Human sphincter of Oddi motility and cholecystokinin response following liver transplantation

The presence and outcome of biliary sphincter disorders in liver-transplant recipients according to the Rome IV classification

Background

Biliary sphincter disorders after liver transplantation (LT) are poorly described. We aim to describe the presence and outcome of patients with papillary stenosis (PS) and functional biliary sphincter disorders (FBSDs) after LT according to the updated Rome IV criteria.

Methods

We reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed in LT recipients between January 2003 and December 2019. Information on clinical and endoscopic findings was obtained from electronic health records and endoscopy databases. Laboratory and clinical findings were collected at the time of ERCP and 1 month after ERCP.

Results

Among the 1,307 LT recipients, 336 underwent 849 ERCPs. Thirteen (1.0%) patients met the updated Rome IV criteria for PS [former sphincter of Oddi dysfunction (SOD) type I] and 14 patients (1.0%) met the Rome IV criteria for FBSD (former SOD type II). Biliary sphincterotomy was performed in 13 PS and 10 FBSD cases. One month after sphincterotomy, bilirubin, gamma-glutamyl transferase and alkaline phosphatase levels decreased in 85%, 61%, and 92% of those in the PS group (P = 0.019, 0.087, and 0.003, respectively) and in 50%, 70%, and 80% of those in the FBSD group (P = 0.721, 0.013, and 0.093, respectively). All the 14 patients initially suspected of having a FBSD turned out to have a different diagnosis during the follow-up.

Conclusions

PS after LT is uncommon and occurs in only 1% of LT recipients. Our data do not support the presence of an FBSD after LT. Sphincterotomy is a safe and effective procedure in LT recipients with PS.

Endoscopic approach to the patient with motility disorders of the bile duct and sphincter of Oddi

Since its original description by Oddi in 1887, the sphincter of Oddi has been the subject of much study. Furthermore, the clinical syndrome of sphincter of Oddi dysfunction (SOD) and its therapy are controversial areas. Nevertheless, SOD is commonly diagnosed and treated by physicians. This article reviews the epidemiology, clinical manifestations, and current diagnostic and therapeutic modalities of SOD.

Complications of the treatment of endoscopic biliary strictures developing after liver transplantation

BACKGROUND

Bile duct strictures remain a major source of morbidity after orthotopic liver transplantation (OLT). Endoscopic management by the conventional methods of biliary dilatation and/or stent placement has been successful, but sometimes severe complications occur, necessitating prolonged therapy. The aim of this study is to clarify the complications of the endoscopic approach for endoscopic dilatation and/or stent placement.

METHOD

Of 46 patients who underwent living-donor liver transplantation, 10 were diagnosed as having anatomic biliary strictures by endoscopic retrograde cholangiopancreatography (ERCP). Two patients developing biliary strictures after deceased-donor liver transplantation were also enrolled in the study. For the purpose of comparison, 302 patients with a total of 550 consecutive ERCP cases (including 115 patients with 250 malignant bile duct strictures) were recruited in this study. Success rate, number of endoscopy sessions, the median procedure time for ERCP, and incidence of complications including post-ERCP pancreatitis were compared in the OLT cases and other cases.

RESULTS

The following results were obtained in the OLT cases, malignant stricture cases, and all cases, respectively: mean number of endoscopy sessions was 3.62, 2.17, and 1.94 (P = 0.0216, P < 0.0001); post-ERCP pancreatitis occurred in 5 (12.5%), 10 (4.0%), and 19 cases (3.5%) (P = 0.0327, P = 0.0093); and severe pancreatitis occurred in 2 cases of OLT. In a univariate analysis for post-ERCP pancreatitis, OLT was extracted as the only significant risk factor.

CONCLUSIONS

Endoscopic maneuvering for biliary dilatation and/or stent placement following OLT was associated with a higher risk of post-ERCP pancreatitis than the use of the same technique for the treatment of malignant biliary stricture. Endoscopic treatment after OLT was a significant risk factor for post-ERCP pancreatitis.

Biliary complications after liver transplantation: A review

After liver transplantation, the prevalence of complications related to the biliary system is 6-35%. In recent years, the diagnosis and treatment of biliary problems has changed markedly. The two standard methods of biliary reconstruction in liver transplant recipients are the duct-to-duct choledochocholedochostomy and the Roux-en-Y-hepaticojejunostomy. Biliary leakage occurs in approximately 5-7% of transplant cases. Leakage from the site of anastomosis, the T-tube exit site and donor or recipient remnant cystic duct is well described. Symptomatic bile leakage should be treated by stenting of the duct by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTCD). Biliary strictures can occur at the site of the anastomosis (anastomotic stricture; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). AS occur in 5-10% of cases and are due to fibrotic healing. Treatment by ERCP or PTCD with dilatation and progressive stenting is successful in the majority of cases. NAS can occur in the context of a hepatic artery thrombosis, or with an open hepatic artery (ischaemic type biliary lesions or ITBL). The incidence is 5-10%. NAS has been associated with various types of injury, e.g. macrovascular, microvascular, immunological and cytotoxic injury by bile salts. Treatment can be attempted with multiple sessions of dilatation and stenting of stenotic areas by ERCP or PTCD. In cases of localized diseased and good graft function, biliary reconstructive surgery is useful. However, a significant number of patients will need a re-transplant. When biliary strictures or ischaemia of the graft are present, stones, casts and sludge can develop.

Liver biochemistry profile, significance and endoscopic management of biliary tract complications post orthotopic liver transplantation

AIM: To correlate the significance of liver biochemical tests in diagnosing post orthotopic liver transplantation (OLT) biliary complications and to study their profile before and after endoscopic therapy.

METHODS: Patients who developed biliary complications were analysed in detail for the clinical information, laboratory tests, treatment offered, response to it, follow up and outcomes. The profile of liver enzymes was determined. The safety, efficacy and outcomes of endoscopic retrograde cholangiography (ERC) were also analysed.

RESULTS: 40 patients required ERC for 70 biliary complications. GGT was found to be > 3 times (388.1 ± 70.9 U/mL vs 168.5 ± 34.2 U/L, P = 0.007) and SAP > 2 times (345.1 ± 59.1 U/L vs 152.7 ± 21.4 U/L, P = 0.003) the immediate post OLT values. Most frequent complication was isolated anastomotic strictures in 28 (40%). Sustained success was achieved in 26 (81%) patients.

CONCLUSION: Biliary complications still remain an important problem post OLT. SAP and GGT can be used as early, non-invasive markers for diagnosis and also to assess the adequacy of therapy. Endoscopic management is usually effective in treating the majority of these biliary complications.

Endoscopic Management of Biliary Complications After Orthotopic Liver Transplantation

After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.

An endoscopic approach to biliary complications following orthotopic liver transplantation

Biliary complications following orthotopic liver transplantation (OLT) may be associated with significant morbidity and mortality. In this report, we reviewed our endoscopic experience of managing post OLT biliary complications in 79 patients over a 12-year period.

METHODS

OLT (n = 423) recipients between 10/86 and 12/98 were obtained from the transplant registry at the Johns Hopkins Hospital. OLT recipient who underwent at least one endoscopic retrograde cholangiography (ERC) were identified through a radiology database. Indications, findings and interventions performed were noted for each ERC report. Outpatient and inpatients medical records were reviewed for outcome and complications.

RESULTS

Seventy-nine (79/423, 18.7%) patients had at least one ERC for suspected biliary complication. Sixty-four (15.1%) patients had at least one or more biliary complications. The mean follow-up for patients with abnormal ERC was 33.9 months. Nineteen patients had bile leaks; 10 of these patients had leak at the exit site of the T-tube and five patients had at the anastomosis. Biliary stenting with or without endoscopic sphincterotomy led to resolution of bile leak in 16 patients. Three patients failed endoscopic therapy: one underwent surgery and two had percutaneous drainage. Twenty-five patients presented with biliary strictures. Nineteen strictures were at the anastomotic or just proximal to the anastomosis, one at the hilum (ischemic in nature) and three were at the distal, recipient common bile duct; one had strictures at the anastomosis as well as the distal recipient bile duct and another had diffuse intrahepatic strictures. Seventeen patients in the stricture group improved with endoscopic intervention. One patient was re-transplanted (diffuse intrahepatic strictures), but no patient underwent percutaneous drainage.

CONCLUSIONS

ERC is safe and effective in the diagnosis and management of biliary complications following liver transplantation with choledochocholedochal anastomosis and obviates the need for surgical or percutaneous transhepatic approaches in majority of cases.

Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy

BACKGROUND

Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy.

METHODS

From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems.

RESULTS

A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree.

CONCLUSION

When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures.

Endoscopic management of postoperative biliary complications in orthotopic liver transplantation

BACKGROUND

Surgery, percutaneous cholangiography, and endoscopic retrograde cholangiopancreatography (ERCP) have been used in the management of biliary complications after orthotopic liver transplantation with varied results. We assessed the role of ERCP in the diagnosis, treatment, and outcome of post-orthotopic liver transplantation biliary complications.

METHODS

We retrospectively reviewed the records of 260 patients who underwent orthotopic liver transplantation. We examined the number of patients referred for ERCP and the indication, diagnosis, therapeutic intervention, success, and complication rate of ERCP post orthotopic liver transplantation. We compared the survival and retransplantation rates of the patients who underwent ERCP with a control group of post-orthotopic liver transplantation patients not undergoing ERCP.

RESULTS

Of the 260 patients undergoing orthotopic liver transplantation, 64 (24.6%) underwent 137 ERCPs. Two categories of indications for ERCP were identified: bile leak (n = 31) and obstruction (n = 39). ERCP identified the site of the bile leak in 27 of 31 cases (87.1%) and the leak was treated by endoscopic means in 26 of 31 (83.9%). Treatment success differed significantly based on location of the leak (T tube, 95.2% vs. anastomosis, 42.9%; p = 0. 009). ERCP identified the site of obstruction in 37 of 39 cases (94. 9%) and obstruction was relieved by endoscopic means in 25 of 35 cases (71.4%). ERCP was significantly less successful in the treatment of biliary casts (25.0%, p = 0.048). There was no difference in survival or retransplantation between patients who did and did not undergo ERCP.

CONCLUSION

ERCP should be the primary method for diagnosis and treatment of post-orthotopic liver transplantation biliary complications. Endoscopic therapy is safe and effective for the majority of post-orthotopic liver transplantation complications and temporizes management for those complications that may require surgery.

Predictors of bile leaks after T-tube removal in orthotopic liver transplant recipients

Bile leaks after T-tube removal are a frequent cause of morbidity in orthotopic liver transplant recipients. The aim of this study was to determine factors that predict the development of these leaks in liver transplant recipients. Records of all patients who had undergone liver transplantation at the University of Washington Medical Center between January 1990 and September 1993 were reviewed. The following were excluded: patients with a Roux-en-Y anastomosis or inadvertent early T-tube removal and patients who died or underwent retransplantation before T-tube removal. All T-tube cholangiograms were reviewed blindly by two authors. Using logistic regression, several variables were assessed for possible association with bile leaks after T-tube removal; these included patient demographics, intraoperative variables, and clinical and cholangiographic variables related to T-tube removal. Of the 166 liver transplants performed in 150 patients, 99 transplants in 97 patients were evaluable for bile leak after T-tube removal. Thirty-three patients developed symptomatic bile leaks, and 21 underwent endoscopic or operative intervention for persistent symptoms. Only duct mural irregularities on the final cholangiogram were strongly associated with the development of a bile leak after T-tube removal (P = 0.001). In conclusion, bile leaks after T-tube removal occurred in one-third of patients undergoing orthotopic liver transplantation; the majority of these patients required some intervention. Duct mural irregularities were associated with bile leaks.

Sphincter of Oddi dysfunction

Evidence continues to accumulate indicating that sphincter of Oddi dysfunction may give rise to cholestasis, pancreatitis, or upper abdominal pain syndromes. Diagnosis of such dysfunction may be inferred from noninvasive tests or more precisely defined by manometric studies. Both the biliary and pancreatic sphincters are commonly involved. If medical therapy is ineffective, sphincter ablation via endoscopy or laparotomy should be considered for highly symptomatic patients. Complication rates of invasive techniques remain relatively high and risk:benefit ratio should be carefully considered. Future research as to etiology, more defined pathophysiology, more accurate noninvasive evaluation, and optimal therapies are awaited.

Endoscopic diagnosis and management of biliary complications following orthotopic liver transplantation

Nonoperative management of biliary complications (BC) with endoscopic retrograde cholangiopancreatography (ERCP) is a natural sequel to the emergence of choledochocholedochostomy as the preferred biliary reconstruction for orthotopic liver transplantation (OLT). Overall, therapeutic ERCP's efficacy for posttransplant BC is difficult to assess because most published data are retrospective, anecdotal, or in abstract form, and there are no prospective, randomized studies. Thus, endoscopic management of posttransplant BC must be individualized. While T-tube-related late bile leaks and ductal calculi are amenable to endoscopic therapy, its efficacy for strictures is more difficult to define. Refined surgical technique has prevented many unifocal anastomotic lesions, while multifocal strictures (for which endoscopic therapeutic experience is minimal) are increasingly prevalent. Whether endoscopic sphincterotomy is appropriate for posttransplant sphincter of Oddi dysfunction is controversial, because the disorder may be transient and the risk significant. Multicenter, prospective studies are needed to determine more accurately the optimal role of endoscopic therapy after OLT.

Normal fasting volume and postprandial emptying of the denervated donor gallbladder in liver transplant recipients

BACKGROUND/AIMS

Truncal vagotomy causes gallbladder dilatation and possibly cholelithiasis. During liver transplantation, when the gallbladder is transplanted with the donor liver, the gallbladder and liver are extrinsically denervated. The aim of this study was to determine whether extrinsic denervation affects gallbladder volume and postprandial emptying.

METHODS

To evaluate fasting gallbladder volume, 26 transplant recipients underwent ultrasonography. Twenty-eight normal volunteers were controls. To evaluate postprandial contractility, seven transplant recipients underwent radionuclide gallbladder-emptying studies. Gastric emptying and cholecystokinin release were simultaneously determined after a fatty meal to exclude a difference in gallbladder stimulus. Sixteen normal volunteers were controls.

RESULTS

There were no differences in fasting gallbladder volume or postprandial contractility, gastric emptying, and cholecystokinin release between transplant patients and controls. Median fasting and postprandial gallbladder volumes for the transplant recipients (95% confidence) were 16 mL (12-34 mL) and 3 mL (0-8 mL), respectively, and for controls were 18 mL (13-21 mL; P = 0.73) and 3 mL (1-6 mL; P = 0.97), respectively.

CONCLUSIONS

These data do not show gallbladder dilatation or impaired postprandial gallbladder contraction in the extrinsically denervated gallbladder. This finding suggests that gallbladder dilatation may be caused by the unopposed activity of the sympathetic system after truncal vagotomy.

Sphincter of Oddi dysfunction following liver transplantation. Screening by bedside manometry and definitive manometric evaluation

Although sphincter of Oddi dysfunction (SOD) has been extensively studied in the nontransplant setting, the diagnostic criteria after liver transplantation are not well defined and have been based on clinical features without manometric documentation. The purpose of this study was twofold: (1) to determine the manometric patterns associated with SOD following orthotopic liver transplantation (OLT) and (2) to define the usefulness of bedside T-tube manometry as a screening tool for SOD. ERCP with simultaneous manometry of the sphincter of Oddi (SO) was performed in five patients following OLT with choledochocholedochostomy (CDCD) between 1990 and 1992. The diagnosis of SOD was suspected based on persistently elevated liver function tests, distal common bile duct dilatation in the absence of strictures, and an elevated resting bile duct pressure as measured by bedside T-tube manometry. Two different manometric patterns of SOD were observed. The first pattern (N = 4) consisted of elevated SO basal pressures, infrequent simultaneous phasic activity, and an abnormal response to cholecystokinin-octapeptide (CCK-OP). The second pattern (N = 1) consisted of low basal pressures and absent phasic activity. Four patients were successfully treated with papillotomy and stenting, while the fifth patient required conversion to a choledochojejunostomy because of a concomitant anastomotic stricture. The abnormal SO manometric profiles in patients suspected of having SOD after OLT were different from those observed in the nontransplant setting. Bedside T-tube manometry allowed measurement of the resting bile duct pressure and may be a useful screening tool for SOD.