyendra Pamecha
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shridhar Vasantrao Sasturkar
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Kumar Sinha
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nihar Mohapatra
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nilesh Patil
- Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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16
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Kang E, Suh SW, Lee SE, Choi YS, Choi SH, Lee BR, Choi Y, Jeong J. Differences in Bile Microbiology and Antibiotic Resistances between Liver Transplant Recipients and Non-Transplant Patients. Surg Infect (Larchmt) 2021; 22:741-751. [PMID: 33533687 DOI: 10.1089/sur.2020.358] [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] [Indexed: 12/07/2022] Open
Abstract
Background: Treatment of biliary infection in liver transplant (LT) recipients is a challenge, especially because of ineffectiveness of the antibiotic agents otherwise recommended for non-transplant populations. We aimed to understand the factors underlying the choice of antibiotic therapy. Patients and Methods: A total of 373 bile cultures from LT recipients with biliary complications (n = 127; LT group) and from a non-transplant population that underwent cholecystectomy for acute cholecystitis (n = 246; non-transplant group) between January 2009 and December 2018, were investigated. Results: Polymicrobial cultures (13.4% vs. 1.6%; p < 0.001), Enterococcus faecium (26.0% vs. 8.5%; p < 0.001), and Pseudomonas (13.4% vs. 4.1%; p = 0.001) in the LT group, and non-faecium enterococci (3.9% vs. 18.3%; p < 0.001) and Enterobacteriales (40.2% vs. 54.9%; p = 0.007), especially Escherichia (11.0% vs. 29.7%; p < 0.001), in the non-transplant group, showed higher abundance. Most of the antibiotic agents recommended as initial antibiotic therapy for the non-transplant population as per previous guidelines were not effective in LT recipients. The incidences of Enterococcus faecium (14.9% vs. 32.5%; p = 0.029) in the LT recipients with model for end-stage liver disease (MELD) score >12 and non-faecium enterococci (8.5% vs. 1.3%; p = 0.042) in those with MELD score ≤12 were higher than those in the other group. The incidence of Enterobacteriales increased over time after LT (p = 0.048) and was similar to that in the non-transplant group after one year of LT. Bile micro-organisms in LT recipients, resistant to most antibiotic agents, especially soon after LT changed over time and became similar to those in the non-transplant group after one year of LT. Conclusions: Antibiotic therapy for biliary infection in LT recipients should be different from that in non-transplant populations, considering clinical factors such as the time interval after LT and MELD score.
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Affiliation(s)
- Eunhye Kang
- Department of Surgery, College of Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Suk-Won Suh
- Department of Surgery, College of Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seung Eun Lee
- Department of Surgery, College of Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yoo Shin Choi
- Department of Surgery, College of Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seong-Ho Choi
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Bo-Ram Lee
- Department of Surgery, College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | - YoungRok Choi
- Department of Surgery, College of Medicine, Seoul National University, Seoul, Korea
| | - Jaehong Jeong
- Department of Surgery, College of Medicine, Soonchunhyang University, Seoul, Korea
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17
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Kilic M, Karaca CA, Yilmaz C, Farajov R, Iakobadze Z, Kilic K, Aydogdu S. Bilioenteric Reconstruction Techniques in Pediatric Living Donor Liver Transplantation. Liver Transpl 2021; 27:257-263. [PMID: 37160015 DOI: 10.1002/lt.25845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/16/2020] [Accepted: 07/01/2020] [Indexed: 01/13/2023]
Abstract
Biliary complications (BCs) are still a major cause of morbidity following liver transplantation despite the advancements in the surgical technique. Although Roux-en-Y (RY) hepaticojejunostomy has been the standard technique for years in pediatric patients, there is a limited number of reports on the feasibility of duct-to-duct (DD) anastomosis, and those reports have controversial outcomes. With the largest number of patients ever reported on the topic, this study aims to discuss the feasibility of the DD biliary reconstruction technique in pediatric living donor liver transplantation (LDLT). After the exclusion of the patients with biliary atresia, patients who received either deceased donor or right lobe grafts, and retransplantation patients, data from 154 pediatric LDLTs were retrospectively analyzed. Patients were grouped according to the applied biliary reconstruction technique, and the groups were compared using BCs as the outcome. The overall BC rate was 13% (n = 20), and the groups showed no significant difference (P = 0.6). Stricture was more frequent in the DD reconstruction group; however, this was not statistically significant (P = 0.6). The rate of bile leak was also similar in both groups (P = 0.6). The results show that the DD reconstruction technique can achieve similar outcomes when compared with RY anastomosis. Because DD reconstruction is a more physiological way of establishing bilioenteric integrity, it can safely be applied.
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Affiliation(s)
- Murat Kilic
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Can A Karaca
- Faculty of Medicine, Izmir University of Economics, Izmir, Turkey
| | - Cahit Yilmaz
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Rasim Farajov
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Zaza Iakobadze
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Kamil Kilic
- Department of Liver Transplantation, Izmir Kent Hospital, Izmir, Turkey
| | - Sema Aydogdu
- Department of Pediatric Gastroenterology, Ege University Faculty of Medicine, Izmir, Turkey
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18
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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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19
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Gupta S, Kandagaddala R, Agarwal S, Dey R, Naganathan S, Varshney P, Patil N. Cystic duct patch closure of remnant bile duct in living donor hepatectomy when primary closure is difficult: An easy solution. Ann Hepatobiliary Pancreat Surg 2020; 24:513-517. [PMID: 33234755 PMCID: PMC7691210 DOI: 10.14701/ahbps.2020.24.4.513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 11/25/2022] Open
Abstract
Backgrounds/Aims In living donor hepatectomy, hepatic duct division is a crucial step and often a technical challenge, with the aim of obtaining a good hepatic duct for anastomosis in the recipient and an adequate stump in the donor for closure. Very rarely, after duct division, the remaining stump may not be adequate for primary closure. In such a difficult situation, the options would be either to close stump transversely or a Roux-en-Y Hepaticojejunostomy. Methods We describe a novel surgical technique of “Cystic duct patch repair”, utilizing the available local tissues for closure of bile duct wall. Results Two year follow up of this technique showed satisfactory results with no evidence of stricture and normal liver functions. Conclusions In living donor hepatectomy, “Cystic duct patch closure” may be used if the post closure cholangiogram is not satisfactory. Although the best method is prevention by ensuring a stump for closure, very rarely this error can occur and can be sorted by cystic duct patch repair.
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Affiliation(s)
- Subash Gupta
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Rajasekhar Kandagaddala
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shaleen Agarwal
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Rajesh Dey
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Selvakumar Naganathan
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Peeyush Varshney
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Nilesh Patil
- Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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20
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Erdoğan MA, Çağın YF, Atayan Y, Bilgiç Y, Yıldırım O, Çalışkan AR, Aladağ M, Karıncaoğlu M, Yılmaz S, Harputluoğlu MM. Endoscopic treatment of biliary complications in donors after living donor liver transplantation in a high volume transplant center. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:614-619. [PMID: 33090097 DOI: 10.5152/tjg.2020.18759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS Although living donor liver transplantation (LDLT) has been accepted as a primary treatment for adults with end-stage liver disease, concerns about donor health have been emerged. As LDLT is technically complex, it creates perioperative morbidity and mortality risk in donors. Biliary complications such as stricture and leakage are seen most frequently in donors after liver transplantation. While some of these complications get treated with conservative approach, endoscopic, surgical, and percutaneous interventions may be required in some others. We aimed to present endoscopic retrograde cholangiography (ERC) results in donors who developed biliary complications after LDLT. MATERIALS AND METHODS Between June 2010 and January 2018, a total of 1521 donors (1291 right lobe grafts, 230 left lobe grafts) of patients who underwent LDLT, were retrospectively reviewed. 63 donors who underwent ERC due to biliary complication, were included in the study. RESULTS Biliary stricture was found in 1.6% (25/1521), biliary leakage in 2.1% (33/1521), and stricture and leakage together in 0.3% (5/1521) donors. Our endoscopic success rates in patients with biliary leakage, biliary stricture, and stricture and leakage were 85% (28/33), 92% (23/25), and 80% (4/5), respectively. Surgical treatment was performed on 12.6% (8/63) donors who failed ERC. CONCLUSION We found that ERC is a successful treatment for post-LDLT donors who have biliary complications.
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Affiliation(s)
- Mehmet Ali Erdoğan
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Yasir Furkan Çağın
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Yahya Atayan
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Yılmaz Bilgiç
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Oğuzhan Yıldırım
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Ali Riza Çalışkan
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Murat Aladağ
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Melih Karıncaoğlu
- Department of Gastroenterology, İnönü University School of Medicine, Malatya, Turkey
| | - Sezai Yılmaz
- Department of Surgery and Liver Transplant Institute, İnönü University School of Medicine, Malatya, Turkey
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21
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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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22
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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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23
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Abstract
PURPOSE OF REVIEW As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage. RECENT FINDINGS Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases. SUMMARY LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.
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24
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Peregrin JH, Kováč J, Prchlík M, Heinige P, Kotanová R, Froňek J, Novotný R, Kočík M, Janoušek L. Interventional Radiological Treatment of Paediatric Liver Transplantation Complications. Cardiovasc Intervent Radiol 2020; 43:765-774. [DOI: 10.1007/s00270-020-02430-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/30/2020] [Indexed: 12/20/2022]
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25
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Hara T, Soyama A, Adachi T, Kobayashi S, Sakai Y, Maruya Y, Kugiyama T, Hidaka M, Okada S, Hamada T, Maekawa K, Ono S, Adachi T, Takatsuki M, Eguchi S. Ameliorated healing of biliary anastomosis by autologous adipose-derived stem cell sheets. Regen Ther 2020; 14:79-86. [PMID: 31988997 PMCID: PMC6970135 DOI: 10.1016/j.reth.2019.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/10/2019] [Accepted: 11/12/2019] [Indexed: 12/13/2022] Open
Abstract
Introduction Cell sheets consisting of adipose-derived stem cells (ADSCs) have been reported to be effective for wound healing. We conducted this study to clarify the efficacy of ADSC sheets in wound healing at the duct-to-duct biliary anastomotic site in pigs. Methods Eleven female pigs (20–25 kg) were divided into two groups: biliary anastomosis with an ADSC sheet (n = 6) or without an ADSC sheet (n = 5). To follow the transplanted ADSCs, PKH26GL-labeled sheets were used in one of the ADSC pigs. Two weeks prior to laparotomy, ADSCs were isolated from the lower abdominal subcutaneous adipose tissue. After three passages, ADSCs were seeded on temperature-responsive culture dishes and collected as cell sheets. ADSC sheets were gently transplanted on the anastomotic site. We evaluated specimens by PKH26GL labeling, macroscopic changes, infiltration of inflammatory cells, and collagen content. Results Labeled ADSCs remained around the bile duct wall. In the no-ADSC group, more adhesion developed at the hepatic hilum as observed during relaparotomy. Histopathological examination showed that the diameter and cross-sectional area of the bile duct wall were decreased in the ADSC group. In the no-ADSC group, a large number of inflammatory cells and more collagen fibers were identified in the bile duct wall. Conclusions The present study demonstrated that autologous ADSC sheet transplantation reduced hypertrophic changes in the bile duct wall at the anastomotic site. A long-term follow-up is required to evaluate the efficacy of this mechanism in prevention of biliary anastomotic strictures. The first study to show the effect of ADSCs on healing of biliary anastomosis. Hypertrophic change in bile duct wall was observed at biliary anastomotic site. Autologous ADSC transplantation reduced the hypertrophic change. The presence of transplanted ADSC was confirmed by PKH26GL-positive ADSCs.
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Key Words
- ADSC, adipose-derived stem cell
- APC, allophycocyanin
- Adipose-derived stem cell
- Anastomotic healing
- BAS, biliary anastomotic strictures
- BMSC, bone marrow stem cells
- Biliary anastomosis
- CBD, common bile duct
- Cell sheet
- FBS, fetal bovine serum
- FGF, fibroblast growth factor
- HGF, hepatocyte growth factor
- MSC, mesenchymal stem cell
- VEGF, vascular endothelial growth factor
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Affiliation(s)
- Takanobu Hara
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Toshiyuki Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Shinichiro Kobayashi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yusuke Sakai
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yasuhiro Maruya
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Tota Kugiyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Satomi Okada
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Takashi Hamada
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Kyoichiro Maekawa
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Shinichiro Ono
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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26
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Santeusanio AD, Weinberg AD, Florman SS, Schiano TD. Safety of direct-acting oral anticoagulants relative to warfarin in a matched cohort of liver transplant recipients. Clin Transplant 2019; 34:e13756. [PMID: 31738454 DOI: 10.1111/ctr.13756] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/23/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023]
Abstract
Despite increasingly widespread utilization of direct-acting oral anticoagulants (DOACs), there remains limited experience with the use of these agents following liver transplantation. We performed a single-center, retrospective review of liver transplant recipients prescribed DOACs or warfarin between January 2014 and January 2018. Patients receiving DOACs were matched with warfarin-treated controls based on discrete clinical parameters and followed from the time of anticoagulant prescription, until treatment discontinuation or study conclusion. The primary endpoint for this review was the incidence of clinically relevant major or non-major bleeding among the treatment groups. Twenty-seven patients prescribed DOACs were identified for inclusion in the review, of which 20 could be matched with suitable warfarin controls. At the conclusion of the study, warfarin-treated patients had a significantly higher incidence of clinically relevant bleeding (45% vs 15%; P = .01). No statistically significant differences were found in the rate of new or recurrent thrombotic events. Multivariable logistic regression demonstrated that warfarin treatment was associated with a significantly higher odds of a bleeding event compared to treatment with a DOAC (OR = 6.9; 95% CI, 1.1-44.6). DOAC use appears relatively safe compared with warfarin in select liver transplant recipients. Patient-specific factors still bear consideration when selecting between the various anticoagulant options.
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Affiliation(s)
- Andrew D Santeusanio
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA.,Department of Pharmacy, Mount Sinai Hospital, New York, NY, USA
| | - Alan D Weinberg
- Department of Population Health Science and Policy, Mount Sinai Hospital, New York, NY, USA
| | - Sander S Florman
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
| | - Thomas D Schiano
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, NY, USA
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27
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Biliary Complications Following Pediatric Living Donor Liver Transplantation: Risk Factors, Treatments, and Prognosis. Transplantation 2019; 103:1863-1870. [DOI: 10.1097/tp.0000000000002572] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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28
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Warner B, Joshi D, Heneghan M, Srinivasan P, Prachalias A, Harrison P. Intraductal deployment of two fully covered metallic stents for anastomotic strictures following living donor liver transplantation. Clin Res Hepatol Gastroenterol 2019; 43:e45-e47. [PMID: 30709757 DOI: 10.1016/j.clinre.2018.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/19/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Ben Warner
- Institute of Liver Studies, King's College Hospital, London, UK.
| | - Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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29
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Endoscopic treatment of biliary complications after duct-to-duct biliary anastomosis in pediatric liver transplantation. Langenbecks Arch Surg 2019; 404:875-883. [DOI: 10.1007/s00423-019-01804-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
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30
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Maggi U, Chierici A, Bianchi E, Fabbi M, Iavarone M, Conte D, Cantù P, Paone G, Colozzi S, Rossi G. Biliary Stones After Brain Dead Liver Transplantation Today: Rates, Risk Factors, Treatments, and Outcomes. Transplant Proc 2019; 51:1939-1945. [PMID: 31303414 DOI: 10.1016/j.transproceed.2019.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 01/29/2019] [Accepted: 03/13/2019] [Indexed: 02/07/2023]
Abstract
AIMS Our aim was to review the rate of biliary duct stones (BDS) after liver transplantation (LT), risk factors, and treatments, and to identify predictive factors for their onset. METHODS LTs performed in our center from 2004 to 2014 were studied. Risk factors for the onset of BDS were identified using univariable Cox's proportional hazards models. RESULTS Three hundred and sixty-four grafts with 317 duct-to-duct end-to-end biliary anastomosis on a T-tube and 47 hepaticojejunal anastomosis (HJ) were analyzed. BDS were identified in 13 of 364 (3.5%) grafts, including 10 duct-to-duct end-to-end biliary anastomosis on a T-tube grafts (3.2%) and 3 HJ grafts (6.4%). Predictive factors for BDS were biliary strictures (hazard ratio [HR] 9.94; 95% confidence interval [95% CI] 3.25-30.4), bilirubin (HR 1.04; 95% CI 1.01-1.06, for 1 unit increase), Model for End-Stage Liver Disease score (HR 1.07; 95% CI 1.01-1.14, for 1 unit increase), surgery time (HR 1.04; 95% CI 1.01-1.08, for 10-minute increase), hepatocellular disease (HR 8.3; 95% CI 1.09-64.0), hepatic artery thrombosis (HR 6.71; 95% CI 1.47-30.6), and retransplantation (HR 3.69; 95% CI 1.02-13.43). Among 51 grafts (14%) with biliary strictures, female sex was identified as a risk factor for BDS (HR 5.19; 95% CI 1.29-20.98). Multimodality treatment of BDS was often successful but open surgery was still needed in 23% of them. One-, 5-, and 10-year graft survival was not influenced by the onset of BDS. CONCLUSION Main predictive factor for BDS in liver grafts is biliary stricture. Recipient's age and body mass index failed to show any statistical importance. In grafts with biliary strictures, female sex is the main risk factor for BDS. In the absence of biliary strictures, hepatic artery thrombosis lead to an increase in the risk of BDS. Multimodality treatment of BDS is often successful. BDS do not influence outcome.
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Affiliation(s)
- Umberto Maggi
- Hepatobiliary and Liver Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy.
| | - Andrea Chierici
- Hepatobiliary and Liver Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Elisa Bianchi
- North Italy Transplantation program (NITp), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Manrica Fabbi
- Hepatobiliary and Liver Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Massimo Iavarone
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Paolo Cantù
- Gastroenterology and Endoscopy Unit, Department of Pathophysiology and Transplantation, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Paone
- Hepatobiliary and Liver Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Sara Colozzi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgio Rossi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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31
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Sanada Y, Katano T, Hirata Y, Yamada N, Okada N, Onishi Y, Yasuda Y, Mizuta K. Long‐term outcome of percutaneous transhepatic biliary drainage for biliary strictures following pediatric liver transplantation. Clin Transplant 2019; 33:e13570. [DOI: 10.1111/ctr.13570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 03/21/2019] [Accepted: 04/11/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Takumi Katano
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Yuta Hirata
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Naoya Yamada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Noriki Okada
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | - Yasuharu Onishi
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
| | | | - Koichi Mizuta
- Department of Transplant Surgery Jichi Medical University Shimotsuke Japan
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32
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Spaggiari M, Mashbari H, Di Bella C, Benedetti E, Tzvetanov I. Portojejunostomy in Split Liver Transplantation as a Rescue Technique for Challenging Biliary Reconstruction: A Case Report. Transplant Proc 2019; 51:575-578. [PMID: 30879593 DOI: 10.1016/j.transproceed.2018.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 11/29/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
Cadaveric split liver transplantation (SLT) is a valid option to increase the pool of cadaveric organs, obtaining 2 functioning grafts from a single donor. Typically, SLT is performed for 1 adult and 1 pediatric recipient. However, on the heels of great results achieved in living donor liver transplantation, splitting cadaveric liver into full right graft and full left graft for 2 adults has become a feasible idea. The rate of biliary complications remains the "Achilles heel" in partial graft liver transplantation, either from cadaveric or living donors. In cases of biliary complications, interventional radiology and/or endoscopic procedures are the cornerstone of management. Surgical revision is left as the last option. When surgical revision fails, retransplantation becomes the only rescue option. Herein we describe the case of a cadaveric SLT, complicated by biliary leakage in the presence of multiple bile ducts. A duct-to-duct anastomosis was not feasible. Therefore, a hepaticojejunostomy was performed and resulted in a high-output biliary leak from different sources. Given the anatomy of the biliary tree, radiologic interventional measures were not feasible to address the leak. The idea of performing a portoenterostomy to restore bilioenteric continuity proved to be successful. Portoenterostomy should not be performed in lieu of other alternatives, but rather as the last option to avoid retransplantation in cases of complicated biliary reconstruction after partial graft liver transplant.
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Affiliation(s)
- M Spaggiari
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - H Mashbari
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
| | - C Di Bella
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
| | - E Benedetti
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
| | - I Tzvetanov
- Division of Transplantation, General Surgery Department, University of Illinois at Chicago, Chicago, Illinois, USA
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33
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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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Czubkowski P, Markiewicz-Kijewska M, Janiszewski K, Rurarz M, Kaliciński P, Jarzębicka D, Pertkiewicz J, Kamińska D, Jankowska I, Teisseyre M, Szymczak M, Pawłowska J. Percutaneous Treatment of Biliary Strictures After Pediatric Liver Transplantation. Ann Transplant 2018; 23:845-851. [PMID: 30531688 PMCID: PMC6299781 DOI: 10.12659/aot.910528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Biliary strictures (BS) are frequent after pediatric liver transplantation (LTx) and in spite of ongoing progress, they remain a significant cause of morbidity. In children, the majority of reconstruction is hepatico-jejunal anastomosis (HJA). The aim of this study was to analyze our experience in percutaneous transhepatic treatment of BS. Material/Methods Between 1998 and 2014, 589 (269 living donor) pediatric LTx were performed in our institution. We retrospectively reviewed clinical data of patients with HJA who developed BS and who underwent percutaneous transhepatic biliary drainage (PTBD). Results Out of 400 patients with HJA, 35 patients developed BS. There were 27 cases (77%) of anastomotic BS (ABS) and 8 cases (23%) of multilevel BS (MBS). Ninety-two PTBD sessions (2.5 per patient) were performed, with successful outcomes in 20 cases (57%). Fifteen patients, after failed PTBD, underwent surgery which was successful in 11 cases. Overall good outcomes were achieved in 31 cases (88.5%). The most common complication of PTBD was cholangitis which occurred in 5.4% of the cases. We did not find any risk factors for PTBD failure, except for treatment occurring before 2007. Conclusions Percutaneous treatment is effective and safe in BS and is recommended as a first-line approach. The majority of patients in our study required multiple interventions, however, the overall risk of complications was low. Surgery is essential in selected cases and always should be considered if PTBD fails.
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Affiliation(s)
- Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | | | | | - Małgorzata Rurarz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery and Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dorota Jarzębicka
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Jan Pertkiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Diana Kamińska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Mikołaj Teisseyre
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marek Szymczak
- Department of Pediatric Surgery and Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Joanna Pawłowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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35
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Czubkowski P, Pertkiewicz J, Markiewicz-Kijewska M, Kaliciński P, Rurarz M, Jankowska I, Pawłowska J. Endoscopic treatment in biliary strictures after pediatric liver transplantation. Pediatr Transplant 2018; 22:e13271. [PMID: 30043420 DOI: 10.1111/petr.13271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM The aim of the study was to assess efficacy and safety of endoscopic treatment in BS after pediatric LTx. METHODS We retrospectively reviewed data of patients with DDA who developed BS and underwent ERCP. RESULTS Of 189 transplanted patients with DDA, strictures developed in 30 (16%). In this subgroup, the median age at LTx was 14.7 (1.5-17.6) and follow-up period was 3.9 (1.3-11.3). ABS were in 76% and NABS in combination with ABS in 24% of patients. Overall, 95 ERCP sessions (3.0 per patient) were performed with successful outcome in 22 (73%) cases. Duration of treatment was 9.1 (1.8-24.1) months. Five patients underwent surgical revision and three patients retransplantation (10%). Risk factors of endoscopy failure were HCV or HBV infection, prolonged CIT and treatment before 2007. The most common complications after ERCP were cholangitis (8.2%) and pancreatitis (4.2%). There were worse overall prognosis and higher risk of post-ERCP complications in NABS. CONCLUSIONS ERCP is safe and effective in the majority of patients with post-transplant duct-to-duct BS, and it is currently recommended as the first-line treatment.
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Affiliation(s)
- Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Jan Pertkiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland
| | | | - Piotr Kaliciński
- Department of Pediatric Surgery and Organ Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Małgorzata Rurarz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Joanna Pawłowska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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Black CK, Termanini KM, Aguirre O, Hawksworth JS, Sosin M. Solid organ transplantation in the 21 st century. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:409. [PMID: 30498736 PMCID: PMC6230860 DOI: 10.21037/atm.2018.09.68] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/29/2018] [Indexed: 12/20/2022]
Abstract
Solid organ transplantation (SOT) has emerged from an experimental approach in the 20th century to now being an established and practical definitive treatment option for patients with end-organ dysfunction. The evolution of SOT has seen the field progress rapidly over the past few decades with incorporation of a variety of solid organs-liver, kidney, pancreas, heart, and lung-into the donor pool. New advancements in surgical technique have allowed for more efficient and refined multi-organ procurements with minimal complications and decreased ischemic injury events. Additionally, immunosuppression therapy has also seen advancements with the expansion of immunosuppressive protocols to dampen the host immune response and improve short and long-term graft survival. However, the field of SOT faces new barriers, most importantly the expanding demand for SOT that is outpacing the current supply. Allocation protocols have been developed in an attempt to address these concerns. Other avenues for SOT are also being explored to increase the donor pool, including split-liver donor transplants, islet cell implantation for pancreas transplants, and xenotransplantation. The future of SOT is bright with exciting new research being explored to overcome current obstacles.
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Affiliation(s)
- Cara K. Black
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Oswaldo Aguirre
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC, USA
| | - Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC, USA
| | - Michael Sosin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
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37
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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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38
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Makki K, Chorasiya V, Srivastava A, Singhal A, Khan AA, Vij V. Analysis of caudate lobe biliary anatomy and its implications in living donor liver transplantation - a single centre prospective study. Transpl Int 2018; 31:1041-1049. [PMID: 29722074 DOI: 10.1111/tri.13272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/03/2018] [Accepted: 04/23/2018] [Indexed: 12/14/2022]
Abstract
Biliary complications are a significant cause of morbidity after living donor liver transplant (LDLT). Bile leak may occur from bile duct (anastomotic site in recipient and repaired bile duct stump in donor), cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post-operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. To minimize caudate duct bile leaks, it is important to understand the anatomy of hilum with attention to the caudate lobe biliary drainage. This single-centre prospective study of 500 consecutive LDLTs between December 2011 and December 2016 aims to define the biliary anatomy of the caudate lobe in liver donors based on intraoperative cholangiograms (IOCs) with special attention to crossover caudate ducts and to study their implications in LDLT. Caudate ducts were identified in 468 of the 500 IOCs. Incidence of left-to-right crossover drainage was 61.37% and right to left was 21.45%. Incidence of bile leak in donors was 0.8% and in recipients was 2.2%. Proper intraoperative identification and closure of divided isolated caudate ducts can prevent bile leak in donors as well as recipients.
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Affiliation(s)
- Kausar Makki
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Vishal Chorasiya
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Ajitabh Srivastava
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Ashish Singhal
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Arif Ali Khan
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
| | - Vivek Vij
- Department of Liver Transplant and HPB surgery, Fortis Hospital, Noida, India
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39
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Wahab MA, Shehta A, Elshoubary M, Yassen AM, Elmorshedi M, Salah T, Sultan AM, Fathy O, Elsarraf WR, Shiha U, Zalata K, Elghawalby AN, Eldesoky M, Monier A, Said R, Elsabagh AM, Ali M, Kandeel A, Abdalla U, Aboelella M, Elsadany M, Abdel-Khalek EE, Marwan A, ElMorsi FM, Adly R. Living-Donor Liver Transplantation in Hepatitis C Virus Era: A Report of 500 Consecutive Cases in a Single Center. Transplant Proc 2018; 50:1396-1406. [PMID: 29880362 DOI: 10.1016/j.transproceed.2018.02.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/28/2018] [Accepted: 02/17/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) is considered a safe alternative to deceased donor liver transplantation (DDLT). In Egypt, DDLT program is still awaited, making LDLT the only hope for patients with end-stage liver disease, mainly due to chronic hepatitis C virus (HCV) infection. The current study is conducted to evaluate our experience of LDLT and discuss the lessons learned from 500 consecutive cases in HCV area. METHODS We reviewed the data of patients who underwent LDLT at Gastrointestinal Surgery Center, Mansoura University during the period between May 2004 and March 2017. RESULTS During the study period, 500 cases underwent LDLT at our unit. The median age was 51 years, and most of our cases were males (446, 89.2%) and had HCV infection (453, 90.6%). The median MELD score was 15. Median ICU stay was 5 days, and hospital stay was 22 days. Postoperative morbidities occurred in 220 cases (44%). Early mortality occurred in 69 patients (13.8%), and late mortality occurred in 45 patients (9%). The 1-, 3-, 5-, and 7-year overall survival rates of all cases were 80.9%, 78.2%, 75.7%, and 75%, respectively. Preoperative creatinine, worm ischemia, blood transfusion, ICU stay, postoperative morbidities, and small for size syndrome were independent predictors for overall survival. CONCLUSIONS In countries lacking DDLT, LDLT is the only effective alternative. LDLT requires a teamwork to achieve successful outcomes. LDLT should only be performed in centers with the adequate experience to avoid and decrease the hazards related to this procedure.
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Affiliation(s)
- M A Wahab
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A Shehta
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt.
| | - M Elshoubary
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A M Yassen
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - M Elmorshedi
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - T Salah
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A M Sultan
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - O Fathy
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - W R Elsarraf
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - U Shiha
- Diagnostic and Interventional Radiology Department, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - K Zalata
- Department of Pathology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A N Elghawalby
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - M Eldesoky
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A Monier
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - R Said
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A M Elsabagh
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - M Ali
- Department of Surgery, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A Kandeel
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - U Abdalla
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - M Aboelella
- Department of Anesthesia and Intensive Care, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - M Elsadany
- Department of Hepatology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - E E Abdel-Khalek
- Department of Hepatology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - A Marwan
- Department of Hepatology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - F M ElMorsi
- Department of Hepatology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
| | - R Adly
- Department of Hepatology, Gastrointestinal Surgery Center, College of Medicine, Mansoura University, Mansoura, Egypt
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Capobianco I, Rolinger J, Nadalin S. Resection for Klatskin tumors: technical complexities and results. Transl Gastroenterol Hepatol 2018; 3:69. [PMID: 30363698 PMCID: PMC6182019 DOI: 10.21037/tgh.2018.09.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/27/2018] [Indexed: 12/18/2022] Open
Abstract
Klatskin's tumors, actually-redefined as perihilar cholangiocarcinoma (phCCA) do represent 50-70% of all CCAs and develop in a context of chronic inflammation and cholestasis of bile ducts. Surgical resection provides the only chance of cure for this disease but is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures at this location. Five years survival rates range between 25-45% (median 27-58 months) in case of R0 resection and 0-23% (median 12-21 months) in case of R1 resection respectively. It should be noted that the major costs of high radicality are represented by relative high morbidity and mortality rates (i.e., 20-66% and 0-9% respectively). Considering the fact that radical resection may represent the only curative treatment of phCCA, we focused our review on surgical planning and techniques that may improve resectability rates and outcomes for locally advanced phCCA. The surgical treatment of phCCA can be successful when following aspects have been fulfilled: (I) accurate preoperative diagnostic aimed to identify the tumor in all its details (localization and extension) and to study all the risk factors influencing a posthepatectomy liver failure (PHLF): i.e., liver volume, liver function, liver quality, haemodynamics and patient characteristics; (II) High end surgical skills taking in consideration the local extension of the tumor and the vascular invasion which usually require an extended hepatic resection and often a vascular resection; (III) adequate postoperative management aimed to avoid major complications (i.e., PHLF and biliary complications). These are technically challenging operations and must be performed in a high volume centres by hepato-biliary-pancreas (HBP)-surgeons with experience in microsurgical vascular techniques.
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Affiliation(s)
- Ivan Capobianco
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Jens Rolinger
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
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Abstract
Acute pancreatitis is a well-recognised complication of endoscopic procedures like endoscopic retrograde cholangiopancreatography but not oesophagogastroduodenoscopy (OGD). I report a case of a 33-year-old woman, admitted with severe epigastric pain and vomiting 2 hours after an elective OGD for evaluation of chronic gastrointestinal symptoms. Pancreatitis was diagnosed on the basis of elevated lipase (40 790 U/L; normal 11-82) and findings on imaging studies. Other common causes of acute pancreatitis such as gallstones, alcohol and medications were ruled out. She had an extended hospital course because of severe disease, characterised by systemic inflammatory response syndrome, pleural effusion and ascites but was successfully managed conservatively with bowel rest, hydration and pain management. Acute pancreatitis should be considered a rare complication of OGD and should be considered in differential diagnosis for abdominal pain post OGD. Pathogenesis is likely from direct trauma to pancreas or gas insufflation.
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Lee EC, Kim SH, Park SJ. Outcomes after liver transplantation in accordance with ABO compatibility: A systematic review and meta-analysis. World J Gastroenterol 2017; 23:6516-6533. [PMID: 29085201 PMCID: PMC5643277 DOI: 10.3748/wjg.v23.i35.6516] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/07/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the differences in outcomes between ABO-incompatible (ABO-I) liver transplantation (LT) and ABO-compatible (ABO-C) LT. METHODS A systematic review and meta-analysis were performed by searching eligible articles published before No-vember 28, 2016 on MEDLINE (PubMed), EMBASE, and Cochrane databases. The primary endpoints were graft survival, patient survival, and ABO-I-related complications. RESULTS Twenty-one retrospective observational studies with a total of 8247 patients were included in this meta-analysis. Pooled results of patient survival for ABO-I LT were comparable to those for ABO-C LT. However, ABO-I LT showed a poorer graft survival than ABO-C LT (1-year: OR = 0.66, 95%CI: 0.57-0.76, P < 0.001; 3-year: OR = 0.74, 95% CI 0.64-0.85, P < 0.001; 5-yearr: OR =0.75, 95%CI: 0.66-0.86, P < 0.001). Furthermore, ABO-I LT was associated with more incidences of antibody-mediated rejection (OR = 74.21, 95%CI: 16.32- 337.45, P < 0.001), chronic rejection (OR =2.28, 95%CI: 1.00-5.22, P = 0.05), cytomegalovirus infection (OR = 2.64, 95%CI: 1.63-4.29, P < 0.001), overall biliary complication (OR = 1.52, 95%CI: 1.01-2.28, P = 0.04), and hepatic artery complication (OR = 4.17, 95%CI: 2.26-7.67, P < 0.001) than ABO-C LT. In subgroup analyses, ABO-I LT and ABO-C LT showed a comparable graft survival in pediatric patients and those using rituximab, and ABO-I LT showed an increased acute cellular rejection in cases involving deceased donor grafts. CONCLUSION Although patient survival in ABO-I LT was comparable to that in ABO-C LT, ABO-I LT was inferior to ABO-C LT in graft survival and several complications. Graft survival of ABO-I LT could be comparable to that of ABO-C LT in pediatric patients and those using rituximab.
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Affiliation(s)
- Eung Chang Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do 410-769, South Korea
| | - Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do 410-769, South Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do 410-769, South Korea
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Santosh Kumar KY, Mathew JS, Balakrishnan D, Bharathan VK, Thankamony Amma BSP, Gopalakrishnan U, Narayana Menon R, Dhar P, Vayoth SO, Sudhindran S. Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial. J Am Coll Surg 2017; 225:747-754. [PMID: 28916322 DOI: 10.1016/j.jamcollsurg.2017.08.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/29/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary complications continue to be the "Achilles heel" of living-donor liver transplantation (LDLT). The use of biliary stents in LDLT to reduce biliary complications is a controversial issue. We performed a randomized trial to study the impact of intraductal biliary stents on postoperative biliary complications after LDLT. STUDY DESIGN Of the 94 LDLTs that were performed during a period of 16 months, ABO-incompatible transplants, left lobe grafts, 3 or more bile ducts on the graft, and those requiring bilioenteric drainage were excluded. Eligible patients were randomized to either a study arm (intraductal stent, n = 31) or a control arm (no stent, n = 33) by block randomization. Stratification was done, based on the number of ducts on the graft requiring anastomosis, into single (n = 20) or 2 ducts (n = 44). Ureteric stents of 3F to 5F placed across the biliary anastomosis and exiting into the duodenum for later endoscopic removal at 3 months were used. The primary end point was postoperative bile leak. RESULTS Bile leak occurred in 15 of 64 (23.4%), the incidence was higher in the stented group compared with the control group (35.5% vs 12.1%; p = 0.03). Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis (p = 0.031 and p = 0.032). During a median follow-up of 2 years, biliary stricture developed in 9 patients (14.1%). Postoperative bile leak is a significant risk factor for the development of biliary stricture (p = 0.003). CONCLUSIONS Intraductal transanastomotic biliary stenting and multiplicity of graft ducts were identified as independent risk factors for the development of postoperative biliary complications.
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Affiliation(s)
- K Y Santosh Kumar
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Johns Shaji Mathew
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India.
| | - Dinesh Balakrishnan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Viju Kumar Bharathan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Binoj Sivasankara Pillai Thankamony Amma
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Unnikrishnan Gopalakrishnan
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Ramachandran Narayana Menon
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Puneet Dhar
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Sudheer Othiyil Vayoth
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
| | - Surendran Sudhindran
- Department of Gastrointestinal Surgery and Solid Organ Transplant, Amrita Institute of Medical Sciences and Research Centre, Amrita University, Kochi, Kerala, India
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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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Shamsaeefar A, Nikeghbalian S, Kazemi K, Motazedian N, Geramizadeh B, Malekhosseini SA. Thirteen-Year Evaluation of the Management of Biliary Tract Complication After Deceased Donor Liver Transplantation. Prog Transplant 2017; 27:192-195. [PMID: 28617155 DOI: 10.1177/1526924817699964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Although patient and graft survival rate has increased in recent years, biliary complications after liver transplantation are associated with significant morbidity and mortality. METHODS AND MATERIALS We reviewed the database of 1930 patients who underwent deceased donor liver transplantation between 2000 and 2013. The patients had abnormal results in liver tests, as well as fever and jaundice. Abdominal sonography was performed, and if complication was identified, the patient underwent an interventional procedure by endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. If the complication was not resolved by the mentioned procedures, exploration of common bile duct and Roux-en-Y choledochojejunostomy or revision of Roux-en-Y choledochojejunostomy was done. RESULTS Our study group comprised 105 patients including 66 (63%) men and 39 (37.1%) women with a mean age of 36.7 ± 12.5 years (range: 15-66 years). Among 1930 patients, 105 (5.4%) cases presented with biliary complication after liver transplantation, of which 97 (5%) and 8 (0.4%) cases presented with biliary stricture and bile leak/biloma, respectively. CONCLUSION In our study, most patients with biliary complications after liver transplantation responded to interventional procedures, with 37.1% requiring surgical exploration.
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Affiliation(s)
- Alireza Shamsaeefar
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saman Nikeghbalian
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kourosh Kazemi
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Motazedian
- 2 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bita Geramizadeh
- 2 Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Malekhosseini
- 1 Department of Hepatobiliary and Transplantation Surgery, Shiraz Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Rao HB, Ahamed H, Panicker S, Sudhindran S, Venu RP. Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome. World J Gastrointest Pathophysiol 2017; 8:77-86. [PMID: 28573070 PMCID: PMC5437505 DOI: 10.4291/wjgp.v8.i2.77] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/23/2017] [Accepted: 04/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To identify factors predicting outcome of endoscopic therapy in bile duct strictures (BDS) post living donor liver transplantation (LDLT).
METHODS Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms (Pruritus, Jaundice, cholangitis), intra-op variables (cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis (HAT), bile leak, infections], stricture morphology (length, donor and recipient duct diameters) and relevant laboratory data both pre- and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0.
RESULTS Forty-one patients were included (age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients (48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy (multiple endoscopic retrograde cholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome (P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak (> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis (P < 0.05).
CONCLUSION Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.
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Sánchez Cabús S, Estalella L, Pavel M, Calatayud D, Molina V, Ferrer J, Fondevila C, Fuster J, García-Valdecasas JC. Analysis of the long-term results of living donor liver transplantation in adults. Cir Esp 2017; 95:313-320. [PMID: 28476200 DOI: 10.1016/j.ciresp.2017.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/13/2017] [Accepted: 03/27/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Living donor liver transplantation (LDLT) is an alternative to conventional transplantation given its excellent results. The aim of this study is to evaluate long-term outcomes in LDLT recipients. METHODS 100 consecutive THDV recipients from the Hospital Clínic of Barcelona from March 2000 to October 2015 were included. The main indication for transplantation was end-stage liver disease (58%) followed by hepatocellular carcinoma (41%). 95% of grafts consisted of the right liver of the donor and the 5% of the left liver. RESULTS After a median follow-up of 65.5 months, patient and graft survival at 1, 3, and 5 years was 93%, 80% and 74% and 90%, 76%, and 71%, respectively. The overall re-transplant rate was 9%. The most common long-term complication was biliary stenosis (40%) with an average time of onset of 13.5±12 months, with repeated admissions and an average of 1.9±2 endoscopic procedures and 3.5±3 Radiological procedures per patient. The definitive treatment was radiological dilation in 40% of cases, surgical intervention in 22.5% and re-transplantation in 7.5%. CONCLUSIONS Given the long-term results, LDLT is confirmed as an alternative to conventional transplantation. However, the high rate of late biliary complications involves repeated admissions and invasive treatments that, while not compromising survival, can affect the patient's quality of life.
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Affiliation(s)
- Santiago Sánchez Cabús
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - Laia Estalella
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - Mihai Pavel
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - David Calatayud
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - Víctor Molina
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - Joana Ferrer
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - Constantino Fondevila
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
| | - Josep Fuster
- Unidad de Cirugía HPB y Trasplantes, ICMDiM. Hospital Clínic de Barcelona, Barcelona, España
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Jeong S, Wang X, Wan P, Sha M, Zhang J, Xia L, Tong Y, Luo Y, Xia Q. Risk factors and survival outcomes of biliary complications after adult-to-adult living donor liver transplantation. United European Gastroenterol J 2017; 5:997-1006. [PMID: 29163966 DOI: 10.1177/2050640616688994] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 12/16/2016] [Indexed: 12/12/2022] Open
Abstract
The objective of this study was to evaluate the risk factors and survival outcomes of biliary complications (BCs) after living donor liver transplantation (LDLT) based on our single-center experience. From 2007 to 2010, 112 adult patients were assessed. Forty-nine patients (43.8%) experienced at least one episode of BCs, including biliary stricture and bile leak, occurring in 37.5% and 16.1% of the patients, respectively. Multivariate analysis indicated that hepatic artery thrombosis (relative risk (RR), 5.692; 95% CI, 2.132 to 15.201; p < 0.001), a hepatic duct diameter of less than 3 mm (RR, 2.523; 95% CI, 1.295 to 4.914; p = 0.005), ductoplasty (RR, 2.175; 95% CI, 1.134 to 4.174; p = 0.018), and cytomegalovirus infection (RR, 4.452; 95% CI, 1.868 to 10.613; p = 0.001) were independent risk factors for the development of BCs. However, these factors and BCs showed no prominent impact on the overall survival (OS) and graft survival (GS). In addition, the patients who developed vascular complications demonstrated poor outcomes in terms of OS (five-year, 56.3% vs. 78.1%; p = 0.017), GS (five-year, 56.3% vs. 77.1%; p = 0.023), and BC-free survival (five-year, 25.0% vs. 63.5%; p = 0.007) compared with patients without vascular complications. In conclusion, BCs remain a common problem after LDLT, especially for patients using duct-to-duct anastomosis. Hepatic artery thrombosis, a short duct diameter, ductoplasty, and cytomegalovirus infection lead to an increased incidence of BCs. The occurrence of BCs manifested no significant influence on the long-term survival outcomes. However, our findings await verification through large-scale randomized studies regarding the risk factors for the development of BCs and their impact on the prognosis.
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Affiliation(s)
- Seogsong Jeong
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xin Wang
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ping Wan
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Meng Sha
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhang
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Xia
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Tong
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Luo
- 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
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Intrahepatic Artery Pseudoaneurysm-induced Hemobilia Caused by a Plastic Biliary Stent After ABO-incompatible Living-donor Liver Transplantation: A Case Report. Transplant Proc 2016; 48:3178-3180. [PMID: 27932176 DOI: 10.1016/j.transproceed.2016.02.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 12/20/2022]
Abstract
Bile leakage after duct-to-duct anastomosis in living-donor liver transplantation (LDLT) can mostly be managed by therapeutic endoscopic retrograde cholangiopancreatography. Following this, various complications such as biliary infection, pancreatitis, perforation, and bleeding can occur, and endoscopic sphincterotomy is primarily associated with post- endoscopic retrograde cholangiopancreatography bleeding; other causes have been published in case reports. In the present case, a plastic biliary stent used for treating liver abscesses and leakage at the bile duct anastomosis site after ABO-incompatible LDLT resulted in an intrahepatic artery pseudoaneurysm and hemobilia, which were managed by angiography and coil embolization. Although the complex postoperative course after LDLT can obscure the prompt diagnosis of an intrahepatic artery pseudoaneurysm and hemobilia, biliary stenting should be considered as a possible cause.
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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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